Family Therapy

c h a p t e r 1

Learning OutcOmes ♦♦ Describe the circumstances that led to

the birth of family therapy. ♦♦ List the founders of family therapy and

where they practiced. ♦♦ List the first family therapy theories and

when they were popular. ♦♦ Describe early family therapy theoretical

concepts.

The evoLuTion of famiLy Therapy A Revolutionary Shift in Perspective

In this chapter, we explore the antecedents and early years of family therapy. There are two compelling stories here: one of personalities,

one of ideas. The first story revolves around the pioneers—visionary iconoclasts who broke 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 systemic perspective was a revolutionary one, 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.

The undeclared War

Although we came to think of asylums as places of cruelty and detention, they were originally built to rescue the insane from being locked away in family attics. Accordingly, except for purposes of footing the bill, hospital psychiatrists kept families at arm’s length. In the 1950s, however, two puzzling devel- 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

M01_NICH6609_11_SE_C01.indd 8 9/25/15 7:03 PM

Chapter 1 The Evolution of Family Therapy 9

getting worse. When she continued to improve, the husband lost his job. Eventually, when the woman was completely well, the husband killed himself. Ap- parently this man’s stability was predicated on having a sick wife.

Another strange story of shifting disturbance was that patients often improved in the hospital only to get worse when they went home.

Case sTuDy In a bizarre case of Oedipus revisited, Salvador Minuchin treated a young man hospitalized for trying to scratch out his eyes. The man functioned normally in Bellevue but returned to self-mutilation each time he went home. He could be sane, it seemed, only in an insane world.

It turned out that the young man was extremely close to his mother, a bond that grew even tighter during the seven years of his father’s mysterious ab- sence. The father was a compulsive gambler who disappeared shortly after being declared legally incompetent. The rumor was that the Mafia had kidnapped him. When, just as mysteriously, the fa- ther returned, his son began his bizarre attempts at self-mutilation. Perhaps he wanted to blind himself so as not to see his obsession with his mother and hatred of his father.

But this family was neither ancient nor Greek, and Minuchin was more pragmatist than poet. So he challenged the father to protect his son by be- ginning to deal directly with his wife, and then he challenged the man’s demeaning attitude toward her, which had driven her to seek her son’s protec- tion. The therapy was a challenge to the family’s structure and, in Bellevue, working with the psychi- atric staff to ease the young man back into the fam- ily, into the lion’s den.

Minuchin confronted the father, saying, “As a father of a child in danger, what you’re doing isn’t enough.”

“What should I do?” asked the man. “I don’t know,” Minuchin replied. “Ask your

son.” Then, for the first time in years, father and son began talking. Just as they were about to run out of things to say, Dr. Minuchin commented to the parents: “In a strange way, he’s telling you that he prefers to be treated like a child. When he was in the hospital he was twenty-three. Now that he’s returned home again, he’s six.”

What this case dramatizes is how parents use their children as a buffer to protect them from in- timacy. To the would-be Oedipus, Minuchin said, “You’re scratching your eyes for your mother, so that she’ll have something to worry about. You’re a good boy. Good children sacrifice themselves for their parents.”

Families are made of strange glue—they stretch but never let go. Few blamed the family for outright malevolence, yet there was an invidious undercurrent to these observations. The official story of family therapy is one of respect for the family, but maybe none of us ever quite gets over the adolescent idea that families are the enemy of freedom.

Small Group Dynamics

Those who first sought to understand and treat fam- ilies found a ready parallel in small groups. Group dynamics were applicable to family therapy because group life is a complex blend of individual personali- ties and properties of the group.

In 1920, the pioneering social psychologist William McDougall published The Group Mind, in which he described how a group’s continuity depends on boundaries for differentiation of function and on customs and habits to make relationships predict- able. A more scientific approach to group dynamics was developed in the 1940s by Kurt Lewin, whose field theory (Lewin, 1951) guided a generation of re- searchers. Drawing on the Gestalt school of percep- tion, Lewin developed the notion that a group is more than the sum of its parts. The transcendent property of groups has obvious relevance to family therapists, who must work not only with individuals but also with fam- ily systems—and their famous resistance to change.

Analyzing what he called quasi-stationary social equilibrium, Lewin pointed out that changing group behavior requires “unfreezing.” Only after something shakes up a group’s beliefs will its members be pre- pared to change. In individual therapy this process is initiated by the unhappy experiences that lead people to seek help. When someone decides to meet with a therapist, that person has already begun to unfreeze old habits. When families come for treatment, it’s a different story.

M01_NICH6609_11_SE_C01.indd 9 9/25/15 7:03 PM

10 Part One: The Context of Family Therapy

Family members may not be sufficiently unsettled by one member’s problems to consider changing their ways. Furthermore, family members bring their own reference group with them, with all its traditions and habits. Consequently, more effort is required to un- freeze, or shake up, families before real change can take place. The need for unfreezing foreshadowed early family therapists’ concern about disrupting fam- ily homeostasis, a notion that dominated family ther- apy for decades.

Wilfred Bion was another student of group func- tioning who emphasized the group as a whole, with its own dynamics and structure. According to Bion (1948), most groups become diverted from their pri- mary tasks by engaging in patterns of fight–flight, dependency, and pairing. Bion’s basic assumptions are easily extrapolated to family therapy: Some families skirt around hot issues like a cat circling a snake. Others use therapy to bicker endlessly, never really contemplating compromise, much less change.

Dependency masquerades as therapy when fami- lies allow therapists to subvert their autonomy in the name of problem solving. Pairing is seen in families when one parent colludes with the children to under- mine the other parent.

The process/content distinction in group dy- namics had a major impact on family treatment. Experienced therapists learn to attend as much to how people talk as to the content of their discus- sions. For example, a mother might tell her daugh- ter that she shouldn’t play with Barbie dolls because she shouldn’t aspire to an image of bubble-headed beauty. The content of the mother’s message is, “Respect yourself as a person.” But if the mother expresses her point of view by disparaging the daughter’s wishes, then the process of her message is, “Your feelings don’t count.”

Unfortunately, the content of some discussions is so compelling that therapists get sidetracked from the process. Suppose that a therapist invites a teenager

Ri ch

ar d

T. N

ow itz

/C or

bi s

The first people to practice family therapy turned to group therapy for a model.

M01_NICH6609_11_SE_C01.indd 10 9/25/15 7:03 PM

Chapter 1 The Evolution of Family Therapy 11

to talk with his mother about wanting to drop out of school. The boy mumbles something about school being stupid, and his mother responds with a lecture about the importance of education. A therapist who gets drawn in to support the mother’s position may be making a mistake. In terms of content, the mother might be right: A high school diploma can come in handy. But maybe it’s more important at that moment to help the boy learn to speak up for himself—and for his mother to learn to listen.

Role theory, explored in the literatures of psy- choanalysis and group dynamics, had important ap- plications to the study of families. The expectations that roles carry bring regularity to complex social situations.

Roles tend to be stereotyped in most groups, and so there are characteristic behavior patterns of group members. Virginia Satir (1972) described family roles such as “the placator” and “the disagreeable one” in her book Peoplemaking. If you think about it, you may have played a fairly predictable role in your fam- ily. Perhaps you were “the good child,” “the moody one,” or “the rebel.” The trouble is, such roles can be hard to put aside.

One thing that makes role theory so useful in un- derstanding families is that roles tend to be comple- mentary. Say, for example, that a woman is a little more anxious to spend time with her boyfriend than he is. Maybe, left to his own devices, he’d call twice a week. But if she calls three times a week, he may never get around to picking up the phone. If their relationship lasts, she may always be the pursuer and he the distancer. Or take the case of two parents, both of whom want their children to behave them- selves at the dinner table. The father has a slightly shorter fuse—he tells them to quiet down five sec- onds after they start getting rowdy, whereas his wife would wait half a minute. If he always speaks up, she may never get a chance. Eventually these par- ents may become polarized into complementary roles of strictness and leniency. What makes such reciprocity resistant to change is that the roles rein- force each other.

It was a short step from observing patients’ reac- tions to other members of a group—some of whom might act like siblings or parents—to observing interactions in real families. Given the wealth of

techniques for exploring interpersonal relationships developed by group therapists, it was natural for some family therapists to apply a group treatment model to families. What is a family, after all, but a group of individuals?

From a technical viewpoint, group and family therapies are similar: Both are complex and dynamic, more like everyday life than individual therapy. In groups and families, patients must react to a number of people, not just a therapist, and therapeutic use of this interaction is the definitive mechanism of change in both contexts.

On closer examination, however, it turns out that the differences between families and groups are so significant that the group therapy model has only limited applicability to family treatment. Family members have a long history and, more importantly, a future together. Revealing yourself to strangers is a lot safer than exposing yourself to members of your own family. There’s no taking back revelations that might better have remained private—the af- fair, long since over, or the admission that a woman cares more about her career than about her husband. Continuity, commitment, and shared distortions all make family therapy very different from group therapy.

Therapy groups are designed to provide an atmo- sphere of warmth and support. This feeling of safety among sympathetic strangers cannot be part of fam- ily therapy, because instead of separating treatment from a stressful environment, the stressful envi- ronment is brought into the consulting room. Fur- thermore, in group therapy, patients can have equal power and status, whereas democratic equality isn’t appropriate in families. Someone has to be in charge. Furthermore, the official patient in a family is likely to feel isolated and stigmatized. After all, he or she is “the problem.” The sense of protection in being part of a compassionate group of strangers, who won’t have to be faced across the dinner table, doesn’t exist in family therapy.

The Child Guidance Movement

It was Freud who introduced the idea that psycholog- ical disorders were the result of unsolved problems of childhood. Alfred Adler was the first of Freud’s

M01_NICH6609_11_SE_C01.indd 11 9/25/15 7:03 PM

12 Part One: The Context of Family Therapy

followers to pursue the implication that treating the growing child might be the most effective way to prevent adult neuroses. To that end, Adler organized child guidance clinics in Vienna, where not only chil- dren but also families and teachers were counseled. Adler offered support and encouragement to help al- leviate children’s feelings of inferiority, so they could work out a healthy lifestyle, achieving confidence and success through social usefulness.

Although child guidance clinics remained few in number until after World War II, they now exist in every city in the United States, providing treatment of childhood problems and the complex forces con- tributing to them. Gradually, child guidance work- ers concluded that the real problem wasn’t a child’s symptoms, but rather the tensions in families that were the source of those symptoms. At first there was a ten- dency to blame the parents, especially the mother.

The chief cause of children’s problems, according to David Levy (1943), was maternal overprotective- ness. Mothers who had themselves been deprived of love became overprotective of their children. Some were domineering, others overindulgent. Children of domineering mothers were submissive at home but had difficulty making friends; children with over indulgent mothers were disobedient at home but well behaved at school.

During this period, Frieda Fromm-Reichmann (1948) coined one of the most damning phrases in the history of psychiatry, the schizophrenogenic mother. These domineering, aggressive, and reject- ing women, especially when married to passive men, were thought to provide the pathological parenting that produced schizophrenia.

The tendency to blame parents, especially moth- ers, for problems in the family was an evolutionary misdirection that continues to haunt the field. Never- theless, by paying attention to what went on between parents and children, Levy and Fromm-Reichmann helped pave the way for family therapy.

John Bowlby’s work at the Tavistock Clinic exem- plified the transition to a family approach. Bowlby (1949) was treating a teenager and making slow prog- ress. Feeling frustrated, he decided to see the boy and his parents together. During the first half of a two-hour session, the child and parents took turns complain- ing about each other. During the second half of the

session, Bowlby interpreted what he thought each of their contributions to the problem were. Eventually, by working together, all three members of the family de- veloped sympathy for each other’s point of view.

Although he was intrigued by this conjoint inter- view, Bowlby remained wedded to the one-to-one format. Family meetings might be a useful catalyst, but only as a supplement to the real treatment, indi- vidual psychotherapy.

What Bowlby tried as an experiment, Nathan Ackerman saw to fruition—family therapy as the pri- mary form of treatment. Once he saw the need to un- derstand the family in order to diagnose problems, Ackerman soon took the next step—family treatment. Before we get to that, however, let us examine compa- rable developments in marriage counseling and research on schizophrenia that led to the birth of family therapy.

Marriage Counseling

For many years there was no apparent need for a sep- arate profession of marriage counselors. People with marital problems talked with their doctors, clergy, lawyers, and teachers. The first centers for mar- riage counseling were established in the 1930s. Paul Popenoe opened the American Institute of Family Relations in Los Angeles, and Abraham and Hannah Stone opened a similar clinic in New York. A third center was the Marriage Council of Philadelphia, be- gun in 1932 by Emily Hartshorne Mudd (Broderick & Schrader, 1981).

At the same time these developments were taking place, a parallel trend among some psychoanalysts led to conjoint marital therapy. Although most an- alysts followed Freud’s prohibition against contact with a patient’s family, a few broke the rules and ex- perimented with therapy for married partners.

In 1948, Bela Mittleman of the New York Psy- choanalytic Institute published the first account of concurrent marital therapy in the United States. Mit- tleman suggested that husbands and wives could be treated by the same analyst, and that by seeing both it was possible to reexamine their irrational percep- tions of each other (Mittleman, 1948). This was a revolutionary notion: that the reality of interpersonal relationships might be at least as important as their intrapsychic representations.

M01_NICH6609_11_SE_C01.indd 12 9/25/15 7:03 PM

Chapter 1 The Evolution of Family Therapy 13

Meanwhile in Great Britain, where object relations were the central concern of psychoanalysts, Henry Dicks and his associates at the Tavistock Clinic 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- cussion Bureau with the Tavistock Clinic, adding that clinic’s prestige to their marital casework and indi- rectly to the field of marriage counseling.

In 1956, Mittleman wrote a more extensive de- scription of marital disorders and their treatment. He described a number of complementary marital pat- terns, including aggressive/submissive and detached/ demanding. These odd matches are made, according to Mittleman, because courting couples see each oth- er’s personalities through the eyes of their illusions: She sees his detachment as strength; he sees her de- pendency as adoration.

At about this time Don Jackson and Jay Haley were exploring marital therapy within the framework of communications analysis. As their ideas gained prominence, the field of marital therapy was absorbed into the larger family therapy movement.

Many writers don’t distinguish between marital and family therapy. Therapy for couples, according to this way of thinking, is just family therapy applied to a particular subsystem. We tend to agree with this per- spective, and therefore you will find our description of various approaches to couples and their problems embedded in discussions of the models considered in this book. There is, however, a case to be made for considering couples therapy a distinct enterprise (Gurman, 2008, 2011).

Historically, many of the influential approaches to couples therapy came before their family therapy counterparts. Among these were cognitive-behavioral marital therapy, object-relations marital therapy, and emotionally-focused couples therapy.

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. Sessions with whole families tend to be noisy affairs. While it’s possible in this context to talk with fam- ily members about their hopes and fears, it isn’t pos- sible to spend much time exploring the psychology of any one individual—much less two. Therapy with

couples, on the other hand, permits greater focus on both dyadic exchanges and the underlying experience of intimate partners.

research on family Dynamics and the etiology of schizophrenia

Families with schizophrenic members proved to be a fertile area for research because their pathological patterns of interaction were so magnified. The fact that family therapy emerged from research on schizo- phrenia led to the hope that family therapy might be the way to cure this baffling form of madness.

Gregory Bateson—Palo Alto

One of the groups with the strongest claim to origi- nating family therapy was Gregory Bateson’s schizo- phrenia project in Palo Alto, California. The Palo Alto project began in the fall of 1952 when Bateson received a grant to study the nature of communica- tion. All communications, Bateson (1951) contended, have two different levels—report and command. Ev- ery message has a stated content, for instance, “Wash your hands; it’s time for dinner,” but in addition, the message carries how it is to be taken. In this case, the second message is that the speaker is in charge. This second message—metacommunication—is covert and often unnoticed. If a wife scolds her husband for running the dishwasher when it’s only half full, and he says OK but turns around and does the same thing two days later, she may be annoyed that he didn’t lis- ten to her. She means the message. But maybe he didn’t like the metamessage. Maybe he doesn’t like her telling him what to do as though she were his

mother.

Watch this video on Gregory Bateson, one of the most influential early family therapy pioneers.

What do you think was his greatest contribution?

www.youtube.com/watch?v= aqihJG2wtpI&index=2&list= pLt10BSjdk4VOrdigJrt8KQaWFvZ2mGKph

M01_NICH6609_11_SE_C01.indd 13 9/25/15 7:03 PM

14 Part One: The Context of Family Therapy

Bateson was joined in 1953 by Jay Haley and John Weakland. In 1954 Bateson received a grant to study schizophrenic communication. Shortly thereafter the group was joined by Don Jackson, a brilliant psychia- trist who served as clinical consultant.

Bateson and his colleagues hypothesized that family stability is achieved by feedback that regulates the be- havior of the family and its members. Whenever a family system is threatened—that is, disturbed—it endeavors to maintain stability, or homeostasis. Thus, apparently puzzling behavior might become understandable if it were seen as a homeostatic mechanism. For example, if whenever two parents argue, one of the children exhibits symptomatic behavior, the symptoms may be a way to stop the fighting by uniting the parents in concern. Thus, symptomatic behavior can serve the cybernetic function of preserving a family’s equilibrium.

In 1956 Bateson and his colleagues published their famous report “Toward a Theory of Schizophrenia,” in which they introduced the concept of the double bind. Patients weren’t crazy in some meaningless way; they were an extension of a crazy family envi- ronment. Consider someone in an important relation- ship in which escape isn’t feasible and response is necessary. If he or she receives two related but con- tradictory messages on different levels but finds it dif- ficult to recognize or comment on the inconsistency (Bateson, Jackson, Haley, & Weakland, 1956), that person is in a double bind.

Because this concept is often misused as a syn- onym for paradox or simply contradiction, it’s worth reviewing each feature of the double bind as the au- thors listed them:

1. Two or more persons in an important relationship

2. Repeated experience

3. A primary negative injunction, such as “Don’t do X or I will punish you”

4. A second injunction at a more abstract level con- flicting with the first, also enforced by punish- ment or perceived threat

5. A tertiary negative injunction prohibiting escape and demanding a response. Without this restric- tion the victim won’t feel bound

6. Finally, the complete set of ingredients is no lon- ger necessary once the victim is conditioned to

perceive the world in terms of double binds; any part of the sequence becomes sufficient to trigger panic or rage

Most examples of double binds in the litera- ture are inadequate because they don’t include all the critical features. Robin Skynner (1976), for in- stance, cited: “Boys must stand up for themselves and not be sissies”; but “Don’t be rough . . . don’t be rude to your mother.” Confusing? Yes. Conflict? Maybe. But these messages don’t constitute a dou- ble bind; they’re merely contradictory. Faced with two such statements, a child is free to obey either one, alternate, or even complain about the contra- diction. This and similar examples neglect the spec- ification that the two messages are conveyed on different levels.

A better example is given in the original article. A young man recovering in the hospital from a schizo- phrenic episode was visited by his mother. When he put his arm around her, she stiffened. But when he withdrew, she asked, “Don’t you love me anymore?” He blushed, and she said, “Dear, you must not be so easily embarrassed and afraid of your feelings.” Fol- lowing this exchange, the patient assaulted an aide and had to be put in seclusion.

Another example of a double bind would be a teacher who urges his students to participate in class but gets impatient if one of them actually interrupts with a question or comment. Then a baffling thing happens. For some strange reason that scientists have yet to decipher, students tend not to speak up in classes where their comments are disparaged. When the professor finally gets around to asking for ques- tions and no one responds, he gets angry. (“Students are so passive!”) If any of the students has the temerity to comment on the professor’s lack of receptivity, he may get even angrier. Thus, the stu- dents will be punished for accurately perceiving that the teacher really wants only his own ideas to be heard and admired. (This example is, of course, purely hypothetical.)

We’re all caught in occasional double binds, but a schizophrenic has to deal with them continually— and the effect is maddening. Unable to comment on the dilemma, the schizophrenic responds defensively, perhaps by being concrete and literal, perhaps by

M01_NICH6609_11_SE_C01.indd 14 9/25/15 7:03 PM

Chapter 1 The Evolution of Family Therapy 15

speaking in metaphors. Eventually the schizophrenic may come to assume that behind every statement lies a concealed meaning.

The discovery that schizophrenic symptoms made sense in the context of some families may have been a scientific advance, but it also had moral and polit- ical overtones. Not only did these investigators see themselves as avenging knights bent on rescuing identified patients by slaying family dragons, but they were also crusaders in a holy war against the psychiatric establishment. Outnumbered and sur- rounded by hostile critics, the champions of family therapy challenged the assumption that schizophrenia was a biological disease. Psychological healers every- where cheered. Unfortunately, they were wrong.

The observation that schizophrenic behavior seems to fit in some families doesn’t mean that families cause schizophrenia. In logic, this kind of inference is called “Jumping to Conclusions.” Sadly, families of schizophrenic members suffered for years under the assumption that they were to blame for the tragedy of their children’s psychoses.

Theodore Lidz—Yale

Theodore Lidz refuted the notion that maternal rejec- tion was the distinguishing feature of schizophrenic families. Frequently the more destructive parent is the father (Lidz, Cornelison, Fleck, & Terry, 1957a). After describing some of the pathological characteristics of fathers in schizophrenic families, Lidz turned his atten- tion to the marital relationship. What he found was an 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 roles, Lidz identified two types of marital discord (Lidz, Cornelison, Fleck, & Terry, 1957b). In the first, marital schism, husbands and wives undermine each other and compete openly for their children’s affec- tion. These marriages are combat zones. The second pattern, marital skew, involves serious character flaws in one partner who dominates the other. Thus one parent becomes passive and dependent while the other appears to be a strong parent figure, but is in fact a pathological bully. In all these families,

Lyman Wynne’s studies linked communication deviance in families to thought disorder in schizophrenic patients.C

ou rt

es y

of S

. H . M

cD an

ie l,

U ni

ve rs

ity o

f Ro

ch es

te r M

ed ic

al C

en te

r

unhappy children are torn by conflicting loyalties and weighed down with the pressure to balance their par- ents’ precarious marriages.

Lyman Wynne—National Institute of Mental Health

Lyman Wynne’s studies of schizophrenic families began in 1954 when he started seeing the parents of hospitalized patients in twice-weekly sessions. What struck Wynne about these families was the strangely unreal qualities of their emotions, which he called pseudomutuality and pseudohostility, and the nature of the boundaries around them—rubber fences— apparently flexible but actually impervious to outside influence (especially from therapists).

Pseudomutuality (Wynne, Ryckoff, Day, & Hirsch, 1958) is a facade of harmony. Pseudomutual families are so committed to togetherness that there’s no room for separate identities. The surface unity of pseudomutual families obscures the fact that they can’t tolerate deeper, more honest relationships, or independence.

Pseudohostility is a different guise for a sim- ilar collusion to stif le autonomy (Wynne, 1961). Although apparently acrimonious, it signals only a superficial split. Pseudohostility is more like the bickering of situation-comedy families than real ani- mosity. Like pseudomutuality, it undermines intimacy and masks deeper conflict, and like pseudomutuality, pseudohostility distorts communication and impairs rational thinking.

M01_NICH6609_11_SE_C01.indd 15 9/25/15 7:03 PM

16 Part One: The Context of Family Therapy

The rubber fence is an invisible barrier that stretches to permit limited extrafamilial contact, such as going to school, but springs back if that involve- ment goes too far. The family’s rigid structure is thus protected by its isolation. Instead of having its eccen- tricities modified in contact with the larger society, the schizophrenic family becomes a sick little society unto itself.

Wynne linked the new concept of communication deviance to the older notion of thought disorder. He saw communication as the vehicle for transmitting thought disorder, the defining feature of schizophre- nia. Communication deviance is a more interactional concept, and more readily observable. By 1978 Wynne had studied over 600 families and gathered in- controvertible evidence that disordered communica- tion is a distinguishing characteristic of families with young adult schizophrenics.

Role Theorists

The founders of family therapy gained momentum for their f ledgling discipline by concentrating on communication. Doing so may have been expedient, but focusing exclusively on this one aspect of family life neglected individual intersubjectivity as well as broader social influences.

Role theorists, like John Spiegel, described how individuals were differentiated into social roles within family systems. This important fact was obscured by simplistic versions of systems theory, in which indi- viduals were treated like interchangeable parts. As early as 1954, Spiegel pointed out that the system in therapy includes the therapist as well as the family (an idea reintroduced later as second-order cybernetics). He also made a valuable distinction between “inter- actions” and “transactions.” Billiard balls interact— they collide but remain essentially unchanged. People transact—they come together in ways that not only alter each other’s course but also bring about internal changes.

R. D. Laing’s analysis of family dynamics was more polemical than scholarly, but his observations helped popularize the family’s role in psychopathology. Laing (1965) borrowed Karl Marx’s concept of mystification (class exploitation) and applied it to the “politics of families.” Mystification means distorting someone’s

experience by denying or relabeling it. An example of this is a parent telling a child who’s feeling sad, “You must be tired” ( Go to bed and leave me alone).

Mystification distorts feelings and, more omi- nously, reality. When parents mystify a child’s ex- perience, the child’s existence becomes inauthentic. Because their feelings aren’t accepted, these children project a false self. In mild instances, this produces a lack of authenticity, but when the real self/false self split is carried to extremes, the result is madness (Laing, 1960).

from research to Treatment: The pioneers of family Therapy

We have seen how family therapy was anticipated by developments in hospital psychiatry, group dynamics, interpersonal psychiatry, the child guidance movement, marriage counseling, and research on schizophrenia. But who actually started family therapy? Although there are rival claims to this honor, the distinction should probably be shared by John Elderkin Bell, Don Jackson, Nathan Ackerman, and Murray Bowen. In addition to these founders of family therapy, Jay Haley, Virginia Satir, Carl Whitaker, Lyman Wynne, Ivan Boszormenyi-Nagy, and Salvador Minuchin were also significant pioneers.

John Bell

John Elderkin Bell, a psychologist at Clark University in Worcester, Massachusetts, who began treating fam- ilies in 1951, occupies a unique position in the history of family therapy. He may have been the first fam- ily therapist, but he is mentioned only tangentially in two of the most important historical accounts of the movement (Guerin, 1976; Kaslow, 1980). The reason for this is that although he began seeing families in the 1950s, he didn’t publish his ideas until a decade later. Moreover, unlike the other parents of family therapy, he had few offspring. He didn’t establish a clinic, develop a training program, or train well- known students.

Bell’s approach (Bell, 1961, 1962) was taken di- rectly from group therapy. Family group therapy

M01_NICH6609_11_SE_C01.indd 16 9/25/15 7:03 PM

Chapter 1 The Evolution of Family Therapy 17

relied primarily on stimulating open discussion to help families solve their problems.

Bell believed that family groups go through pre- dictable phases, as do groups of strangers. In his early work (Bell, 1961), he carefully structured treat- ment in a series of stages. First was a child-centered phase, in which children were encouraged to express their wishes and concerns. In the parent-centered stage, parents typically complained about their chil- dren’s behavior. During this phase, Bell was careful to soften the harshest parental criticisms in order to focus on problem solving. In the final, or family- centered, stage, the therapist equalized support for the entire family while they continued to improve their communication and work out solutions to their prob- lems. The following vignette illustrates Bell’s (1975) style of intervening:

After remaining silent for a few sessions, one father came in with a great tirade against his son, daughter, and wife. I noticed how each individ- ual in his own way, within a few minutes, was withdrawing from the conference. Then I said, “Now I think we should hear what Jim has to say about this, and Nancy should have her say, and perhaps we should also hear what your wife feels about it.” (p. 136)

♦♦ ♦♦ ♦

Three specialized applications of group methods to family treatment were multiple family group therapy, multiple impact therapy, and network therapy.

Peter Laqueur developed multiple family group therapy in 1950 at Creedmoor State Hospital in New York (Laqueur, 1966, 1976). Multiple family group therapy involved four to six families seen together for weekly sessions of ninety minutes. Laqueur and his cotherapists conducted family groups like traditional therapy groups with the addition of encounter-group and psychodrama techniques. Although multiple family therapy lost its most creative force with Peter Laqueur’s untimely death, it is still occasionally used in hospital settings, both inpatient (McFarlane, 1982) and outpatient (Gritzer & Okum, 1983).

Robert MacGregor and his colleagues at the University of Texas Medical Branch in Galveston

developed multiple impact therapy as a way to maximize their impact on families who came from all over Texas (MacGregor, 1967, 1972). Team members met with various combinations of family members and then assembled in a group to make recommenda- tions. Although multiple impact therapy is no longer practiced, its intense but infrequent meetings pre- figured later developments in experiential therapy (Chapter 7) and the Milan model (Chapter 5).

Network therapy was developed by Ross Speck and Carolyn Attneave for assisting families in crisis by assembling their entire social network— family, friends, neighbors—in gatherings of as many as fifty people. Teams of therapists were used, and the emphasis was on breaking destructive patterns of relationship and mobilizing support for new options (Ruevini, 1975; Speck & Attneave, 1973).

Palo Alto

The Bateson group stumbled onto family therapy more or less by accident. Once they began to inter- view schizophrenic families in 1954, hoping to deci- pher their strange patterns of communication, project members found themselves drawn into helping roles by the pain of these unhappy people (Jackson & Weakland, 1961). Although Bateson was the scien- tific leader of the group, Don Jackson and Jay Haley were most influential in developing family treatment.

Jackson rejected the psychodynamic concepts he’d been taught and focused instead on the dynamics of interchange between persons. Analysis of communi- cation was his primary instrument.

Jackson’s concept of family homeostasis— families as units that resist change—was to become the defining metaphor of family therapy’s early years. In hindsight, we can say that the focus on homeo- stasis overestimated the conservative properties of families. At the time, however, the recognition that families resist change was enormously productive for understanding what keeps patients from improving.

In Schizophrenic Symptoms and Family Interac- tion (Jackson & Weakland, 1959), Jackson illustrated how patients’ symptoms preserve stability in their families. In one case, a young woman diagnosed as catatonic schizophrenic had as her most prominent symptom a profound indecisiveness. When she did act

M01_NICH6609_11_SE_C01.indd 17 9/25/15 7:03 PM

18 Part One: The Context of Family Therapy

decisively, her parents fell apart. Her mother became helpless and her father became impotent. In one family meeting, her parents failed to notice when the patient made a simple decision. Only after listening to a taped replay of the session three times did the parents finally hear their daughter’s statement. This woman’s indecision was neither crazy nor sense- less; rather, it protected her parents from facing their own conflicts. This is one of the earliest published examples of how even psychotic symptoms can be meaningful in the family context. This article also contains the shrewd observation that children’s symptoms are often an exaggerated version of their parents’ problems.

Another construct important to Jackson’s thinking was the distinction between complementary and sym- metrical relationships. (Like so many of the seminal ideas of family therapy, this one was first articulated by Bateson.) Complementary relationships are those in which partners are different in ways that fit together, like pieces of a jigsaw puzzle: If one is logi- cal, the other is emotional; if one is weak, the other is strong. Symmetrical relationships are based on sim- ilarity. Marriages between two people who both have careers and share housekeeping chores are symmet- rical. (Incidentally, if you actually find a couple who shares responsibilities equally, you’ll know you’re not in Kansas, Dorothy!)

Jackson’s (1965) family rules hypothesis was based on the observation that within any committed unit (dyad, triad, or larger group), there are redun- dant behavior patterns. Rules (as students of philos- ophy learn when studying determinism) can describe

Don Jackson described problematic patterns of communication in ways that are still useful.C

ou rt

es y

of D

on J

ac ks

on

regularity, rather than regulation. A corollary of the rules hypothesis is that family members use only a fraction of the full range of behavior available to them. This seemingly innocent fact is what makes family therapy so useful.

Jackson’s therapeutic strategies were based on the premise that psychiatric problems resulted from the way people behave with each other. In order to dis- tinguish functional interactions from those that were dysfunctional (problem maintaining), he observed when problems occurred and in what context, who was present, and how people responded to the prob- lem. Given the assumption that symptoms are homeo- static mechanisms, Jackson would wonder out loud how a family might be worse off if the problem got solved. An individual might want to get better, but the family may need someone to play the sick role. Even positive change can be a threat to the defensive order of things.

A father’s drinking, for example, might keep him from making demands on his wife or disciplining his children. Unfortunately, some family therapists jumped from the observation that symptoms may serve a purpose to the assumption that some families need a sick member, which, in turn, led to a view of parents victimizing scapegoated children. Despite the fancy language, this was part of the time-honored tradition of blaming parents for the failings of their children. If a six-year-old misbehaves around the house, perhaps we should look to his parents. But a husband’s drink- ing isn’t necessarily his wife’s fault; and it certainly wasn’t fair to imply that parents were responsible for the schizophrenic symptoms of their children.

♦♦ ♦♦ ♦

The great discovery of the Bateson group was that there’s no such thing as a simple communication; ev- ery message is qualified by a different message on another level. In Strategies of Psychotherapy, Jay Haley (1963) explored how covert messages are used in the struggle for control that characterizes many relationships. Symptoms, he argued, represent an in- congruence between levels of communication. The symptomatic person does something, such as touch- ing a doorknob six times before turning it, while at the same time denying that he’s really doing it. He

M01_NICH6609_11_SE_C01.indd 18 9/25/15 7:03 PM

Chapter 1 The Evolution of Family Therapy 19

can’t help it; it’s his illness. Meanwhile, the person’s symptoms—over which he has no control—have con- sequences. A person who has a compulsion of such proportions can hardly be expected to hold down a job, can he?

Since symptomatic behavior wasn’t reasonable, Haley didn’t try to reason with patients to help them. Instead, therapy became a strategic game of cat and mouse.

Haley (1963) defined therapy as a directive form of treatment and acknowledged his debt to Milton Erickson, with whom he studied hypnosis. In what he called brief therapy, Haley zeroed in on the context and possible function of a patient’s symptoms. His first moves were designed to gain control of the ther- apeutic relationship. Haley cited Erickson’s device of advising patients that in the first interview there will be things they may be willing to say and other things they’ll want to withhold, and that these, of course, should be withheld. Here, of course, the therapist is directing patients to do precisely what they would do anyway and thus subtly gaining the upper hand.

The decisive techniques in brief therapy were directives. As Haley put it, it isn’t enough to explain problems to patients; what counts is getting them to do something about them.

One of Haley’s patients was a freelance photog- rapher who compulsively made silly blunders that ruined every picture. Eventually he became so pre- occupied with avoiding mistakes that he was too nervous to take pictures at all. Haley instructed the man to go out and take three pictures, making one de- liberate error in each. The paradox here is that you can’t accidentally make a mistake if you are doing so deliberately.

In another case, Haley told an insomniac that if he woke up in the middle of the night he should get out of bed and wax the kitchen floor. Instant cure! The cybernetic principle here: People will do anything to get out of housework.

Another member of the Palo Alto group who played a leading role in family therapy’s first decade was Virginia Satir, one of the great charismatic heal- ers. Known more for her clinical artistry than for the- oretical contributions, Satir’s impact was most vivid to those lucky enough to see her in action. Like her confreres, Satir was interested in communication, but

she added an emotional dimension that helped coun- terbalance what was otherwise a relatively cool and calculated approach.

Satir saw troubled family members as trapped in narrow roles, such as victim, placator, defiant one, or rescuer, that limited options and sapped self-esteem. Her concern with freeing family members from the grip of such life-constricting roles was consistent with her major focus, which was always on the in- dividual. Thus, Satir was a humanizing force in the early days of family therapy, when others were so en- amored of the systems metaphor that they neglected the emotional life of families.

Satir was justly famous for her ability to turn nega- tives into positives. In one case, cited by Lynn Hoffman (1981), Satir interviewed the family of a local min- ister, whose teenage son had gotten two of his class- mates pregnant. On one side of the room sat the boy’s parents and siblings. The boy sat in the opposite cor- ner with his head down. Satir introduced herself and said to the boy, “Well, your father has told me a lot about the situation on the phone, and I just want to say before we begin that we know one thing for sure: We know you have good seed.” The boy looked up in amazement as Satir turned to the boy’s mother and asked brightly, “Could you start by telling us your perception?”

Murray Bowen

Like many of the founders of family therapy, Murray Bowen was a psychiatrist who specialized in schizo- phrenia. Unlike others, however, he emphasized the- ory, and to this day Bowen’s theory is the most fertile system of ideas in family therapy.

Bowen began his clinical work at the Menninger Clinic in 1946, where he studied mothers and their schizophrenic children. His major interest at the time was mother–child symbiosis, which led to his concept of differentiation of self (autonomy and levelhead- edness). From Menninger, Bowen moved to NIMH, where he developed a program to hospitalize whole families with schizophrenic members. This project expanded the focus on mother–child symbiosis to include the role of fathers and led to the concept of triangles (diverting conflict between two people by involving a third).

M01_NICH6609_11_SE_C01.indd 19 9/25/15 7:03 PM

20 Part One: The Context of Family Therapy

Beginning in 1955, when Bowen started bringing family members together to discuss their problems, he was struck by their emotional reactivity. Feelings overwhelmed reason. Bowen felt families’ tendency to pull him into the center of this undifferentiated family ego mass, and he had to make a concerted ef- fort to remain objective (Bowen, 1961). The ability to remain neutral and focus on the process, rather than content, of family discussions is what distinguishes a therapist from a participant in a family’s drama.

To control the level of emotion, Bowen encour- aged family members to talk to him, not to each other. He found that it was easier for family members to avoid becoming reactive when they spoke to the ther- apist instead of to each other.

Bowen discovered that therapists weren’t immune to being sucked into family conflicts. This awareness led to his greatest insight: Whenever two people are struggling with conflict they can’t resolve, there is an automatic tendency to involve a third party. In fact, as Bowen came to believe, a triangle is the smallest stable unit of relationship.

A husband who can’t stand his wife’s habitual lateness but is afraid to say so may start complaining to his children. His complaining may let off steam, but the very process of complaining to a third party makes him less likely to address the problem at its source. We all complain about other people from time to time, but what Bowen realized was that this trian- gling process is destructive when it becomes a regular feature of a relationship.

Another thing Bowen discovered about triangles is that they spread out. In the following case, a family became entangled in a whole labyrinth of triangles.

Case sTuDy One Sunday morning “Mrs. McNeil,” who was anx- ious to get the family to church on time, yelled at her nine-year-old son to hurry up. When he told her to “quit bitching,” she slapped him. At that point her fourteen-year-old daughter, Megan, grabbed her, and the two of them started wrestling. Then Megan ran next door to her friend’s house. When the friend’s parents noticed that she had a cut lip and Megan told them what had happened, they called the police.

One thing led to another, and by the time the family came to therapy, the following triangles were in place: Mrs. McNeil, who’d been ordered out of the house by the family court judge, was allied with her lawyer against the judge; she also had an individual therapist who joined her in thinking she was being harassed by the child-protective work- ers. The nine-year-old was still mad at his mother, and his father supported him in blaming her for fly- ing off the handle. Mr. McNeil, who was a recover- ing alcoholic, formed an alliance with his sponsor, who felt that Mr. McNeil was on his way to a break- down unless his wife started being more supportive. Meanwhile Megan had formed a triangle with the neighbors, who thought her parents shouldn’t be allowed to have children. In short, everyone had an advocate—everyone, that is, except the family unit.

In 1966 an emotional crisis in Bowen’s family led to a personal voyage of discovery that turned out to be as significant for Bowen’s theory as Freud’s self-analysis was for psychoanalysis.

As an adult, Bowen, the oldest of five children from a tightly knit rural family, kept his distance from his parents and the rest of his extended family. Like many of us, he mistook avoidance for emancipation. But as he later realized, unfinished emotional busi- ness stays with us, making us vulnerable to repeat conflicts we never worked out with our families.

Bowen’s most important achievement was detri- angling himself from his parents, who’d been accus- tomed to complaining to him about each other. Most of us are flattered to receive such confidences, but Bowen came to recognize this triangulation for what it was. When his mother complained about his father, he told his father: “Your wife told me a story about you; I wonder why she told me instead of you.” Nat- urally, his father mentioned this to his mother, and, naturally, she was not pleased.

Although his efforts generated the kind of emo- tional upheaval that comes of breaking family rules, Bowen’s maneuver was effective in keeping his par- ents from trying to get him to take sides—and made it harder for them to avoid discussing things between themselves. Repeating what someone says to you about someone else is one way to stop triangling in its tracks.

M01_NICH6609_11_SE_C01.indd 20 9/25/15 7:03 PM

Chapter 1 The Evolution of Family Therapy 21

Through his efforts in his own family Bowen discovered that differentiation of self is best accom- plished by developing personal relationships with as many members of the family as possible. If visiting is difficult, letters and phone calls can help reestab- lish relationships, particularly if they’re personal and intimate. Differentiating one’s self from the family is completed when these relationships are maintained without becoming emotionally reactive or taking part in triangles.

Nathan Ackerman

Nathan Ackerman was a child psychiatrist whose pioneering work with families remained faithful to his psychoanalytic roots. Although his interest in intrapsychic conflict may have seemed less innova- tive than the Palo Alto group’s communications the- ory, he had a keen sense of the overall organization of families. Families, Ackerman said, may give the appearance of unity, but underneath they are split into competing factions. This you may recognize as similar to the psychoanalytic model of individuals, who, despite apparent unity of personality, are actu- ally minds in conflict, driven by warring drives and defenses.

Ackerman joined the staff at the Menninger Clinic and in 1937 became chief psychiatrist of the Child Guidance Clinic. At first he followed the child guid- ance model of having a psychiatrist treat the child and a social worker see the mother. But by the mid-1940s, he began to experiment with having the same thera- pist see both. Unlike Bowlby, Ackerman did more than use these conjoint sessions as a temporary expe- dient; instead, he began to see the family as the basic unit of treatment.

In 1955 Ackerman organized the first session on family diagnosis at a meeting of the American Orthopsychiatric Association. At that meeting, Jackson, Bowen, Wynne, and Ackerman learned about each other’s work and joined in a sense of common purpose. Two years later Ackerman opened the Fam- ily Mental Health Clinic of Jewish Family Services in New York City and began teaching at Columbia University. In 1960 he founded the Family Institute, which was renamed the Ackerman Institute following his death in 1971.

Although other family therapists downplayed the psychology of individuals, Ackerman was as con- cerned with what goes on inside people as with what goes on between them. He never lost sight of feelings, hopes, and desires. In fact, Ackerman’s model of the family was like the psychoanalytic model of individ- uals writ large; instead of conscious and unconscious issues, Ackerman talked about how families con- front some issues while avoiding others, particularly those involving sex and aggression. He saw his job as bringing family secrets into the open.

To encourage families to relax their emotional restraint, Ackerman himself was unrestrained. He sided first with one member of a family and later with an- other. He didn’t think it was necessary—or possible— to always be neutral; instead, he believed that bal- ance was achieved in the long run by moving back and forth, giving support now to one, later to another family member. At times he was unabashedly blunt. If he thought someone was lying, he said so. To crit- ics who suggested this directness might generate too much anxiety, Ackerman replied that people get more reassurance from honesty than from false politeness.

Carl Whitaker

Even among the iconoclastic founders of family ther- apy, Carl Whitaker stood out as the most irreverent. His view of psychologically troubled people was that they were alienated from feeling and frozen into devitalized routines (Whitaker & Malone, 1953). Whitaker turned up the heat. His “Psychotherapy of the Absurd” (Whitaker, 1975) was a blend of warm support and emotional goading, designed to loosen people up and help them get in touch with their expe- rience in a deeper, more personal way.

Given his inventive approach to individual ther- apy, it wasn’t surprising that Whitaker became one of the first to experiment with family treatment. In 1943 he and John Warkentin, working in Oak Ridge, Tennessee, began to include spouses and eventu- ally children in treatment. Whitaker also pioneered the use of cotherapy, in the belief that a supportive partner helped free therapists to react without fear of countertransference.

Whitaker never seemed to have an obvious strat- egy, nor did he use predictable techniques, preferring,

M01_NICH6609_11_SE_C01.indd 21 9/25/15 7:03 PM

22 Part One: The Context of Family Therapy

as he said, to let his unconscious run the therapy (Whitaker, 1976). Although his work seemed totally spontaneous, even outrageous at times, there was a consistent theme. All of his interventions promoted flexibility. He didn’t so much push families to change in a particular direction as he challenged them to open up—to become more fully themselves and more fully together.

In 1946 Whitaker became chairman of the depart- ment of psychiatry at Emory University, where he continued to experiment with family treatment with a special interest in schizophrenics and their families. During this period Whitaker organized a series of fo- rums that eventually led to the first major convention of the family therapy movement. Beginning in 1946 Whitaker and his colleagues began twice-yearly con- ferences during which they observed and discussed each other’s work with families. The group found these sessions enormously helpful, and mutual obser- vation, using one-way vision screens, became one of the hallmarks of family therapy.

Whitaker resigned from Emory in 1955 and en- tered private practice, where he and his partners at the Atlanta Psychiatric Clinic developed an experiential form of psychotherapy, using a number of provoca- tive techniques in the treatment of families, individu- als, groups, and couples (Whitaker, 1958).

During the late 1970s Whitaker seemed to mel- low and added a greater understanding of family dynamics to his shoot-from-the-hip interventions. In the process, the former wild man of family therapy became one of its elder statesmen. Whitaker’s death in April 1995 left the field with a piece of its heart missing.

Ivan Boszormenyi-Nagy

Ivan Boszormenyi-Nagy, who came to family ther- apy from psychoanalysis, was one of the seminal thinkers in the movement. In 1957 he founded the Eastern Pennsylvania Psychiatric Institute in Phila- delphia, where he attracted a host of highly talented colleagues. Among these were James Framo, one of the few psychologists in the early family therapy movement, and Geraldine Spark, a social worker who collaborated with Boszormenyi-Nagy on Invisible Loyalties (Boszormenyi-Nagy & Spark, 1973).

Boszormenyi-Nagy went from being an analyst, prizing confidentiality, to a family therapist, ded- icated to openness. One of his most important con- tributions was to add ethical accountability to the usual therapeutic goals and techniques. According to Boszormenyi-Nagy, neither pleasure nor expediency is a sufficient guide to human behavior. Instead, he believed that family members have to base their rela- tionships on trust and loyalty and that they must bal- ance the ledger of entitlement and indebtedness. He died in 2008.

Salvador Minuchin

When Minuchin first burst onto the scene, it was the drama of his clinical interviews that captivated people. This compelling man with the elegant Latin accent would seduce, provoke, bully, or bewilder families into changing—as the situation required. But even Minuchin’s legendary flair didn’t have the same galvanizing impact as the elegant simplicity of his structural model.

Minuchin began his career as a family therapist in the early 1960s when he discovered two patterns common to troubled families: Some are enmeshed— chaotic and tightly interconnected; others are disengaged—isolated and emotionally detached. Both lack clear lines of authority. Enmeshed parents are too close to their children to exercise leadership; disengaged parents are too distant to provide effec- tive support.

Family problems are tenacious and resistant to change because they’re embedded in powerful but unseen structures. Take, for example, a mother fu- tilely remonstrating with a willful child. The mother can scold, punish, or reward, but as long as she’s en- meshed (overly involved) with the child, her efforts will lack force because she lacks authority. More- over, because the behavior of one family member is always related to that of others, the mother will have trouble stepping back as long as her husband remains uninvolved.

Once a social system such as a family becomes structured, attempts to change the rules constitute what family therapists call first-order change— change within a system that itself remains invari- ant. For the mother in the previous example to start

M01_NICH6609_11_SE_C01.indd 22 9/25/15 7:03 PM

Chapter 1 The Evolution of Family Therapy 23

practicing stricter discipline would be first-order change. The enmeshed mother is caught in an illusion of alternatives. She can be strict or lenient; the result is the same because she remains trapped in a triangle. What’s needed is second-order change—a reorgani- zation of the system itself.

Minuchin worked out his ideas while struggling with the problems of juvenile delinquency at the Wil- twyck School for Boys in New York. Family therapy with urban slum families was a new development, and publication of his discoveries (Minuchin, Mon- talvo, Guerney, Rosman, & Schumer, 1967) led to his becoming the director of the Philadelphia Child Guidance Clinic in 1965. Minuchin brought Braulio Montalvo and Bernice Rosman with him, and they were joined in 1967 by Jay Haley. Together they trans- formed a traditional child guidance clinic into one of the great centers of the family therapy movement.

In 1981 Minuchin moved to New York and es- tablished what is now known as the Minuchin Cen- ter for the Family, where he taught family therapists from all over the world. He also continued to turn out a steady stream of the most influential books in the field. His 1974 Families and Family Therapy is deservedly the most popular book in the history of family therapy, and his 1993 Family Healing con- tains some of the most moving descriptions of family therapy ever written.

Other Early Centers of Family Therapy

In New York, Israel Zwerling and Marilyn Mendel- sohn organized the Family Studies Section at Albert Einstein College of Medicine and Bronx State Hos- pital. Andrew Ferber was named director in 1964, and later Philip Guerin, a protégéof Murray Bow- en’s, joined the section. Nathan Ackerman served as a consultant, and the group assembled an impressive array of family therapists with diverse orientations. These included Chris Beels, Betty Carter, Mon- ica McGoldrick, Peggy Papp, and Thomas Fogarty. Philip Guerin became director of training in 1970 and shortly thereafter founded the Center for Family Learning in Westchester, where he and Thomas Foga- rty developed one of the finest family therapy training programs in the nation.

As we mentioned previously, Robert MacGregor and his colleagues in Galveston, Texas developed multiple impact therapy (MacGregor, 1967). It was a case of necessity being the mother of invention. MacGregor’s clinic served a population scattered widely over southeastern Texas, and many of his cli- ents had to travel hundreds of miles. Therefore, to have maximum impact in a short time, MacGregor assembled a team of professionals who worked inten- sively with the families for two full days. Although few family therapists have used such marathon ses- sions, the team approach continues to be one of the hallmarks of the field.

In Boston the two most significant early contribu- tions to family therapy were both in the experiential wing of the movement. Norman Paul developed an operational mourning approach designed to resolve impacted grief, and Fred and Bunny Duhl set up the Boston Family Institute, where they developed integrative family therapy.

In Chicago, the Family Institute of Chicago and the Institute for Juvenile Research were important centers of the early scene in family therapy. At the Family Institute, Charles and Jan Kramer developed a clinical training program, which was later affili- ated with Northwestern University Medical School. The Institute for Juvenile Research also mounted a training program under the leadership of Irv Borstein, with the consultation of Carl Whitaker.

The work of Nathan Epstein and his colleagues, first formulated in the department of psychiatry at McMaster University in Hamilton, Ontario, was a problem-centered approach (Epstein, Bishop, & Baldarin, 1981). The McMaster model goes step by step—elucidating the problem, gathering data, con- sidering alternatives for resolution, and assessing the learning process—to help families understand their own interactions and build on their newly acquired coping skills. Epstein later relocated to Brown Uni- versity in Rhode Island.

Important developments in family therapy also occurred outside the United States: Robin Skynner (1976) introduced psychodynamic family therapy at the Institute of Family Therapy in London; British psychiatrist John Howells (1971) developed a system of family diagnosis as a necessary step for planning therapeutic intervention; and West German Helm

M01_NICH6609_11_SE_C01.indd 23 9/25/15 7:03 PM

24 Part One: The Context of Family Therapy

Stierlin (1972) integrated psychodynamic and sys- temic ideas in treating troubled adolescents. In Rome, Maurizio Andolfi worked with families early in the 1970s and established a training clinic that continues to accept clients and students today. In 1974 Andolfi also founded the Italian Society for Family Therapy; in Milan Mara Selvini Palazzoli and her colleagues founded the Institute for Family Studies in 1967.

♦♦ ♦♦ ♦

Now that you’ve seen how family therapy emerged in several different places at once, we hope you ha- ven’t lost sight of one thing: There is a tremendous satisfaction in seeing how people’s behavior makes sense in the context of their families. Meeting with a family for the first time is like turning on a light in a dark room.

The Golden age of family Therapy

In their first decade, family therapists had all the bra- vado of new kids on the block. “Look at this!” Haley and Jackson and Bowen seemed to say when they discovered how the whole family was implicated in the symptoms of individual patients. While they were struggling for legitimacy, family clinicians em- phasized their common beliefs and downplayed their differences. Troubles, they agreed, came in families. But if the watchword of the 1960s was “Look at this”—emphasizing the leap of understanding made possible by seeing whole families together—the ral- lying cry of the 1970s was “Look what I can do!” as the new kids flexed their muscles and carved out their own turf.

The period from 1970 to 1985 saw the flowering of the classic schools of family therapy as the pio- neers established training centers and worked out the implications of their models. The leading approach to family therapy in the 1960s was the communica- tions model developed in Palo Alto. The book of the decade was Pragmatics of Human Communication, the text that introduced the systemic version of fam- ily therapy. The model of the 1980s was strategic

therapy, and the books of the decade described its three most vital approaches: Change by Watzlawick, Weakland, and Fisch1; Problem-Solving Therapy by Jay Haley; and Paradox and Counterparadox by Mara Selvini Palazzoli and her Milan associates. The 1970s belonged to Salvador Minuchin. His Families and Family Therapy and the simple yet compelling model of structural family therapy it described domi- nated the decade.

Structural theory seemed to offer just what fam- ily therapists were looking for: a straightforward way of describing family organization and a set of easy- to-follow steps to treatment. In hindsight we might ask whether the impressive power of Minuchin’s approach was a product of the method or the man. (The answer is, probably a little of both.) But in the 1970s the widely shared belief that structural family therapy could be easily learned drew people from all over the world to what was then the epicenter of the family therapy movement: the Philadelphia Child Guidance Clinic.

The strategic therapy that flourished in the 1980s was centered in three unique and creative groups: MRI’s brief therapy group, including John Weak- land, Paul Watzlawick, and Richard Fisch; Jay Haley and Cloe Madanes in Washington, DC; and Mara Selvini Palazzoli and her colleagues in Milan. But the leading influence on the decade of strategic ther- apy was exerted by Milton Erickson, albeit from beyond the grave.

Erickson’s genius was much admired and much imitated. Family therapists came to idolize Erick- son the way we as children idolized Captain Marvel. We’d come home from Saturday matinees all pumped up, get out our toy swords, put on our magic capes— and presto! We were superheroes. We were just kids and so we didn’t bother translating our heroes’ mythic powers into our own terms. Unfortunately, many of those starstruck by Erickson’s legendary therapeutic tales did the same thing. Instead of grasping the prin- ciples on which they were predicated, many thera- pists just tried to imitate his “uncommon techniques.” To be any kind of competent therapist, you must keep your psychological distance from the supreme

1Although actually published in 1974, this book and its sequel, The Tactics of Change, were most widely read in the 1980s.

M01_NICH6609_11_SE_C01.indd 24 9/25/15 7:03 PM

Chapter 1 The Evolution of Family Therapy 25

artists—the Minuchins, the Milton Ericksons, the Michael Whites. Otherwise you end up aping the magic of their styles, rather than grasping the substance of their ideas.

Part of what made Haley’s strategic directives so attractive was that they were a wonderful way to gain control over people—for their own good—without the usual frustration of trying to convince them to do the right thing. (Most people know what’s good for them. The hard part is getting them to do it.) So, for example, in the case of a person who is bulimic, a strategic directive might be for the patient’s family to set out a mess of fried chicken, french fries, cookies, and ice cream. Then, with the family watching, the patient would mash up all the food with her hands, symbolizing what goes on in her stomach. After the food was reduced to a soggy mess, she would stuff it into the toilet. Then when the toilet clogged, she would have to ask the family member she resented most to unclog it. This task would symbolize not only what the person with bulimia does to herself but also what she puts the family through (Madanes, 1981).

What the strategic camp added to Erickson’s cre- ative approach to problem solving was a simple framework for understanding how families got stuck in their problems. According to the MRI model, prob- lems develop from mismanagement of ordinary life difficulties. The original difficulty becomes a prob- lem when mishandling leads people to get stuck in more-of-the-same solutions. It was a perverse twist on the old adage, “If at first you don’t succeed, try, try again.”

The Milan group built on the ideas pioneered at MRI, especially the use of the therapeutic double bind, or what they referred to as counterparadox. Here’s an example from Paradox and Counterparadox (Selvini Palazzoli, Boscolo, Cecchin, & Prata, 1978). The au- thors describe a counterparadoxical approach to a six- year-old boy and his family. At the end of the session, young Bruno was praised for acting crazy to protect his father. By occupying his mother’s time with fights and tantrums, the boy generously allowed his father more time for work and relaxation. Bruno was encour- aged to continue doing what he was already doing, lest this comfortable arrangement be disrupted.

The appeal of the strategic approach was pragma- tism. Making use of the cybernetic metaphor, strategic

therapists zeroed in on how family systems were reg- ulated by negative feedback. They achieved results simply by disrupting the interactions that maintained symptoms. What eventually turned therapists off to these approaches was their gamesmanship. Their in- terventions were transparently manipulative. The re- sult was like watching a clumsy magician—you could see him stacking the deck.

Meanwhile, as structural and strategic approaches rose and fell in popularity, four other models of fam- ily therapy f lourished quietly. Though they never took center stage, experiential, psychoanalytic, be- havioral, and Bowenian models grew and prospered. Although these schools never achieved the cachet of family therapy’s latest fads, each of them produced solid clinical approaches, which will be examined at length in subsequent chapters.

summary

For many years therapists resisted the idea of seeing patients’ families in order to safeguard the privacy of the therapeutic relationship. Freudians excluded the real family to uncover the unconscious, introjected family; Rogerians kept the family away to provide unconditional positive regard; and hospital psychi- atrists discouraged family visits lest they disrupt the benign milieu of the hospital.

Several converging developments in the 1950s led to a new view—namely, that the family was an organic whole. Although clinicians in hospitals and child guidance clinics prepared the way for fam- ily therapy, the most important breakthroughs were achieved in the 1950s by people who were scientists first, healers second. In Palo Alto, Gregory Bateson, Jay Haley, and Don Jackson discovered that schizo- phrenia made sense in the context of pathological family communication. Schizophrenics weren’t crazy in some meaningless way; their behavior made sense in their families. Murray Bowen’s observation of how mothers and their schizophrenic offspring go through cycles of closeness and distances was the forerunner of the pursuer–distancer dynamic.

These observations launched the family therapy movement, but the excitement they generated blurred

M01_NICH6609_11_SE_C01.indd 25 9/25/15 7:03 PM

26 Part One: The Context of Family Therapy

the distinction between what researchers observed and what they concluded. What they observed was that the behavior of schizophrenics fit with their fam- ilies; what they concluded was that the family was the cause of schizophrenia. A second conclusion was even more inf luential. Family dynamics—double binds, pseudomutuality, undifferentiated family ego mass—began to be seen as products of a system, rather than features of persons who share certain qualities because they live together. Thus was born a new creature, the family system.

Who was the first to practice family therapy? This turns out to be a difficult question. As in ev- ery field, there were visionaries who anticipated the development of family therapy. Freud, for example, treated “Little Hans” by working with his father as early as 1909. Such experiments weren’t, however, sufficient to challenge the authority of individual therapy until the climate of the times was receptive. In the early 1950s family therapy was begun inde- pendently in four different places: by John Bell at Clark University, Murray Bowen at NIMH, Nathan Ackerman in New York, and Don Jackson and Jay Haley in Palo Alto.

These pioneers had distinctly different back- grounds. Not surprisingly, the approaches they de- veloped were also quite different. This diversity still characterizes the field today. In addition to those just mentioned, others who made significant contributions to the founding of family therapy were Virginia Satir, Carl Whitaker, Ivan Boszormenyi-Nagy, and Salva- dor Minuchin.

What we’ve called family therapy’s golden age—the flowering of the schools in the 1970s and 1980s—was the high-water mark of our self-con- fidence. Armed with Haley’s or Minuchin’s latest text, therapists set off with a sense of mission. What drew them to activist approaches was certainty and charisma. What soured them was hubris. To some, structural family therapy—at least as they saw it demonstrated at workshops—looked like bullying. Others saw the cleverness of the strategic approach as manipulative. Families were described as stub- born; they couldn’t be reasoned with. Therapists got tired of that way of thinking.

In the early years, family therapists were animated by confidence and conviction. Today, in the wake of

Click here to apply your knowledge of chapter concepts.

Click here to test your application and analysis of the content found within this chapter.

managed care and biological psychiatry, we’re less sure of ourselves.

Although we may be less cocky, we are certainly more effective (Sexton & Datachi, 2014). While the early years were dominated by creative ideas (e.g., Haley, 1962), the field today focuses more on ef- fective interventions (e.g., Nichols & Tafuri, 2013). Much has been learned about families and family systems. Methods have been refined (Minuchin, Re- iter, & Borda, 2014). What has emerged is “a more participatory, more culturally and gender sensitive, and more collaborative set of methods that builds on a set of common factors with a stronger evidence base” (Lebow, 2014, p. 368).

In subsequent chapters we’ll see how today’s fam- ily therapists have managed to synthesize creative new ideas with some of the best of the earlier mod- els. But as we explore each of the famous models in depth, we’ll also see how some good ideas have been unwisely neglected.

All the complexity of the family therapy field should not obscure its basic premise: The family is the context of human problems. Like all human groups, the family has emergent properties—the whole is greater than the sum of its parts. Moreover, no matter how many and varied the explanations of these emergent properties are, they all fall into two categories: struc- ture and process. The structure of families includes triangles, subsystems, and boundaries. Among the processes that describe family interaction—emotional reactivity, dysfunctional communication, and so on— the central concept is circularity. Rather than wor- rying about who started what, family therapists treat human problems as a series of moves and counter- moves in repeating cycles.

M01_NICH6609_11_SE_C01.indd 26 9/25/15 7:03 PM

27

c h a p t e r 2

Basic Techniques of family Therapy From Symptom to System

Learning OutcOmes ♦♦ Discuss and demonstrate the basic skills

required for the initial client contact and interview, the early and middle phases of treatment, and termination.

♦♦ Describe the basic issues for which to assess when working with families, and summarize techniques for doing so.

♦♦ Discuss the basic ethical responsibilities of family therapy.

♦♦ Describe principles guiding work with marital violence and the sexual abuse of children.

♦♦ Describe the basics of working with managed care and establishing a private practice.

Getting started

The Initial Telephone Call

The goal of the initial contact is to get an overview of the presenting problem and arrange for the family to come for a consultation. Listen to the caller’s descrip- tion of the problem and identify all members of the household as well as others who might be involved (including the referral source and other agencies). Although the initial phone call should be brief, it’s important to establish a connection with the caller as a basis for engagement. Then schedule the first inter- view, specifying who should attend (usually everyone in the household) and the time and place.

While there are things you can say to encourage the whole family to attend, the most important con- sideration is attitudinal. First, understand and respect that the worried mother who wants you to treat her child individually or the unhappy husband who wants to talk to you alone has a perfectly legitimate point of view, even if it doesn’t happen to coincide with your own. But if you expect to meet with the entire fam- ily, at least for an initial assessment, a matter-of-fact statement that that’s how you work will get most fam- ilies to agree to a consultation.

When the caller presents the problem as limited to one person, a useful way to broaden the focus is to ask how the problem is affecting other members of the family. If the caller balks at the idea of bringing in the family or says that a particular member won’t attend, say that you’ll need to hear from everyone, at least initially, in order to get as much information as possible. Most people accept the need to give their point of view; what they resist is the implication that they’re to blame.1

27

1Not all therapists routinely meet with the whole family. Some find that they have more room to maneuver by meeting first with individuals or subgroups and then gradually involving others. Others attempt to work with the problem-determined system, only those people directly involved. Still others try to determine who are the “customers,” those who seem most con- cerned. The point to remember is that family therapy is more a way of looking at things than a technique that always requires seeing the entire family together.

M02_NICH6609_11_SE_C02.indd 27 9/25/15 7:09 PM

28 Part One: The Context of Family Therapy

Finally, because most families are reluctant to sit down and face their conflicts, a reminder call before the first session helps cut down on the no-show rate.

The First Interview

The goal of the first interview is to build an alliance with the family and develop a hypothesis about what’s maintaining the presenting problem. It’s a good idea to come up with a tentative hypothesis (in technical terms, a hunch) after the initial phone call and then test it in the first interview. (Remain open to refuting, not just con- firming, your initial hypothesis.) The point isn’t to jump to conclusions but to start actively thinking.

The primary objectives of a consultation are to establish rapport and gather information. Introduce yourself to the contact person and then to the other adults. Ask parents to introduce their children. Shake hands and greet everyone. Orient the family to the room (observation mirrors, videotaping, toys for chil- dren) and to the format of the session (length and purpose). Repeat briefly what the caller told you over the phone (so as not to leave others wondering), and then ask for elaboration. Once you’ve acknowledged that person’s point of view (“So what you’re saying is . . .?), ask the other members of the family for their viewpoints.

One of the things beginning therapists worry about is that bringing in the whole family may lead to a shouting match that will escalate out of control. The

antidote to arguing is insisting that family members speak one at a time. Giving everyone a chance to talk and be heard is a good idea in every case; with emo- tionally reactive families, it’s imperative.

Most families are anxious and uncertain about therapy. They’re not sure what to expect, and they may be uncomfortable discussing their concerns in front of the whole family. And above all, most people are afraid that someone is going to blame them or ex- pect them to change in ways they aren’t prepared to. For these reasons, it’s important to establish a bond of sympathy and understanding with every member of the family.

A useful question to ask each person is, “How did you feel about coming in?” This helps establish the therapist as someone willing to listen. If, for example, a child says “I didn’t want to come” or “I think it’s stupid,” you can say “Thanks for being honest.”

While most of the first session should be taken up with a discussion of the presenting problem, this problem-centered focus can have a disheartening effect. Spending some time exploring family mem- bers’ interests and accomplishments is never wasted and sometimes dramatically changes the emotional energy of sessions. People need to be seen as more than just problems (the distant father, the rebellious teenager); they need to be seen as three-dimensional human beings.

Bringing in the whole family means including young children. The presence of the children allows you to see how their parents relate to them. Are the parents able to get the children to play quietly in the corner if you ask them to? Do they overmanage mi- nor squabbles between siblings? Do both parents in- teract with the children or only the mother? Children of about five and under should be provided with toys. The inhibited child who is fearful of the family’s dis- approval will sit quietly on a chair and may be afraid to play. The aggressive child will attack the toys and play violent games. The anxious child will flit around the room, unable to settle on any one thing. The en- meshed child will frequently interrupt the parents’ conversation with the therapist.

In gathering information, some therapists find it useful to take a family history, and many use genograms to diagram the extended family network (see Chapter 4). Others believe that whatever history

The initial phone contact should be relatively brief to avoid developing an alliance with just one family member.

Fo to

s 59

3/ Fo

to lia

M02_NICH6609_11_SE_C02.indd 28 9/28/15 2:28 PM

Chapter 2 Basic Techniques of Family Therapy 29

is important will emerge in the natural course of events; they prefer to concentrate on the family’s presenting complaint and the circumstances surrounding it.

Family therapists develop hypotheses about how family members might be involved in the presenting problem by asking what they’ve done to try to solve it and by watching how they interact. Ideas are as im- portant as actions, so it’s useful to notice unhelpful explanations of problems as well as unproductive interactions.

Two kinds of information that are particularly im- portant are solutions that don’t work and transitions in the life cycle. If whatever a family has been doing to resolve their difficulties hasn’t worked, it may be that those attempts are part of the problem. A typical example is overinvolved parents trying to help a shy child make friends by coaxing and criticizing him. Sometimes family members will say they’ve “tried everything.” Their mistake is inconsistency. They give up too quickly.

Despite the natural tendency to focus on prob- lems and what causes them, it is a family’s strengths, not their weaknesses, that are most important in

successful therapy. Therefore, the therapist should search for resilience (Walsh, 1998). What have these people done well? How have they handled problems successfully in the past? Even the most discouraged families have been successful at times, but those posi- tive episodes may be obscured by the frustration they feel over their current difficulties.

Although it isn’t always apparent (especially to them), most families seek treatment because they have failed to adjust to changing circumstances. If a couple develops problems within a few months after a baby’s birth, it may be because they haven’t shifted effectively from being a unit of two to a unit of three. A young mother may be depressed because she doesn’t have enough support. A young father may be jealous of the attention his wife lavishes on the baby.

Although the strain of having a new baby may seem obvious, it’s amazing how often depressed young mothers are treated as though there were something wrong with them—“unresolved depen- dency needs,” “inability to cope,” or perhaps a Prozac deficiency. The same is true when families develop problems around the time a child starts school, enters

The challenge of first interviews is to develop an alliance without accepting at face value the family’s description of one person as the problem.

M on

ke y

B us

in es

s Im

ag es

/C or

bi s

M02_NICH6609_11_SE_C02.indd 29 9/25/15 7:09 PM

30 Part One: The Context of Family Therapy

adolescence, or reaches some other developmental milestone. The transitional demands on the family are obvious, if you think about them.

Young therapists may have no experience with some of the challenges their clients are facing. This underscores the need to remain curious and respect- ful of families’ predicaments rather than jumping to conclusions. For example, a young therapist couldn’t understand why so many clients with young children rarely went out together as a couple. He assumed that they were avoiding being alone together. Later, with small children of his own, he began to wonder how those couples got out at all!

Family therapists explore the process of family interaction by asking questions about how family members relate to each other and by inviting them to discuss their problems with one another in the ses- sion. The first strategy, asking process or circular questions, is favored by Bowenians, and the second, by structural therapists. In either case, the question is, What’s keeping the family stuck?

Once a therapist has met with a family, explored the problem that brings them to treatment, made an effort to understand the family’s context, and for- mulated a hypothesis about what needs to be done to resolve the problem, he or she should make a recommendation to the family. This might include consulting another professional (a learning disabil- ity expert, a physician, a lawyer) or even suggesting that the family doesn’t need—or doesn’t seem ready for—treatment. Most often, however, the recommen- dation will be for further meetings. Although many therapists try to make recommendations at the end of the first interview, doing so may be hasty. If it takes two or three sessions to form a bond with the family, understand their situation, and assess the feasibility of working with them, then take two or three sessions.

If you think you can help the family with their problems, offer them a treatment contract. Acknowl- edge why they came in, say that it was a good idea, and say that you think you can help. Then establish a meeting time, the frequency and length of sessions, who will attend, the presence of observers or use of videotape, the fee, and how insurance will be han- dled. Remember that resistance doesn’t magically disappear after the first (or fourteenth) session. Stress the importance of keeping appointments, the need for

everyone to attend, and your willingness to hear con- cerns about you or the therapy. Finally, don’t forget to emphasize the family’s goals and the strengths they have to meet them.

First Session Checklist

1. Make contact with each member of the family, and acknowledge his or her point of view about the problem and feelings about coming to therapy.

2. Establish leadership by controlling the structure and pace of the interview.

3. Develop a working alliance with the family by balancing warmth and professionalism.

4. Compliment clients on positive actions and fam- ily strengths.

5. Maintain empathy with individuals and respect for the family’s way of doing things.

6. Focus on specific problems and attempted solutions.

7. Develop hypotheses about unhelpful interactions around the presenting problem. Be curious about why these have persisted. Also notice helpful in- teractions that can support the family in moving forward.

8. Don’t overlook the possible involvement of family members, friends, or helpers who aren’t present.

9. Offer a treatment contract that acknowledges the family’s goals and specifies the therapist’s framework for structuring treatment.

10. Invite questions.

The Early Phase of Treatment

The early phase of treatment is devoted to refining the initial hypothesis into a formulation about what’s maintaining the problem and beginning to work on resolving it. Now the strategy shifts from building al- liances to challenging actions and assumptions. Most therapists are able to figure out what needs to change; what sets good therapists apart is their willingness to push for those changes.

“Pushing for change” may suggest a confronta- tional style. But what’s required to bring about change isn’t any particular way of working; rather, it is a

M02_NICH6609_11_SE_C02.indd 30 9/25/15 7:09 PM

Chapter 2 Basic Techniques of Family Therapy 31

relentless commitment to helping make things bet- ter. This commitment is evident in Michael White’s dogged questioning of problem-saturated stories, Phil Guerin’s calm insistence that family members stop blaming each other and start looking at themselves, and Virginia Goldner’s determined insistence that vi- olent men take responsibility for their behavior.

No matter what techniques a therapist uses to push for change, it’s important to maintain a therapeutic alliance. Although the term therapeutic alliance may sound like jargon, there’s nothing abstract about it. It means listening to and acknowledging the client’s point of view. It is this empathic understanding that makes family members feel respected—and makes them open to accepting challenges.

Regardless of what model they follow, effective therapists are persistent in their pursuit of change. This doesn’t just mean perseverance. It means be- ing willing to intervene, at times energetically. Some therapists prefer to avoid confrontation and find it more effective to use gentle questions or persistent encouragement. Regardless of whether they work di- rectly (and at times use confrontation) or indirectly (and avoid it), good therapists are finishers. Strategies vary, but what sets the best therapists apart is their commitment to doing what it takes to see families through to successful resolution of their problems.

Effective family therapy addresses interpersonal conflict, and the first step in doing so is to bring it into the consulting room and locate it between fam- ily members. Often this isn’t a problem. Couples in conflict or parents arguing with their children usually speak right up about their disagreements. If a family only came because someone sent them (the court, the school, the Department of Protective Services), begin by addressing the family’s problem with these agen- cies. How must the family change to resolve their conflict with these authorities?

When one person is presented as the problem, a therapist challenges linearity by asking how others are involved (or affected). What role did others play in creating (or managing) the problem? How have they responded to it?

For example, a parent might say, “The problem is Malik. He’s disobedient.” The therapist might ask, “How does he get away with that?” or “How do you respond when he’s disobedient?” A less

confrontational therapist might ask, “How does his disobedience affect you?”

In response to a family member who says “It’s me, I’m depressed,” a therapist might ask “Who in the family is contributing to your depression?” The response “No one” would prompt the question, “Then who’s helping you with it?”

Challenges can be blunt or gentle, depending on the therapist’s style and assessment of the family. The point, incidentally, isn’t to switch from blaming one person (a disobedient child, say) to another (a parent who doesn’t discipline effectively) but to broaden the problem to an interactional one—to see the prob- lem as shared and co-maintained. Maybe mother is too lenient with Malik because she finds father too strict. Moreover, she may be overinvested in the boy because of emotional distance in the marriage.

The best way to challenge unhelpful interactions is to point out patterns that seem to be keeping people stuck. A useful formula is “The more you do X, the more he does Y—and the more you do Y, the more she does X.” (For X and Y, try substituting nag and withdraw or control and rebel.) Incidentally, when you point out what people are doing that isn’t work- ing, it’s a mistake to then tell them what they should be doing. Once you shift from pointing out something to giving advice, the client’s attention shifts from their own behavior to you and your advice.2 Consider this exchange:

Therapist: When you ignore your wife’s com- plaints, she feels hurt and angry. You may have trouble accepting the anger, but she doesn’t feel supported.

Client: What should I do?

Therapist: I don’t know. Ask your wife.

Even though family therapists sometimes chal- lenge assumptions or actions, they continue to listen to people’s feelings. Listening is a silent activity, rare in our time, even among therapists. Family members seldom listen to each other for long without becoming

2Being anxious to change people is one of the two greatest handicaps for a therapist. (The other is the need to be liked.) Being attached to what should be distracts a therapist from figuring out what is—and it communicates a pressure that does the same thing to clients.

M02_NICH6609_11_SE_C02.indd 31 9/25/15 7:09 PM

32 Part One: The Context of Family Therapy

defensive. Unfortunately, therapists don’t always lis- ten, either—especially when they’re eager to offer advice. But remember that people aren’t likely to re- consider their assumptions until they’ve been heard and understood.

Homework can be used to test f lexibility (sim- ply seeing if it’s carried out measures willingness to change), to make family members more aware of their role in problems (telling people just to no- tice something, without trying to change it, is often instructive), and to suggest new ways of relating. Typical homework assignments include suggest- ing that overinvolved parents hire a babysitter and go out together, having argumentative partners take turns talking about their feelings and listening to one another without saying anything (but noticing ten- dencies to become reactive), and having dependent family members practice spending time alone (or with someone outside the family) and doing more things for themselves. Homework assignments that are likely to generate conflict, such as negotiating house rules with teenagers, should be avoided. Diffi- cult discussions should be saved for when the thera- pist can act as referee.

Early Phase Checklist

1. Identify major conflicts, and bring them into the consulting room.

2. Develop a hypothesis and refine it into a formula- tion about what the family is doing to perpetuate (or fail to resolve) the presenting problem. A for- mulation should consider process and structure, family rules, triangles, and boundaries.

3. Keep the focus on primary problems and the inter- personal conditions supporting them. But do not neglect to support constructive interactions.

4. Assign homework that addresses problems and the underlying structure and dynamics perpetuating them.

5. Challenge family members to see their own roles in the problems that trouble them.

6. Push for change, both during the session and between sessions at home.

7. Make use of supervision to test the validity of formulations and effectiveness of interventions.

The Middle Phase of Treatment

When therapy is anything other than brief and prob- lem focused, much of the middle phase is devoted to helping family members deal more constructively with each other in sessions. If a therapist is too ac- tive in this process—filtering all conversation through himself or herself—family members won’t learn to deal with each other.

For this reason, in the middle phase the therapist should take a less active role and encourage family members to interact more with each other. As they do so, the therapist can step back and observe. When dia- logue bogs down, the therapist can either point out what went wrong or simply encourage family members to keep talking—but with less interruption and criticism.

When family members address their conflicts di- rectly, they tend to become reactive. Anxiety is the enemy of listening. Some therapists (e.g., Bowenians) attempt to control anxiety by having family members talk only to them. Others prefer to let family members deal with their own anxiety by helping them learn to talk with each other less defensively (by saying how they feel and acknowledging what others say). How- ever, even therapists who work primarily with family dialogue need to interrupt when anxiety escalates and conversations become destructive.

Thus, in the middle phase of treatment, the therapist takes a less directive role and encourages family mem- bers to begin to rely on their own resources. The level of anxiety is regulated by alternating between having family members talk with each other or with the ther- apist. In either case the therapist encourages family members to get beyond trading blame to talking about what they feel and what they want—and to learn to see their own part in unproductive interactions.

What enables therapists to push for change with- out provoking resistance is an empathic bond with clients. We mentioned the working alliance in our discussion of the opening session, but it’s such an important subject that we would like to re-emphasize it. Although there is no formula for developing good relationships with clients, four attitudes are important in maintaining a therapeutic alliance: calmness, curi- osity, empathy, and respect.

Calmness on the part of the therapist is an essen- tial antidote to the anxiety that keeps families from

M02_NICH6609_11_SE_C02.indd 32 9/25/15 7:09 PM

Chapter 2 Basic Techniques of Family Therapy 33

seeing their dilemmas in a broader perspective. Two things that enable a therapist to remain calm are: (1) not taking responsibility for solving a family’s problems, and (2) knowing where to look for the constraints that are keeping them from doing so. Letting go of the illusion that anyone but the clients can solve their problems allows a therapist to con- centrate on the job at hand, which is helping clients in the session discover something new and useful. Calmness conveys confidence that problems, how- ever difficult, can be solved.

Curiosity implies that the therapist doesn’t know all the answers. The curious therapist says, in effect, “I don’t fully understand, but I’d like to.”

Empathy and respect have been reduced to clichés, but since we think both are essential, let us be clear about what we mean. People resist efforts to change them by therapists they feel don’t under- stand them. That makes it difficult for therapists to get anywhere if they can’t put themselves in their clients’ shoes and get a sense of what the world looks like to them. Some therapists are all too ready to say “I understand” when they don’t. You can’t fake empathy.

Instead of telling an overprotective mother that you understand her worrying, be honest enough to ask, “How did you learn to be a worrier?” or say, “I’ve never been a single mom. Tell me what it is that scares you.”

Finally, respect. What passes for respect in ther- apists isn’t always sincere. Being respectful doesn’t mean treating people with kid gloves, nor does it mean accepting their version of events as the only possible way to look at the situation. Respect means treating clients as equals, not patronizing them or deferring to them out of fear of making them angry. Respecting people means believing in their capacity for change.

Middle Phase Checklist

1. Use intensity to challenge family members, in- genuity to get around resistance, and empathy to reduce defensiveness.

2. Avoid being so directive that the family doesn’t learn to improve their own ways of relating to each other.

3. Foster individual responsibility and mutual understanding.

4. Make certain that efforts to improve relationships are having a positive effect on the presenting complaint.

5. When meeting with subgroups, don’t lose sight of the whole family picture, and don’t neglect any individuals or relationships—especially those contentious ones that are so tempting to avoid.

6. Does the therapist take too active a role in choosing what to talk about? Have the therapist and family developed a social relationship that has become more important than addressing conflicts? Has the therapist assumed a regular role in the family (an empathic listener to the spouses or a parent figure to the children), substi- tuting for a missing function in the family? When therapists find themselves drawn to taking an active response to family members’ needs, they should ask themselves who in the family should be taking that role, and then encourage that per- son to do so.

Termination

Termination comes for brief therapists as soon as the presenting problem is resolved. For psychoanalysts, therapy may continue for years. For most therapists, termination comes somewhere between these two extremes and has to do with a family feeling that they’ve achieved what they came for and the thera- pist’s sense that treatment has reached a point of di- minishing returns.

In individual therapy, where the relationship to the therapist is often the primary vehicle of change, termination focuses on reviewing the relationship and saying good-bye. In family therapy, the focus is more on what the family has been doing. Termina- tion is therefore a good time to review what they’ve accomplished.

It can be helpful to ask clients to anticipate upcom- ing challenges: “How will you know when things are heading backward, and what will you do?” Families can be reminded that their present harmony can’t be maintained indefinitely and that people have a

M02_NICH6609_11_SE_C02.indd 33 9/25/15 7:09 PM

34 Part One: The Context of Family Therapy

tendency to overreact to the first sign of relapse, which can trigger a vicious cycle. To paraphrase Zorba the Greek, life is trouble. To be alive is to con- front difficulties. The test is how you handle them.

Finally, although in the business of therapy no news is usually good news, it might be a good idea to check in with clients a few weeks after termi- nation to see how they’re doing. This can be done with a letter, e-mail, phone call, or brief follow-up session. A therapeutic relationship is of necessity somewhat artificial or at least constrained. But there’s no reason to make it less than human—or to forget about families once you’ve terminated with them.

Termination Checklist

1. Has the presenting problem improved?

2. Is the family satisfied that they have achieved what they came for, or are they interested in continuing to learn about themselves and improve their relationships?

3. Does the family understand what they were doing that wasn’t working and how to avoid similar problems in the future?

4. Do minor recurrences of problems reflect the lack of resolution of some underlying dynamic or merely that the family has to readjust to function without the therapist?

5. Have family members developed and improved relationships outside the immediate family context as well as within it?

Watch this video of a termination session with a woman in therapy who was attempting to stop

using drugs so she could get her son back. What does the therapist do to help the client understand her progress?

family assessment

The reason we’re reviewing assessment after the guidelines for treatment is that assessment is a com- plex subject, deserving more consideration than it usually gets.

The Presenting Problem

Every first session presents the fundamental challenge of being a therapist: A group of unhappy strangers walks in and hands you their most difficult problem— and expects you to solve it.

“My fifteen-year-old is failing tenth grade. What should I do?”

“We never talk anymore. What’s happened to our marriage?”

“It’s me. I’m depressed. Can you help me?”

There are land mines in these opening presenta- tions: “What should we do?” “What’s wrong with Johnny?” These people have been asking themselves these questions for some time, maybe years. And they usually have fixed ideas about what the answers are, even if they don’t always agree. Furthermore, they have typically evolved strategies to deal with their problems, which they insist on repeating even if they haven’t worked. In this, they are like a car stuck in the mud with wheels spinning, sinking deeper and deeper into the mire.

The stress of life’s troubles makes for anxiety, and anxiety makes for inflexible thinking. And so fami- lies who come for therapy tend to hold tenaciously to their assumptions: “He (or she) is hyperactive, de- pressed, bipolar, insensitive, selfish, rebellious,” or some other negative attribute that resides inside the complicated machinery of the stubborn human psy- che. Even when the complaint is phrased in the form of “We don’t communicate,” there’s usually an as- sumption of where the responsibility lies—and that somewhere is usually elsewhere.

Exploring the presenting symptom is the first step in helping families move from a sense of helplessness to an awareness of how by working together they can overcome their problems. It may seem obvious that the first consideration should be the presenting com- plaint. Nevertheless, it’s worth emphasizing that in- quiry into the presenting problem should be detailed and empathic. The minute some therapists hear that a family’s problem is, say, misbehavior or poor com- munication, they’re ready to jump into action. They know how to deal with misbehaving children and communication problems. But before therapists get started, they should realize that they’re not dealing

M02_NICH6609_11_SE_C02.indd 34 9/25/15 7:09 PM

Chapter 2 Basic Techniques of Family Therapy 35

with misbehaving children or communication prob- lems: rather, they’re dealing with a unique instance of one of these difficulties.

In exploring the presenting complaint, the goal for a systemic therapist is to question the family’s settled certainty about who has the problem and why. There- fore, the first challenge for a family therapist is to move families from linear (“It’s Johnny”) and medical model thinking (“He’s hyperactive”) to an interactional per- spective. To initiate this shift, a therapist begins by ask- ing about the presenting problem. But these inquiries are aimed not merely at getting details about the condi- tion-as-described but to open up the family’s entrenched beliefs about what is the problem and who has it.

Helpful questions convey respect for family mem- bers’ feelings but skepticism about accepting the identified patient as the only problem in the family. Helpful questions continue to explore and open things up. Helpful questions invite new ways of seeing the problem, or the family generally. Unhelpful questions accept things as they are described and concentrate only on the identified patient. To be effective in this first stage, a therapist’s attitude should be, “I don’t fully understand, but I’m interested. I’m curious about the particular way you organize your life.” A therapist who is too eager ingratiate himself or herself by say- ing, “Oh, yes, I understand,” closes off exploration.

The next thing to explore is the family’s attempts to deal with the problem: What have they tried? What’s been helpful? What hasn’t worked? Has anyone other than those present been involved in trying to help (or hinder) with these difficulties? This exploration makes room to discover how family members may be re- sponding in ways that perpetuate the presenting prob- lem. This isn’t a matter of shifting blame—say, from a misbehaving child to an indulgent parent.3 Nor do we mean to suggest that family problems are typically caused by how people treat the identified patient.

In fact, what family therapists call circular causality is a misnomer. The shift from linear to circular thinking not only expands the focus from individuals to patterns of interaction but also moves away from cause-and-effect explanations. Instead of

3It’s always worth remembering that even actions that perpet- uate problems usually have benign intentions. Most people are doing the best they can.

joining families in a logical but unproductive search for who started what, circular thinking suggests that problems are sustained by an ongoing series of ac- tions and reactions. Who started it? It doesn’t matter.

Understanding the Referral Route

It’s important for therapists to understand who referred their clients and why. What are their expectations? What expectations have they communicated to the family? It’s important to know whether a family’s par- ticipation is voluntary or coerced, whether all or only some of them recognize the need for treatment, and whether other agencies will be involved with the case.

When therapists make a family referral, they often have a particular agenda in mind.

case sTuDy A college student’s counselor referred him and his family for treatment. The young man had uncovered a repressed memory of sexual abuse and assumed that it must have been his father. The family therapist was somehow supposed to mediate between the young man, who couldn’t imagine who else might have been responsible for this vaguely remembered incident, and his parents, who vehemently denied that any such thing had ever happened.

Did the counselor expect confrontation, con- fession, and atonement? Some sort of negotiated agreement? What about the boy himself? It’s best to find out.

It’s also important to find out if clients have been in treatment elsewhere. If so, what happened? What did they learn about themselves or their family? What expectations or concerns did the previous therapy generate? It’s even more important to find out if any- one in the family is currently in treatment. Few things are more likely to cause a stalemate than two thera- pists pulling in different directions.

Identifying the Systemic Context

Regardless of who a therapist elects to work with, it’s imperative to have a clear understanding of the interpersonal context of the problem. Who is in the

M02_NICH6609_11_SE_C02.indd 35 9/25/15 7:09 PM

36 Part One: The Context of Family Therapy

family? Are there important figures in the life of the problem who aren’t present? Perhaps a live-in boy- friend? A grandmother who lives next door? Are other agencies involved? What is their input? Does the family see them as helpful?

Remember that family therapy is an approach to people in context. The most relevant context may be the immediate family, but families don’t exist in a vacuum. It may be important to meet with the teachers and counselors of a child who’s having trouble at school. There are even times when the family isn’t the most important context. Some- times, for example, a college student’s depression has more to do with what’s going on in the class- room or dormitory than with what’s happening back home.

Stage of the Life Cycle

Most families come to treatment not because there’s something inherently wrong with them but because they’ve gotten stuck in a life-cycle transition (see Chapter 3). Sometimes this will be apparent. Par- ents may complain, for example, that they don’t know what’s gotten into Janey. She used to be such a good girl; but now that she’s fourteen, she’s be- come sullen and argumentative. (One reason parent- ing remains an amateur sport is that just when you think you’ve got the hang of it, the kids get a little older and throw you a whole new set of curves.) Ad- olescence is that stage in the family life cycle when young parents have to grow up and relax their grip on their children.

Sometimes it isn’t obvious that a family is hav- ing trouble adjusting to a new stage in the life cycle. Couples who marry after living together for years may not anticipate how matrimony stirs up un- conscious expectations about what it means to be a family. More than one couple has been surprised to discover a sharp falling off in their sex life after tying the knot. At other times, significant life-cycle changes occur in the grandparents’ generation, and you won’t always learn of these inf luences unless you ask.

Always consider life-cycle issues in formulating a case. One of the best questions a therapist can ask is, Why now?

Family Structure

The simplest systemic context for a problem is an in- teraction between two parties. She nags and he with- draws. Parental control provokes adolescent rebellion, and vice versa. But sometimes a dyadic perspective doesn’t take in the whole picture.

Family problems become entrenched because they’re embedded in powerful but unseen structures. Regardless of what approach a therapist takes, it’s wise to understand something about a family’s structure. What are the subsystems and the nature of the boundaries between them? What is the status of the boundary around the couple or family? What triangles are present? Are individuals and subsystems protected by boundaries that allow them to operate without un- due interference—but with access to support?

In enmeshed families, parents may intrude into sib- ling conflicts so regularly that brothers and sisters never learn to settle their own differences. In disengaged fam- ilies, parents may not only refrain from interrupting sib- ling quarrels but also fail to offer sympathy and support for a child who feels bad about a sibling’s treatment.

Here, too, there is a temporal dimension. If a wife goes back to work after years of staying home with the children, the parental subsystem is challenged to shift from a complementary to a symmetrical form. Whether or not family members complain directly about these strains, they’re likely to be relevant.

Communication

Although some couples come to therapy saying they have “communication problems” (usually meaning that one person won’t do what the other one wants), working on communication has become a cliché in family therapy. Because communication is the vehicle of relationship, all therapists deal with it.

Although conflict doesn’t magically disappear when family members start to listen to each other, it’s unlikely that conflicts will get solved before people start to listen to each other (Nichols, 2009). If, after a session or two (and the therapist’s encouragement), family members still seem unwilling to listen to each other, talk therapy will be an uphill battle.

Family members who learn to listen to each other with understanding often discover that they don’t

M02_NICH6609_11_SE_C02.indd 36 9/25/15 7:09 PM

Chapter 2 Basic Techniques of Family Therapy 37

need to change each other (Jacobson & Christensen, 1996). Many problems can be solved, but the prob- lem of living with other people who don’t always see things the way you do isn’t one of them.

Drug and Alcohol Abuse

The most common mistake novice therapists make regarding substance abuse is to overlook it. Sub- stance abuse is especially common with people who are depressed or anxious. It’s also associated with violence, abuse, and accidents. Although it may not be necessary to ask every client about drug and al- cohol consumption, it’s critical to inquire carefully if there’s any suspicion that this may be a problem. Don’t be too polite. Ask straightforward and specific questions.

Questions that may help to uncover problem drink- ing (Kitchens, 1994) include the following:

♦♦ Do you feel you are a normal drinker? ♦♦ How many drinks a day do you have? ♦♦ How often do you have six or more drinks? ♦♦ Have you ever awakened after a bout of drinking

and been unable to remember part of the day or evening before?

♦♦ Does anyone in your family worry or complain about your drinking?

♦♦ Can you stop easily after one or two drinks? Do you? ♦♦ Has drinking ever created problems between you

and your partner? ♦♦ Have you ever gotten into trouble at work because

of your drinking? ♦♦ Do you ever drink before noon?

These same questions can be asked about substances other than alcohol. If a member of a family who’s seeking couples or family therapy seems to be abusing drugs or alcohol, think twice about assuming that talk therapy will be the answer to the family’s problems.

Domestic Violence and Sexual Abuse

If there is any hint of domestic violence or sexual abuse, a therapist should look into it. The process of questioning can start with the family present, but when there is any suggestion of abuse, it may be wise

to meet with family members separately to allow them to talk more openly.

Most states require professionals to report any sus- picion of child abuse. Reporting suspected child abuse can jeopardize a therapeutic alliance, but sometimes therapy needs to take second place to safety. Any cli- nician who considers not reporting suspected child abuse should consider the possible consequences of making a mistake.

Perpetrators and victims of childhood sexual mal- treatment don’t usually volunteer this information. Detection is up to the clinician, who may have to rely on indirect clues. Further exploration may be indi- cated if a child shows any of the following symptoms: sleep disturbance, encopresis or enuresis, abdomi- nal pain, an exaggerated startle response, appetite disturbance, sudden unexplained changes in behav- ior, overly sexualized behavior, regressive behavior, suicidal thoughts, or running away (Edwards & Gil, 1986; Campbell, Cook, LaFleur, & Keenan, 2010).

Extramarital Affairs

The discovery of an affair is a crisis that will strike many couples some time in their relationship. Infidel- ity is common, but it’s still a crisis, and it can destroy a marriage.

Extramarital involvements that don’t involve sex- ual intimacy, although less obvious, can sabotage treatment if one or both partners regularly turn to third parties to deal with issues that should be worked out together. (One clue that an outside relationship is part of a triangle is that it isn’t talked about.) Would-be helpful third parties may include family members, friends, and therapists.

case sTuDy A couple once came to therapy complaining that the intimacy had gone out of their relationship. It wasn’t so much a matter of conflict; they just never seemed to spend any time together. After a few weeks of slow progress, the wife mentioned that she’d been seeing an individual therapist. When the couple’s therapist asked why, she replied that she needed someone to talk to. When he asked why she hadn’t told him, she said, “You didn’t ask.”

M02_NICH6609_11_SE_C02.indd 37 9/25/15 7:09 PM

38 Part One: The Context of Family Therapy

Gender

Gender inequalities contribute to family problems in a variety of ways. A wife’s dissatisfaction may have deeper roots than the family’s current problems. A husband’s reluctance to become more involved in the family may be as much a product of cultural pro- gramming as a flaw in his character.

Every therapist must work out individually how to avoid the extremes of naively ignoring gender inequal- ity or imposing his or her personal point of view on clients. One way to strike a balance is to raise questions but allow clients to find their own answers. You can raise moral questions without being moralistic. It is, however, not reasonable to assume that both partners enter marriage with equal power or that complementar- ity is the only dynamic operating in their relationship.

Conflict over gender expectations, whether dis- cussed openly or not, is especially common given the enormous shifts in cultural expectations in recent de- cades. Is it still considered a woman’s duty to follow her husband’s career, moving whenever necessary for his advancement? Is it still true that women should be strong, self-supporting, and the primary (which often turns out to be a euphemism for only) caregivers for infants and young children?

Regardless of the therapist’s values, do the gender roles established in a couple seem to work for them? Or do unresolved differences, conflicts, or confusions appear to be sources of stress? Perhaps the single most useful question to ask about gender equality is, “How does each partner experience the fairness of give-and-take in their relationship?”

It’s not uncommon for differences in gender so- cialization to contribute to conflict in couples (Patter- son, Williams, Grauf-Grounds, & Chamow, 1998), as the following example illustrates.

case sTuDy Kevin complained that Courtney was always check- ing up on him, which made him feel that she didn’t trust him. Courtney insisted that she only asked about what Kevin was doing in order to be part of his life. She expected the same interest in her life from him. She wasn’t checking up on him; she just wanted them to share things.

When Courtney asked Kevin too many questions, he got angry and withdrew, which made her feel shut out. Happy not to be interrogated any further, Kevin didn’t notice how hurt and angry Courtney was until finally she exploded in tearful recrimina- tion. Kevin felt helpless in the face of Courtney’s crying, and so he did his best to placate her. When he reassured her that he loved her and promised to tell her more about what was going on in his life, she calmed down and peace was restored. Until the next time.

For couples like Courtney and Kevin, gender socialization contributes to a pursuer–distancer dynamic. Men are typically socialized to value inde- pendence and to resist anything they see as an effort to control them. Thus, Kevin interpreted Courtney’s questions about his activities as attempts to restrict his freedom. Courtney, on the other hand, was social- ized to value caring and connection. Naturally, she wanted to know what was going on in Kevin’s life. She couldn’t understand why he got so defensive about her wanting them to check in with each other.

While it’s a mistake to ignore gender socializa- tion in favor of family dynamics, it’s also a mistake to assume that gender socialization isn’t influenced by family dynamics. In the previous example, the enmeshed family that Courtney grew up in rein- forced the notion that family members should share everything and that independent activities were a sign of disloyalty. Kevin’s reluctance to tell his wife everything he was doing was partly a residue of his coming from a family with two bossy and con- trolling parents.

Culture

In assessing families for treatment, therapists should consider the unique subculture of the family (McGol- drick, Pearce, & Giordano, 2005) as well as how un- questioned assumptions from the larger culture may affect a family’s problems (Doherty, 1991).

In working with minority families, it may be more important for therapists to develop cultural sensi- tivity than to actually share the same background as their clients. Families may come to trust a therapist who has taken the time to learn about their particular

M02_NICH6609_11_SE_C02.indd 38 9/25/15 7:09 PM

Chapter 2 Basic Techniques of Family Therapy 39

culture as much as one who happens to be of the same race or nationality.

One way to develop cultural sensitivity is to make connections after working hours. For example, a white therapist could attend an African American church service in the community where his or her cli- ents live, go to a Latino dance, or visit an Asian com- munity center. Doing these things won’t make you an expert, but it may demonstrate to client families that you care enough to respect their ways. It’s also im- portant to take a one-down position in regard to cul- tural and ethnic diversity—that is, to ask your clients to teach you about their experience and traditions, rather than assume the role of expert.

The challenge for a practitioner is twofold: learn- ing to respect diversity and developing sensitivity to some of the issues faced by members of other cultures and ethnic groups. Numerous books are available describing the characteristics and values of various ethnic groups, many of which are listed in the sec- tion on multiculturalism in Chapter 10. In addition to these academic books, novels such as The Kite Run- ner, Beloved, Song of Solomon, How the Garcia Girls Lost their Accent, The Mambo Kings Play Songs of Love, The Scent of Green Papaya, The Brief Wondrous Life of Oscar Wao, and The Joy Luck Club often bring other cultures more vividly to life.

In working with clients from other cultures, it’s more important to be respectful of differences and to be curious about other ways of doing things than to attempt to become an expert on ethnicity. Yet while it’s important to respect other people’s differences, it can be a problem to accept uncritically statements to the effect that “We do these (counterproductive) things because of our culture.” Unfortunately, it’s dif- ficult for a therapist from another culture to assess the validity of such claims. Perhaps the best advice is to be curious. Stay open-minded, but ask questions.

The ethical Dimension

Most therapists are aware of the ethical responsibili- ties of their profession:

♦♦ Therapy should be for the client’s benefit, not to work out unresolved issues for the therapist.

Watch this video of a beginning therapist experiencing a clash in values with her client.

What do you learn from the supervisor about navigating ethical dilemmas?

♦♦ Clients are entitled to confidentiality, and so limits on privacy imposed by requirements to report to probation officers, parents, or man- aged care companies should be made clear from the outset.

♦♦ Therapists should avoid exploiting the trust of their clients and students and therefore must make every effort to avoid dual relationships.

♦♦ Professionals are obligated to provide the best possible treatment; if they aren’t qualified by training or experience to meet the needs of a particular client, they should refer the case to someone who is.

Whenever there is any question or doubt regard- ing ethical issues, it’s a good idea to consult with a colleague or supervisor.

Although most therapists are aware of their own responsibilities, many think less than they might about the ethical dimensions of their clients’ be- havior. This is an area where there are no hard-and- fast rules. However, a complete and conscientious assessment of every family should include some consideration of family members’ entitlements and obligations. What obligations of loyalty do members of a family have? Are invisible loyalties constraining their behavior? (Boszormenyi-Nagy & Spark, 1973) If so, are these loyalties just and equitable? What is the nature of the partners’ commitment to each other? Are these commitments clear and balanced? What obligations do family members have with re- gard to fidelity and trustworthiness? Are these obli- gations being met?

A good place to start in understanding the eth- ical responsibilities of clinical practice is with the guidelines of your profession. The Ethics Code of the American Psychological Association (APA), for example, outlines principles such as these:

♦♦ Psychologists offer services only within the areas of their competence based on their education, training, supervision, and professional experience.

M02_NICH6609_11_SE_C02.indd 39 9/25/15 7:09 PM

40 Part One: The Context of Family Therapy

♦♦ When understanding age, gender, race, ethnicity, culture, national origin, religion, sexual orienta- tion, disability, language, or socioeconomic status is essential for the effective delivery of services, psychologists will have or seek out training and supervision in these areas or make the appropriate referrals.

♦♦ When psychologists become aware of personal problems that might interfere with their profes- sional duties, they take appropriate measures, such as obtaining professional assistance and determin- ing whether they should limit, suspend, or termi- nate their work-related duties.

The Code of Ethics for the National Associ- ation of Social Workers (NASW) mandates the following:

♦♦ Social workers should not engage in dual relation- ships with clients or former clients.

♦♦ Social workers should not solicit private informa- tion from clients unless it is essential to providing services.

♦♦ Social workers should not disclose confidential information to third-party payers unless clients have authorized such disclosure.

♦♦ Social workers should terminate services to clients when such services are no longer required.

The American Counseling Association (ACA, 2014) covers many of the same issues as the APA and NASW, yet it provides further mandates related to social media, such as:

♦♦ Counselors are not allowed to maintain a relationship with current clients through social media.

♦♦ Counselors must wait five years after the last clinical contact to have a sexual or romantic rela- tionship with a former client or a family member of a client. This applies to both in-person and electronic interactions or relationships.

While some of these principles may seem obvious, they provide fairly strict guidelines within which prac- titioners should operate. When it comes to working with couples and families, however, complications arise that create a host of unique ethical dilemmas.

It’s clear that therapists must protect their clients’ right to confidentiality. But what if a woman reveals she’s having an extramarital af- fair and isn’t sure whether to end it? When she

When, for example, should a family therapist share with parents information learned in sessions with a child? If a twelve-year-old starts drinking, should the therapist tell her parents?

Recently, professional codes of conduct have added guidelines to address issues involved in treating couples and families. For example, the APA specifies that when a psychologist provides services to several people who have a relationship (such as spouses or parents and children), he or she must clarify at the outset which individuals are clients and what relation- ship he or she will have with each person. In addi- tion, if it becomes apparent that a psychologist may be called on to perform potentially conflicting roles (such as family therapist and then witness for one party in divorce proceedings), he or she must attempt to clarify and modify those rules or withdraw from them appropriately.

Similarly, the NASW states that when social work- ers provide services to couples or family members, they should clarify with all parties the nature of their professional obligations to the various individuals re- ceiving services. And when social workers provide counseling to families, they should seek agreement among the parties concerning each individual’s right to confidentiality.

The American Association for Marriage and Fam- ily Therapy (AAMFT, 2001) publishes its own code of ethics, which covers many of the same points as the codes of the APA and NASW. The AAMFT does, however, directly address complications with respect to confidentiality when a therapist sees more than one person in a family. Without a written waiver, a fam- ily therapist should not disclose information received from any family member, presumably not even to other family members.

Still, as with many things, it may be easier to expound ethical principles in the classroom than to apply them in the crucible of clinical practice. Consider the following:

M02_NICH6609_11_SE_C02.indd 40 9/25/15 7:09 PM

Chapter 2 Basic Techniques of Family Therapy 41

Can a therapist offer effective couples treatment while one of the partners is carrying on an extramar- ital relationship? How much pressure should a thera- pist exert on a client to do something he or she doesn’t want to do? How much pressure should a therapist apply to urge a family member to reveal a secret that might have dangerous consequences? When does a therapist have the right to discontinue treatment of a client who wants to continue, because the client refuses to accept the therapist’s recommendation?

One way to resolve ambiguous ethical dilemmas is to use your own best judgment. In the case of the woman who wanted to work on her marriage but wasn’t willing to end her affair or inform her hus- band, a therapist might decline to offer therapy under circumstances that would make it unlikely to be effec- tive. In that case, the therapist would be obligated to refer the client to another therapist.

Subprinciple 1.10 of the AAMFT’s Code of Ethi- cal Principles (2011) states that “Marriage and family therapists respectfully assist persons in obtaining ap- propriate therapeutic services if the therapist is unable or unwilling to provide professional help. And Sub- principle 1.11 states that “Marriage and family ther- apists do not abandon or neglect clients in treatment without making reasonable arrangements for the con- tinuation of such treatment.”

Given the same set of circumstances, another thera- pist might decide that even though the woman refuses to end her affair, treating the couple might make it pos- sible for the woman to break off the affair later or to talk to her husband about it. In this scenario, the thera- pist would be bound by the principle of confidentiality not to reveal what the woman discussed in private.

While the outlines of ethical professional con- duct are clear, the pressures on practitioners are often

goes on to say that her marriage has been stale for years, the therapist recommends a course of couples therapy to see if the marriage can be improved. The woman agrees. But when the therapist then suggests that she either break off the affair or tell her husband about it, the woman adamantly refuses. What should the therapist do?

powerful and subtle. When dealing with clients who are having affairs or considering divorce—or mar- riage, for that matter—therapists may be influenced by their own unconscious attitudes as well as clients’ projections. What would you assume, for example, about a therapist whose depressed, married clients all tended to get divorced after their individual therapy? What might you speculate about the level of satisfac- tion in that therapist’s own marriage?

The risk involved in trusting your own judgment in ambiguous ethical situations lies in imposing your own values on what should be a professional decision. The principles of sound ethical practice are broader and may be stricter than our own private morality and good intentions. When in doubt, we recommend that clinicians ask themselves two questions: First, what would happen if the client or important others found out about your actions? Thus, for example, strategi- cally telling two siblings in separate conversations that each is the only one mature enough to end the fighting between them violates the “what if” principle, because it’s entirely possible that one or both might brag to the other about what the therapist said. (Trust me!)

The second question to ask in ethical decision making is, Can you talk to someone you respect about what you’re doing or considering? If you’re afraid to discuss with a colleague that you are treat- ing two married couples in which the wife of one is having an affair with the husband of the other or that you’re considering lending a client money, you may be guilty of the arrogance of assuming that you are above the rules that govern your profession. Feeling compelled to keep something secret suggests that it may be wrong. The road to hell is paved with the as- sumption that this situation is special, that this client is special, or that you are special.

The following red flags signal potentially unethi- cal practices:

♦♦ Specialness—Something about this situation is special; the ordinary rules don’t apply.

♦♦ Attraction—Intense attraction of any kind, not only romantic but also being impressed with the status of the client.

♦♦ Alterations in the therapeutic frame—Longer or more frequent sessions, excessive self-disclosure, being unable to say no to the client, and other

M02_NICH6609_11_SE_C02.indd 41 9/25/15 7:09 PM

42 Part One: The Context of Family Therapy

things that signal a potential violation of profes- sional boundaries.

♦♦ Violating clinical norms—Not referring someone in a troubled marriage for couples therapy, accepting personal counseling from a supervisor, and so on.

♦♦ Professional isolation—Not being willing to dis- cuss your decisions with professional colleagues.

♦♦ ♦♦ ♦

The Marriage and Family Therapy License

In 1964, California created the marriage and family therapy license, and in 2009 Montana became the fiftieth state to offer an MFT license. This milestone added to the legitimacy of the profession and opened doors for inclusion in federal programs such as Sub- stance Abuse and Mental Health Services and the Vet- erans Administration. Today MFT is one of the fastest growing mental health disciples, inclusion in more federal programs is pending, and managed care pan- els are increasingly accepting MFTs.

What does it take to obtain an MFT license? Though requirements vary by state, plan on compet- ing a master’s degree that prepares you to work with couples and families and includes approximately 500 hours of practicum experience, followed by one or two years of post-degree supervised clinical experience, and a state licensing exam. Education and experience requirements vary from state to state and reciprocity is rarely granted; therefore, you must take the licensing exam in whatever state in which you plan to practice.

The MFT license is similar to licensed profes- sional counselors (LPCs) and licensed clinical social workers (LCSWs) in that a master’s degree is the terminal degree and in most states job opportunities and responsibilities are similar. Working systemically with couples and families is the main thing that sets the MFT apart from other master’s level licenses. The MFT license differs most from a license in psychol- ogy. Licensure in psychology requires a doctoral de- gree and extensive training in research and diagnostic testing. Historically, doctoral-level psychologists have been paid more and have had a wider range of job op- portunities. The recent downturn in the economy has changed this somewhat, and many agencies are now

replacing psychology positions with lower-paying master’s level clinicians. It’s unclear whether this trend will continue, but at present licensed MFTs have very good prospects in the job market.

family Therapy with specific presenting problems

Once, most family therapists assumed that their approach could be applied to almost any problem. Today, it has become increasingly common to develop specific techniques for particular populations and problems.

The following are samples of special treatment approaches for two frequently encountered clinical problems: marital violence and sexual abuse of chil- dren. While we hope these suggestions will provide some ideas for dealing with these difficult situations, remember that responsible therapists recognize the limits of their expertise and refer cases they aren’t equipped to handle to more experienced practitioners.

Marital Violence

The question of how to treat marital violence polar- izes the field like no other. The prevailing paradigm is to separate couples, referring the offender to an anger management program and treating his partner in a battered women’s group (Edleson & Tolman, 1992; Gondolf, 1995). Traditional couples therapy is seen as dangerous because placing a violent man and his abused partner in close quarters and inviting them to address contentious issues puts the woman in danger and provides the offender with a platform for self- justification (Bograd, 1984, 1992; Avis, 1992; Hansen, 1993). Treating the partners together implies that they share responsibility for the violence and confers a sense of legitimacy on a relationship that may be malignant.

The argument for seeing violent couples together is that violence is the outcome of mutual provocation— an escalation, albeit unacceptable, of the emotionally destructive behavior that characterizes many relation- ships (Goldner, 1992; Minuchin & Nichols, 1993). When couples are treated together, violent partners can learn to recognize the emotional triggers that set

M02_NICH6609_11_SE_C02.indd 42 9/25/15 7:09 PM

Chapter 2 Basic Techniques of Family Therapy 43

them off and take responsibility for controlling their actions. Their mates can learn to recognize the same danger signals and take responsibility for ensuring their own safety.

Because few systemic therapists advocate treating couples together when the violence has gone beyond pushing and shoving, some of the debate between ad- vocates of a systemic versus an offender-and-victim model is between apples and oranges. Michael Johnson (1995) argues that there are two types of partner violence in families. The first type is patriarchal ter- rorism, which is part of a pattern in which violence is used to exercise control over a partner. Patriarchal terrorism is frequent and severe and tends to escalate over time. The second pattern is common couple vio- lence and doesn’t involve a pattern of power and con- trol. This violence erupts as a response to a particular conflict, is more likely to be mutual, occurs infre- quently, and tends not to escalate. Nevertheless, many feminist thinkers remain opposed to couples therapy when any form of violence is present (Bograd, 1984; Avis, 1992; Hansen, 1993).

In the absence of empirical evidence showing gender-specific group treatment to be safer or more effective than couples therapy (Brown & O’Leary, 1995; Feldman & Ridley, 1995; Smith, Rosen, McColum, & Thomsen, 2004), clinicians remain split into two camps when it comes to the treatment of marital violence. Rather than choose between attempting to resolve the relationship issues that lead to violence or concentrating on providing safety and protection for the victims of violence, it’s possible to combine elements of both approaches—not, however, by doing traditional couples therapy.4

In working with violent couples, there must be no compromise on the issue of safety. A therapist doesn’t have to choose between maintaining thera- peutic neutrality (and focusing on relationship issues) and advocating on behalf of the victim (and focusing on safety). It’s possible to pursue both agendas. Re- lationship issues can be construed as mutual, but the perpetrator must be held responsible for the crime of violence. As Pamela Anderson said when her husband

4The following guidelines draw heavily from the work of Virginia Goldner and Gillian Walker, codirectors of the Gender and Violence Project at the Ackerman Institute.

5Domestic violence is committed by women as well as men, but to avoid having to keep writing “he or she” we will refer to violent partners as “he” and battered mates as “she.”

In cases of domestic violence, couples therapy may be inadvisable unless the man’s violence is infrequent, not physically injurious, not psychologically intimidat- ing, and not fear-producing for his partner.

Ro y

M cM

ah on

/C O

RB IS

Tommy Lee was arrested for domestic battery, “It takes two people to start an argument, but it only takes one to break the other one’s nose.”

In the initial consultation with a couple in which there is a suspicion of violence, it’s useful to meet with the partners together and then separately. Seeing the couple together permits you to see them in action, while speaking with the partners privately allows you to inquire whether either of them has left out infor- mation about the level of violence or other forms of intimidation to which she has been subjected.5

Violent partners and battered mates trigger strong reactions in anyone who tries to help them. When such couples seek therapy, they are often polarized

M02_NICH6609_11_SE_C02.indd 43 9/25/15 7:09 PM

44 Part One: The Context of Family Therapy

between love and hate, blaming and feeling ashamed, wanting to escape and remaining obsessed with each other. Thus, it’s not surprising that professional help- ers tend to react in extremes: siding with one against the other, refusing ever to take sides, exaggerating or minimizing danger, treating the partners like children or like monsters—in other words, splitting into good and bad, just like the dynamics of the couples them- selves. In order to form an alliance with both partners, it’s important to convey respect for them as persons, even if you can’t condone all of their actions.

To assess the level of violence, it’s important to ask direct questions: “How often do conflicts between the two of you end in some kind of violence?” “When did this happen most recently?” “What’s the worst thing that’s ever happened?” It’s important to find out if any incidents have resulted in injuries, if weapons have been used, and if one the woman is currently afraid.

In addition to assessing the level of violence, a therapist must also evaluate the partners’ ability to work constructively in therapy. Is the man willing to accept responsibility for his behavior? Is he argumen- tative or defensive toward his partner? Toward the therapist? Is the woman willing to take responsibility for her own protection, making her physical safety the first priority? Is the couple able to talk together and take turns, or are they so emotionally reactive that the therapist must constantly interrupt to control them?

If a therapist decides to treat the couple together, it’s essential to establish zero tolerance for violence. One way of doing this is to make therapy contingent on no further episodes of physical aggression. Vir- ginia Goldner and Gillian Walker define the first cou- ple of sessions as a consultation to determine whether it’s possible to create a “therapeutic safety zone,” where issues can be confronted without putting the woman in harm’s way. They use these initial sessions to focus on the risk of violence and the question of safety, while reserving the right to terminate the con- sultation and propose other treatment alternatives if they feel the case is too volatile for couples therapy (Goldner, 1998).

With most couples it’s useful to encourage dia- logue as a way of exploring how the partners com- municate. But violent couples tend to be emotionally reactive, and when that’s the case, it’s better to have them take turns talking to the therapist. The therapist

should do everything possible to slow them down and make them think.

One of the best antidotes to emotionality is to ask for specific, concrete details. A good place to start is with the most recent violent incident. Ask each part- ner for a detailed, moment-to-moment description of what happened. Be alert for linguistic evasions (Scott & Straus, 2007). A violent man may describe his ac- tions as the result of his partner’s “provocation” or of “built-up pressures.” Thus, it’s not he who hits his wife; it’s the pressures that are the culprit. A more subtle form of evasion is for the violent partner to describe the problem as his impulsivity. When argu- ments escalate, he starts to “lose it.” In this formula- tion the man’s impulsive actions are not a choice he makes but an unavoidable consequence of emotions welling up inside of him.

To this kind of evasion a therapist might respond “When you say you start to ‘lose it’ let’s think about what you mean. What happened inside of you at that moment that you felt justified in breaking your promise never to hit her again?” The therapeutic task is to hold the man account- able for his violence, while also trying to under- stand him in complex and sympathetic terms. This double agenda is in contrast to either shaming the man, which will only exacerbate his rage, or trying to understand the couple’s dynamics without also holding the man respon- sible for his actions.

Once both partners have begun to take responsi- bility for their actions—he for choosing to control his violent impulses, she for taking steps to ensure her safety—it becomes possible to explore the relation- ship issues that lead to escalating emotional reactivity (Holtzworth-Munroe, Meehan, Rehman, & Marshall, 2002). This does not, however, mean that at a certain point a violent couple can be treated just like any other couple. Exploring the interactional processes that both partners participate in should never be allowed to imply that both are equally responsible for acts of violence.

When the couple is ready to explore relationship issues, it should be possible to encourage dialogue,

M02_NICH6609_11_SE_C02.indd 44 9/25/15 7:09 PM

Chapter 2 Basic Techniques of Family Therapy 45

so that the therapist and couple can understand what transpires when they try to talk with each other. This brings the relationship into the consulting room. It’s one thing to tell a man that he should leave before he gets too angry. It’s another thing to actually observe the beginnings of emotional escalation and ask him if he’s aware that he’s started to get upset and inter- rupt his partner. It then becomes possible to say, “This is the moment when you should leave.” At this same point his partner can be asked if she has begun to feel the first signs of tension and fear.

Taking time-out is an almost universally employed strategy in marital violence programs. Recognizing the cues of escalating anger (racing heart, growing agitation, standing up, pacing) and removing oneself from the situation before violence occurs is encour- aged as a way to head off destructive actions that the partners will later regret. Saying “I’m feeling angry (or scared), and I’m going to take a time-out” helps distinguish this safety device from simply refusing to talk. Each person must be responsible for his or her own time-outs. Telling the other person to take a time-out is not allowed, nor is trying to stop the other from leaving.

Although eliminating the escalating aggressive interactions must be the first priority, couples should also learn more constructive methods of addressing their differences. Here, there is a paradox: Violent partners must learn to control their behavior, but it is counterproductive to stifle their resentments and complaints. In fact, it is precisely this kind of sup- pression that leads to the emotional buildups that re- sult in violent explosions. Moreover, a person who resorts to violence with his or her partner is usually a weak man—weak in the sense of not knowing how to articulate his feelings in a way that his partner can hear. Thus, in helping couples learn to negotiate their differences, it is essential to ensure that both partners learn to speak up and to listen to each other.

Sexual Abuse of Children

When treating a family in which a child has been sexually abused, the primary goals are first to en- sure that the abuse does not recur and second to re- duce the long-term effects of the trauma (Trepper & Barrett, 1989). As with marital violence, treatment

of sexual abuse tends to fall into one of two cate- gories: (1) a child-protective approach, which can undermine the integrity of the family, or (2) a fam- ily systems approach, which can fail to protect the child. We recommend supporting the family while at the same time protecting the child. When these goals seem incompatible—for example, when a father has raped his daughter—protecting the child should take precedence.

Assessment of sexual abuse is often complicated by conflicting stories about what happened (Herman, 1992; Campbell, Cook, LaFleur, & Keenan, 2010). A father may say that touching his daughter’s labia was accidental, whereas the daughter may report that this has happened more than once and that she experiences it as abusive. A grandfather may claim that his caress- ing of his grandson is perfectly innocent, while the district attorney may file charges of indecent assault. A child-protective worker may believe that a mother is tacitly supporting her husband’s abuse of her child, while a family therapist may see a mother who is do- ing her best to save her marriage. Such discrepancies are best resolved by social and legal agencies.

The first priority is restricting unsupervised access to children for the offender. Next a careful assessment should be made to uncover other possible incidents of abuse or patterns of inappropriate sexual expression (Furniss, 1991). The offender must take responsibil- ity for his behavior and receive appropriate treatment for his actions (which may include legal punishment). Often these measures will have already been taken by a child-protective agency before a family is referred for therapy.

One of the goals of therapy should be to estab- lish a support system to break through the isolation that facilitates sexual abuse and inhibits disclosure. For this reason many programs favor a multimodal approach that includes individual, group, and family sessions (Bentovim, Elton, Hildebrand, Tranter, & Vizard, 1988; Trepper & Barrett, 1989; Ramchandani & Jones, 2003). Family sessions should be geared toward increasing support for the victimized child, which may entail strengthening the parental unit.

When a child is the victim of sexual abuse, so- cial control agents may have to step in to protect the child, which can involve taking over what might be considered parental responsibilities. In the long run,

M02_NICH6609_11_SE_C02.indd 45 9/25/15 7:09 PM

46 Part One: The Context of Family Therapy

however, it is the family who will be responsible for the child. Therefore, supporting the parents in devel- oping appropriate ways of carrying out their responsi- bilities, rather than taking over for them, is usually in the best interests of the child.

In cases where a father or stepfather is sent to jail for sexual crimes against his children, part of a ther- apist’s job is to help the family draw a boundary that excludes the offender. The same is true if the chil- dren are taken out of the home and sent to live with relatives or foster parents. Subsequently, however, if reunion is planned, therapy involves gradually re- opening this boundary through visits and phone calls, which gives the family and therapist the opportunity to work together to improve the family’s functioning.

One of the keys to helping resolve the trauma of abuse is to give the child a safe forum to explore his or her complex and often ambivalent feelings about what happened. In addition to feeling violated and an- gry, the child may feel guilty about getting an adult in trouble. Often a child will secretly blame the other parent, usually the mother, for not preventing the abuse. And finally, the child may fear that his or her mother’s dependence on the abuser might result in his return, leaving the child again vulnerable to abuse.

A combination of individual and conjoint sessions helps make it safe to talk about feelings. Meeting first with the nonoffending parent (or parents) allows the mother (or parents) to describe what happened and to express feelings about the abuse without having to edit what she says because the child is present.6 Among the mother’s complex feelings will surely be rage and a sense of betrayal. But a part of her may still love the abuser and miss him if he’s been sen- tenced. She may also feel guilty for not having pro- tected her child. It’s important to make it safe for her to share all of these feelings.

When first meeting with a mother and abused daughter, it’s reassuring to say that although they will probably eventually want to talk about the abuse, it’s up to them to choose where to start. It’s also helpful to give parents and children the choice of how much to talk about the abuse and whether to do so first in

6For the sake of simplicity, the following discussion will assume the common instance of a stepfather as abuser and a mother and her abused daughter as clients.

an individual session or conjointly. If children choose to discuss their feelings privately, they should be re- assured that it’s up to them to decide what they later want to share with their parents.

When meeting with abused children, it’s helpful to explain that the more they talk about what happened, the less troubling their feelings are likely to be. How- ever, it’s essential to let them decide when and how much to open up. Abused children need to recover a sense of control over their lives (Sheinberg, True, & Fraenkel, 1994).

When family members talk about their feelings, it’s wise to keep in mind that feelings don’t come in either/or categories. One way to help make it safe for them to talk about complex and even con- tradictory emotions is to use the metaphor of parts of the self (Schwartz, 1995). Thus, an abused child might be asked, “Does part of you think your mother should have figured out what was happening?” Like- wise, a mother might be asked, “Does part of you miss him?”

One problem with meeting privately with a child is that doing so creates secrets. At the end of a pri- vate session, it’s helpful to ask the child what she wants to share with her family and how she wants to do it. Some children ask the therapist to take the lead in opening up some of what they want their mothers to understand but find it hard to talk about. Finally, although it’s important to help children voice any thoughts they may have about feeling guilty for what happened, after exploring these feelings, abused chil- dren need to hear over and over that what happened was not their fault.

Working with managed care

Rarely has a profession undergone such upheaval as mental health providers experienced with the advent of managed care. Practitioners used to making deci- sions based on their own clinical judgment were now told by the managed care industry which patients they could see, which treatments to apply, what they can charge, and how many sessions they could offer. Pro- fessionals taught to maintain confidentiality in their dealings with patients found themselves negotiating with anonymous strangers over the telephone.

M02_NICH6609_11_SE_C02.indd 46 9/25/15 7:09 PM

Chapter 2 Basic Techniques of Family Therapy 47

Now several decades into its existence, the managed care industry is coming to terms with two important facts. First, while their mandate is still to contain costs, their ultimate responsibility is to see that patients receive effective treatment. Second, de- spite what once seemed to be a built-in adversarial re- lationship with practitioners, industry case managers are discovering something that clinicians should also come to terms with: that both sides profit when they begin to work in partnership.

The key to succeeding in a managed care environ- ment is to get over the sense that the case manager is your enemy. Actually, for those who learn to collab- orate effectively with managed care, case managers can be the best source of referrals.

Learning to work with managed care should begin as early as planning one’s education. Most managed care companies accept licensed practitioners from all major mental health disciplines, though some will only accept certain degrees on their preferred provider lists. So, just as it’s prudent to take state li- censing requirements into account when planning a postgraduate education, it’s also wise to consider the requirements of the major managed care companies. Moreover, because most companies require at least three years of post-degree experience, it’s a good idea to begin your career in a supervised agency. Working in a public agency almost invariably includes regular internal and external oversight and the opportunity not only to refine clinical practices but also to docu- ment them in effective ways.

In areas with a high concentration of mental health providers, it may be necessary to market your skills in order to be selected as a managed care provider. Case managers are always looking for practitioners who can make their jobs easier. Showing willingness to accept crisis referrals and work with difficult cases (e.g., people with borderline personality disorder, chronic and multiproblem clients), being accessible, and having specialized expertise help make therapists attractive to managed care companies.

Once you have the opportunity to become a pro- vider, remember to work with case managers, not against them. Managed care companies maintain databases that include information such as the av- erage number of sessions a professional provides to each client. Outliers who use a significantly greater

number of sessions per client are warned and referrals often decrease. Treatment plans that include clear, measurable objectives are probably the most helpful but most often poorly executed component of clini- cal documentation. Paperwork can be frustrating, but keep in mind that case managers have feelings, too— and they have memories.

Case managers appreciate getting succinct and in- formative reports. When challenged, some therapists fall back on justifying their requests by saying, “It’s my clinical opinion.” Being asked to justify their con- clusions makes some practitioners angry. They feel they are doing their best for their patients, and they’re not used to having someone looking over their shoul- der. Get used to it. If you use sound clinical judg- ment, you should be able to provide reasons for your recommendations.

If you can’t reach agreement with a case manager, don’t lose your temper. If you can’t be friendly, don’t be hostile. Follow the grievance procedure. Do the re- quired paperwork, and submit it on time. Write con- cise, well-defined treatment plans. Return phone calls promptly.

Being successful in the current health care cli- mate means developing a results-oriented mindset. If you’re trained in solution-focused therapy, by all means say so, but don’t try to pass yourself off as something you’re not. Calling yourself “eclectic” is more likely to sound fuzzy than flexible. Your goal is to establish a reputation for working within estab- lished time limits—and getting results.

♦♦ ♦♦ ♦

On March 23, 2010, President Obama signed the Affordable Care Act, often referred to as Obamacare. The goal of the Affordable Care Act is to enhance the quality of health care by lowering costs, increasing provider accountability, and making health insurance available to everybody in the United States. The feasi- bility of these goals and the mechanisms for achieving them have been bitterly divisive political issues, and as a result Affordable Care Act has changed consid- erably since it was signed into law. It is unclear how the new law will affect mental health delivery, but it will likely make mental health services available to a much wider group of patients. The bill’s primary

M02_NICH6609_11_SE_C02.indd 47 9/25/15 7:09 PM

48 Part One: The Context of Family Therapy

impact—that people can no longer be denied health insurance or charged more based on a pre-existing mental illness—will mean that an increased number of patients will have the means to seek mental health care. If you work in a hospital or agency that serves a low-income population, it is anticipated that you will treat more people with severe problems than in the past due to their increased access to health care (Ras- mussen, 2013). How the Affordable Care Act will af- fect private practice is still unclear.

Fee-for-Service Private Practice

Managed care radically changed the face of private practice. While prior to the advent of managed care most therapists were willing to sign insurance forms to allow their patients to be reimbursed, many were unwilling to accept the increased documentation and lower reimbursement rates under managed care. These constraints drove many therapists out of private prac- tice and into agency work. Some practitioners, how- ever, continued their private practices but now insisted that their patients pay 100% of their fees out of pocket.

Although many well-established therapists con- tinue to thrive in fee-for-service practices, it has be- come difficult (nearly impossible in some markets) to begin a private practice and attract cash-paying clients. The Affordable Care Act is expected to fur- ther erode the pool of fee-for-service clients, because many previously uninsured people will now have insurance and therefore be eligible to be treated by therapists accepting managed care. Furthermore, the Affordable Care Act stipulates that people with a Flexible Spending Account (which allows enrollees to set aside pretax money to pay for uncovered medical expenses such as therapy) are only allowed to allocate $2500 per year, which could affect the length of time people remain in treatment. Nevertheless, given that the Affordable Care Act is changing rapidly as it rolls out, it is difficult to anticipate how, if at all, it will af- fect those wishing to establish a private practice.

Despite these uncertainties, there will always be some people in every community who are willing to pay out of pocket for high quality, and truly confiden- tial, mental health services. The challenge for some- one wanting to establish a private practice is to learn how to position oneself in the marketplace to attract

these clients. While doing so requires business savvy that you don’t typically learn in graduate school, es- tablishing and maintaining a fee-for-service practice is nevertheless possible in most metropolitan areas and can be very rewarding.

Your reputation is your most valuable asset for building a fee-for-service practice. Do all you can to establish and maintain a solid reputation, because once it is established your practice will be essentially self-perpetuating. A good reputation starts with your training and skills. The best investment you can make in your career is some form of advanced training af- ter you obtain your graduate degree. Attendance at a training institute or taking a year-long externship will go a long way to helping you master your craft. A se- ries of workshops can stimulate and enhance the skills of experienced practitioners, but it cannot substitute for a protracted immersion in the approach of your choice. Developing a specialty and providing training in that specialty can also help cement your reputation.

Attending networking meetings with other thera- pists is also helpful. Networking sessions can be a great place to meet a private practice mentor who can help show you the ropes in your local marketplace. Most communities have a core of successful private practi- tioners, and many are willing to help mentor someone who seems to have something to offer. Approach these mentors with an attitude of “how can I help you,” rather than “how can you help me.” Offer to assist with mar- keting, practice management, and so on in exchange for advice and counsel, instead of simply asking them to help you. Many states allow pre-licensed therapists to work under the supervision of a therapist in private practice, which is ideal because once you are licensed you will have developed your own caseload.

Marketing is also important to spreading your rep- utation and establishing a successful private practice. If you have a specialty, be sure to network with related professionals. If you work with couples struggling with infertility, be sure to take the local infertility doc- tors to lunch and bring their office staff coffee. Same with divorce lawyers if you work with divorce-related issues; churches, if you focus your practice on a par- ticular religious tradition, and so forth. Offering to give lectures or workshops at local schools or other service organizations in, say parenting, or commu- nication skills is other useful way to attract clients.

M02_NICH6609_11_SE_C02.indd 48 9/25/15 7:09 PM

Chapter 2 Basic Techniques of Family Therapy 49

Building and maintaining an attractive website is vitally important in today’s market. Once you have built a website (it’s inexpensive and relatively easy to create one yourself), search for relevant key words (e.g., “couples therapy,” “anxiety,” or whatever is rele- vant to your practice) and make sure you’re promoting your website on the first page of the search results.

A successful private practice requires management of income and expenses. An ideal office is one that al- lows you to keep overhead low while still projecting competence. Check the fees of local therapists to deter- mine what you should charge for your services. Pricing your services too high, particularly if you are new to the market, will take longer to build your practice. Many clinicians start in the middle, and move up over time.

In most markets if a therapist stays clinically up to date, builds a strong reputation, markets effectively, keeps overhead low, is priced right, and can be patient, he or she can establish a successful private practice.

summary

Getting a whole family to come in; developing a sys- temic hypothesis, pushing for change; knowing when to terminate; being sensitive to ethnicity, gender, and

social class; working with managed care—there’s a lot to learn, isn’t there? Yes, and it takes time. But there are some things you can’t learn, at least not from books.

Personal qualities, such as sincere concern for other people and dedication to making a difference, are also important. Techniques may be the tools, but human qualities are what distinguish the best ther- apists. You can’t be an effective therapist without learning how to intervene, but without compassion and respect for people and their way of doing things, therapy will remain a technical operation, not a cre- ative human endeavor.

Click here to apply your knowledge of chapter concepts.

Click here to test your application and analysis of the content found within this chapter.

M02_NICH6609_11_SE_C02.indd 49 9/25/15 7:09 PM

c h a p t e r 3

Learning OutcOmes ♦♦ Describe the main tenets of cybernetics. ♦♦ Describe the main tenets of systems

theory. ♦♦ Describe the main tenets of social

constructionism. ♦♦ Describe the main tenets of attachment

theory. ♦♦ Describe contemporary working

concepts of family therapy.

The FunDamenTal ConCepTs oF Family Therapy A Whole New Way of Thinking about Human Behavior

Prior to the advent of family therapy, the individual was regarded as the locus of psychological problems and the target

for treatment. If a mother called to complain that her fifteen-year-old son was depressed, a clinician would meet with the boy to find out what was wrong. A Rogerian might look for low self-esteem, a Freudian for repressed anger, and a behaviorist for a lack of reinforcing activities. But all would assume that the forces shaping the boy’s mood were located within him and that therapy, therefore, required only the presence of the patient and a therapist.

Family therapy changed all that. Today, if a mother were to seek help for a depressed teen- ager, most therapists would meet with the boy and his parents together. If a fifteen-year-old is depressed, it’s not unreasonable to assume that something might be going on in his family. Per- haps the boy’s parents don’t get along and he’s worried that they might get divorced. Maybe he’s having a hard time living up to the expecta- tions created by a successful older sister.

Suppose you are the therapist. You meet with the boy and his family and discover that he’s not worried about his parents or jealous of his sister. In fact, everything “is fine” at home. He’s just depressed. Now what?

That now-what feeling is a common experi- ence when you start seeing families. Even when there is something obviously wrong—the boy is worried about his parents, or everybody is shouting and no one is listening—it’s often hard to know where to start. You could start by trying to solve the family’s problems for them. But then you wouldn’t be helping them deal with why they’re having problems.

To address what’s making it hard for a family to cope with their problems, you have to know where to look. For that, you need some way of

50

M03_NICH6609_11_SE_C03.indd 50 9/25/15 7:08 PM

Chapter 3 The Fundamental Concepts of Family Therapy 51

understanding what makes families tick. You need a theory.

When they first began to observe families discussing their problems, therapists could see immediately that everyone was involved. In the clamor of noisy quarrels, however, it’s hard to see beyond personalities—the sullen adolescent, the controlling mother, the distant father—to notice the patterns that connect them. Instead of con- centrating on individuals and their personalities, family therapists consider how problems may be, at least in part, a product of the relationships surrounding them. How to understand those relationships is the subject of this chapter.

Cybernetics

The first and perhaps most influential model of how families operate was cybernetics, the study of feed- back mechanisms in self-regulating systems. What a family shares with other cybernetic systems is a tendency to maintain stability by using information about its performance.

At the core of cybernetics is the feedback loop, the process by which a system gets the information necessary to maintain a steady course. This feedback includes information about the system’s performance and the relationship among the system’s parts.

If you see behavior that persists over time, there is likely a mechanism maintaining that behavior. That mechanism operates through a feedback loop. A con- sistent behavior pattern is the first hint of the existence of a feedback loop. Feedback loops can be negative or positive. This distinction refers to the effect they have on homeostasis, not whether they are beneficial. Negative feedback indicates that a system is straying off the mark and that corrections are needed to get it back on course. It signals the system to restore the sta- tus quo. Thus, negative feedback is not such a negative thing. Its error-correcting information gives order and self-control to automatic machines, to the body and the brain, and to people in their daily lives. Positive feedback reinforces the direction a system is taking.

A

C B

Figure 3.1 Circular Causality of a Feedback Loop

A familiar example of negative feedback occurs in a home heating system. When the temperature drops below a certain point, the thermostat triggers the fur- nace to heat the house back to the pre-established range. It is this self-correcting feedback loop that makes a system cybernetic, and it is the system’s response to change as a signal to restore its previous state that illustrates negative feedback.

Figure 3.1 shows the basic circularity involved in a feedback loop. Each element has an effect on the next, until the last element “feeds back” the cumulative effect into the first part of the cycle. Thus A affects B, which in turn affects C, which feeds back to A, and so on.

In the example of a home heating system, A might be the room temperature, B the thermostat, and C the furnace. Figure 3.2 shows a similar cybernetic feed- back loop for a couple. In this case, Jan’s houseclean- ing efforts (output) affect how much housework gets done, which subsequently affects how much house- cleaning Billie has to do, which then feeds back (in- put) to how much housecleaning Jan thinks still needs to be done, and so on.

Figure 3.2 Feedback Loop in a Couple’s Housecleaning

Jan’s Contribution

Billie’s Contribution Housecleaning

M03_NICH6609_11_SE_C03.indd 51 9/25/15 7:08 PM

52 Part One: The Context of Family Therapy

The cybernetic system turned out to be a useful metaphor for describing how families maintain sta- bility (Jackson, 1959). Sometimes stability is a good thing, as for example, when a family continues to function as a cohesive unit despite being threatened by conflict or stress. Sometimes, however, resisting change is not such a good thing, as when a fam- ily fails to accommodate to the growth of one of its members. More about this later.

Like negative feedback, positive feedback can have desirable or undesirable consequences. If left unchecked, the reinforcing effects of positive feed- back tend to compound a system’s errors, leading to a runaway process. The hapless driver on an icy road who sends positive feedback to his automobile engine by accidentally stepping on the accelerator can spin out of control. Similarly, malignant worry, phobic avoidance, and other forms of neurotic behavior may start out with a relatively trivial concern and escalate into an out-of-control process.

Consider, for example, that a panic attack may start out as a relatively harmless instance of being out of breath, but a panicky response to breathlessness may spiral into a terrifying experience. Or, for a slightly more complex example, take the workings of the fed- eral government. Because presidents generally surround themselves with advisers who share their viewpoint and who, because they are eager to maintain access, tend to support whatever position the president takes. This pos- itive feedback can result in taking a bad policy and run- ning with it—like Lyndon Johnson’s escalation of the Vietnam War. Fortunately, however, the checks and bal- ances provided by the legislative and judicial branches usually provide negative feedback to keep administra- tions from going too far in unwise directions. To survive and adapt to the world around them, all communication systems—including families—need a balance of neg- ative and positive feedback. As we will see, however, early family therapists tended to overemphasize nega- tive feedback and resistance to change.

Cybernetics was the brainchild of MIT math- ematician Norbert Wiener (1948), who devel- oped what was to become the first model of family dynamics in an unlikely setting. During

World War II, Wiener was asked to design a better way to control the targeting of antiaircraft artillery (Conway & Siegelman, 2005). The German bombers blackening the skies over Eu- rope flew at speeds over 300 miles per hour and at altitudes as high as 30,000 feet. The flight of an artillery shell to that height could take as long as twenty seconds, and firing that shot accurately—nearly two miles downrange—was no easy task. Wiener’s solution was to incorpo- rate a system of internal feedback that enabled antiaircraft guns to regulate their own oper- ations. The signal used to control the artillery was a self-regulating servomechanism—the technical term for the first automated machines.

To capture the essence of the new science of control by feedback, Wiener chose the name cybernetics, from the Greek for “steersman.” He distinguished two modes of information, discrete or continuous—digital or analog—and their diverse applications in communication, electronic computing, and automatic control systems. Moreover, he pointed out that the new technical methods of control by informa- tion feedback were, in essence, the same uni- versal processes that nature long ago selected as its basic operating system for all living things (Wiener, 1948). He even suggested that

Norbert Wiener developed cybernetics at MIT.

A lfr

ed E

is en

st ae

dt /P

ix In

c. /T

he L

IF E

Pi ct

ur e

C

ol le

ct io

n/ G

et ty

Im ag

es

M03_NICH6609_11_SE_C03.indd 52 9/25/15 7:08 PM

Chapter 3 The Fundamental Concepts of Family Therapy 53

As applied to families, cybernetics focused atten- tion on: (1) family rules, which govern the range of behavior a family system can tolerate (the family’s homeostatic range); (2) negative feedback mecha- nisms that families use to enforce those rules (guilt, punishment, symptoms); (3) sequences of interaction around a problem that characterize a system’s re- action to it (feedback loops); and (4) what happens when a system’s accustomed negative feedback is in- effective, triggering positive feedback loops.

Examples of positive feedback loops are vicious cycles, in which the actions taken only make things worse. A self-fulfilling prophecy is one such positive feedback loop; one’s apprehensions lead to actions that precipitate the feared situation, which in turn justifies

cybernetic theory could be used to explain mental illnesses as self-reinforcing patterns of behavior—as the brain gets stuck in a biochem- ical rut.

Gregory Bateson learned about cybernetics from Wiener in 1942 at a series of interdisci- plinary meetings called the Macy conferences (Heims, 1991). The dialogues between these two seminal thinkers were to have a profound impact on Bateson’s application of systems the- ory to family therapy.

Because cybernetics emerged from the study of machines, where positive feedback loops led to destructive runaways, causing the machinery to break down, the emphasis was on negative feedback and the maintenance of homeostasis. A system’s environment would change—the temperature would go up or down—and this change would trigger negative feedback mechanisms to bring the system back to homeostasis—the heat would go on or off. Negative feedback loops control everything from endocrine systems to ecosystems. Animal species are balanced by starvation and preda- tors when they overpopulate and by increases in birthrates when their numbers are depleted. Blood sugar levels are balanced by increases in insulin output when they get too high and increases in appetite when they get too low.

one’s fears, and so on. Another example of positive feedback is the bandwagon effect—the tendency of a cause to gain support simply because of its growing number of adherents. You can probably think of some fads and more than a few pop music groups that owe much of their popularity to the bandwagon effect.

As an example of a self-fulfilling prophesy, consider a young therapist who expects men to be uninvolved in family life. She believes that fathers should play an active role in the lives of their children, but her own experience has taught her not to expect much. Suppose she’s trying to arrange for a family consultation, and the mother says that her husband won’t be able to attend. How is our hypothetical therapist likely to respond? She might accept the mother’s statement at face value and thus collude to ensure what she expected. Alternatively, she might challenge the mother’s statement aggressively, thereby displacing her attitude toward men into her relationship with the mother—or push the mother into an oppositional stance with her husband.

Negative political campaigning is a perverse example of positive feedback escalation. One candi- date smears the other, so the other smears back, and so forth, until the voters have no idea whether the candidates have any constructive ideas. The same kind of escalation leads to increasingly intrusive advertis- ing, increasingly loud conversation at parties, longer and longer limousines, bawdier rock bands, and more and more outrageous television reality shows.

One way out of an escalating feedback loop is dis- armament. Or one can simply refuse to compete. If one sibling pushes the other, the second sibling can simply refuse to push back—thereby stopping the process of escalation in its tracks. (But, don’t hold your breath.)

To shift to a family example: in a family with a low threshold for the expression of anger, Marcus, the adolescent son, blows up at his parents over their in- sistence that he not stay out past midnight. Mother is shocked by his outburst and begins to cry. Father re- sponds by grounding Marcus for a month. Rather than reducing Marcus’s deviation—bringing his anger back within homeostatic limits—this feedback produces the opposite effect: Marcus explodes and challenges their authority. The parents respond with more crying and punishing, which further increases Marcus’s anger,

M03_NICH6609_11_SE_C03.indd 53 9/25/15 7:08 PM

54 Part One: The Context of Family Therapy

and so on. In this way, the intended negative feedback (crying and punishing) becomes positive feedback. It amplifies rather than diminishes Marcus’s anger. The family is caught in a positive-feedback runaway, oth- erwise known as a vicious cycle, which escalates until Marcus runs away from home.

Later, cyberneticians like Walter Buckley and Ross Ashby recognized that positive feedback loops aren’t always bad; if they don’t get out of hand, they can help systems adjust to changed circumstances. Marcus’s family might need to recalibrate their rules to accom- modate an adolescent’s increased assertiveness. The crisis that this positive feedback loop produced could lead to a reexamination of the family’s rules—if the family could step out of the loop long enough to get some perspective. In so doing they would be meta- communicating, communicating about their ways of communicating, a process that can lead to a change in a system’s rules (Bateson, 1956).

Family cyberneticians focused on the feedback loops within families, otherwise known as patterns of communication, as the fundamental source of family dysfunction. Hence the family theorists most influenced by cybernetics came to be known as the communications school (see Chapter 5). Faulty com- munication results in inaccurate feedback, so the sys- tem cannot self-correct (evaluate and change its rules) and consequently overreacts or underreacts to change.

systems Theory

Experience teaches that what shows up as one person’s behavior may be a product of relation- ship. The same individual may be submissive in one relationship, dominant in another. Like so many qual- ities we attribute to individuals, submissiveness is only half of a two-part equation. Family therapists use a host of concepts to describe how two people in a relationship contribute to what goes on between them, including pursuer–distancer, overfunctioning– underfunctioning, and control-and-rebel cycles. The advantage of such concepts is that either party can change his or her part in the pattern. But while it’s relatively easy to discover themes in two-person relationships, it’s more difficult to see patterns of

interaction in larger groups like families. That’s why family therapists found systems theory so useful.

Systems theory had its origins in the 1940s, when theoreticians began to construct models of the struc- ture and functioning of mechanical and biological units. What these theorists discovered was that things as diverse as jet engines, amoebas, and the human brain share the attributes of a system—that is, an orga- nized assemblage of parts forming a complex whole.

According to systems theory, the essential proper- ties of a system arise from the relationships among its parts. These properties are lost when a system is re- duced to isolated elements. The whole is greater than the sum of its parts. Thus, from a systems perspec- tive, it would make little sense to try to understand a child’s behavior by interviewing him or her without the rest of the child’s family.

Although some therapists use terms like systemic and systems theory to mean little more than consider- ing families as units, systems actually have a number of specific and interesting properties. To begin with, the shift from looking at individuals to considering the family as a system means shifting the focus to pat- terns of relationship.

Let’s take a simple example. If a father scolds his son, his wife tells him not to be so harsh, and the boy continues to misbehave, a systemic analysis would concentrate on this sequence. For it is sequences of interaction that reveal how systems function. In or- der to focus on inputs and outputs, a systems analysis avoids asking why individuals do what they do.

The most radical expression of this systemic per- spective was the “black box” metaphor: “The im- possibility of seeing the mind ‘at work’ has in recent years led to the adoption of the Black Box concept from telecommunication . . . applied to the fact that electronic hardware is by now so complex that it is sometimes more expedient to disregard the internal structure of a device and concentrate on the study of its specific input–output relations. . . .” (Watzlawick, Beavin, & Jackson, 1967, p. 43) Viewing people as black boxes may seem like the ultimate expression of mechanistic thinking, but this metaphor had the ad- vantage of simplifying the field of study by eliminat- ing speculation about the inner workings of the mind in order to concentrate on their input and output—that is, communication and behavior.

M03_NICH6609_11_SE_C03.indd 54 9/25/15 7:08 PM

Chapter 3 The Fundamental Concepts of Family Therapy 55

Among the features of systems seized on by early family therapists, few were more inf luential than homeostasis, the self-regulation that keeps systems stable. Don Jackson’s notion of family homeostasis emphasized that dysfunctional families’ tendency to resist change went a long way toward explaining why, despite heroic efforts to improve, so many patients remain stuck (Jackson, 1959). Today we look back on this emphasis on homeostasis as exaggerating the conservative properties of families.

Thus, although many of the cybernetic concepts used to describe machines could be extended by anal- ogy to human systems like the family, living systems, it turns out, cannot be adequately described by the same principles as mechanical systems.

General Systems Theory

In the 1940s, an Austrian biologist, Ludwig von Ber- talanffy, attempted to combine concepts from sys- tems thinking and biology into a universal theory of living systems—from the human mind to the global ecosphere. Starting with investigations of the endo- crine system, he began extrapolating to more complex social systems and developed a model that came to be called general systems theory.

Mark Davidson (1983), in his fascinating biog- raphy Uncommon Sense, summarized Bertalanffy’s definition of a system as “any entity maintained by the mutual interaction of its parts, from atom to cosmos, and including such mundane examples as telephone, postal, and rapid transit systems. A Bertalanffian sys- tem can be physical like a television set, biological like a cocker spaniel, psychological like a personality, sociological like a labor union, or symbolic like a set of laws. . . . A system can be composed of smaller systems and can also be part of a larger system, just as a state or province is composed of smaller jurisdic- tions and also is part of a nation.” (p. 26)

The last point is important. Every system is a sub- system of larger systems. But family therapists tended to forget this spreading network of influence. They treated the family as a system while largely ignoring the larger systems of community, culture, and politics in which families are embedded.

Bertalanffy used the metaphor of an organism for social groups, but an organism was an open system,

continuously interacting with its environment. Open systems, as opposed to closed systems (e.g., ma- chines), sustain themselves by exchanging resources with their environment—for example, taking in oxy- gen and expelling carbon dioxide.

Living organisms are active and creative. They work to sustain their organization, but they aren’t motivated solely to preserve the status quo. In an open system, feedback mechanisms process infor- mation from the environment, which helps it adjust. For example, the cooling of the blood from a drop in environmental temperature stimulates centers in the brain to activate heat-producing mechanisms so that temperature is maintained at a steady level. Family therapists picked up on the concept of homeostasis, but according to Bertalanffy, an over- emphasis on this conservative aspect of the organ- ism reduced it to the level of a machine: “If [this] principle of homeostatic maintenance is taken as a rule of behavior, the so-called well-adjusted indivi- dual will be [defined as] a well-oiled robot” (quoted in Davidson, 1983, p. 104).

Unlike mechanical systems, which strive only to maintain a fixed structure, family systems also change when necessary to adapt to new circumstances. Walter Buckley (1968) coined the term morphogenesis to describe this plastic quality of adaptive systems.

To summarize, Bertalanffy brought up many of the issues that have shaped family therapy:

♦♦ A system as more than the sum of its parts ♦♦ Emphasis on interaction within and among

systems versus reductionism ♦♦ Human systems as ecological organisms versus

mechanism ♦♦ Concept of equifinality ♦♦ Homeostatic reactivity versus spontaneous activity.

social Constructionism

Systems theory taught us to see how people’s lives are shaped by their interactions with those around them. But in focusing on behavior, systems theory left something out—actually, two things: how family members’ beliefs affect their actions, and how cul- tural forces shape those beliefs.

M03_NICH6609_11_SE_C03.indd 55 9/25/15 7:08 PM

56 Part One: The Context of Family Therapy

Constructivism

Constructivism captured the imagination of family therapists in the 1980s when studies of brain function showed that we can never really know the world as it exists out there; all we can know is our subjective ex- perience of it. Research on neural nets (von Foerster, 1981) and the vision of frogs (Maturana & Varela, 1980) indicated that the brain doesn’t process images literally, like a camera, but rather registers experience in patterns organized by the nervous system.1 Nothing is perceived directly. Everything is filtered through the mind of the observer.

When this new perspective on knowing was re- ported to the family field by Paul Watzlawick (1984), the effect was a wake-up call—alerting us to the im- portance of cognition in family life.

Constructivism is the modern expression of a phil- osophical tradition that goes back as far as the eigh- teenth century. Immanuel Kant (1724–1804) regarded knowledge as a product of the way our imaginations are organized. The outside world doesn’t simply im- press itself onto the tabula rasa (blank slate) of our minds, as British Empiricist John Locke (1632–1704) believed. In fact, as Kant argued, our minds are any- thing but blank. They are active filters through which we process and interpret the world.

Constructivism found its way into psychotherapy in the personal construct theory of George Kelly (1955). According to Kelly, we make sense of the world by creating our own constructs of the envi- ronment. We interpret and organize events, and we make predictions that guide our actions on the basis of these constructs. You might compare this to see- ing the world through a pair of eyeglasses. Because we may need to adjust constructs, therapy became a matter of revising old constructs and developing new ones—trying on different lenses to see which ones en- able us to navigate the world in more satisfying ways.

The first application of constructivism in family therapy was the technique of reframing—relabeling behavior to shift how family members respond to it. Clients react very differently to a child seen as

1The eye of the frog, for example, doesn’t register much but lateral movement—which may be all you really need to know if your main interest in life is catching flies with your tongue.

“hyperactive” than to one perceived as “misbehaving.” Likewise, the dispirited parents of a rebellious ten-year-old will feel better about themselves if they become convinced that, rather than being “ineffective disciplinarians,” they have an “oppositional child.” The first diagnosis suggests that the parents should get tough but also that they probably won’t succeed. The second suggests that coping with a difficult child requires strategizing. The point isn’t that one descrip- tion is more valid than the other, but rather that if whatever label a family applies to its problems leads to ineffective coping strategies, then perhaps a new label will alter their viewpoint and lead to a more effective response.

When constructivism took hold of family ther- apy in the 1980s, it triggered a fundamental shift in emphasis. Systems metaphors focused on behavior; constructivism shifted the focus to the assumptions people have about their problems. The goal of therapy changed from interrupting problematic patterns of in- teraction to helping clients find new perspectives on their lives.

Constructivism teaches us to look beyond behavior to the ways we interpret our experience. In a world where all truth is relative, the perspective of the ther- apist has no more claim to objectivity than that of the clients. Thus constructivism undermined the status of the therapist as an impartial authority with privileged knowledge of cause and cure. It’s probably well to re- member that even our most cherished metaphors of family life—system, enmeshment, dirty games, trian- gles, and so on—are just that: metaphors. They don’t exist in some objective reality; they are constructions, some more useful than others.

In emphasizing the idiosyncratic perspective of the individual, constructivists were accused by some (e.g., Minuchin, 1991) of ignoring the social context. Once that solipsistic streak was pointed out, leading constructivists clarified their position: When they said that reality was constructed, they meant socially constructed.

The Social Construction of Reality

Social constructionism expanded constructivism much as family therapy expanded individual psy- chology. Constructivism says that we relate to the

M03_NICH6609_11_SE_C03.indd 56 9/25/15 7:08 PM

Chapter 3 The Fundamental Concepts of Family Therapy 57

world on the basis of our own interpretations. Social constructionism points out that those interpretations are shaped by our context.

If a fourteen-year-old consistently disobeys his parents, a constructivist might point out that the boy may not think they deserve his respect. In other words, the boy’s actions aren’t simply a product of the parents’ disciplinary efforts but also of the boy’s construction of their authority. A social construction- ist would add that an adolescent’s attitudes about pa- rental authority are shaped not only by what goes on in the family but also by messages transmitted from the culture at large.

At school or work, at lunch, in phone conversa- tions, at the movies, and from television, we absorb attitudes and opinions that we carry into our families. Television, to pick one very potent influence on the average fourteen-year-old, has made today’s children more sophisticated and more cynical. What commu- nications scholar Joshua Meyrowitz (1985) said over thirty years ago in No Sense of Place is even more true now: today’s children are exposed to the “back stage” of the adult world, to otherwise hidden doubts and conflicts, foolishness and failures of adult types they see on TV. This demystification undermines ad- olescent trust in traditional authority structures. It’s hard to respect adult wisdom when your image of a parent is Homer Simpson.

Both constructivism and social constructionism focus on interpretation of experience as a mediator of behavior. But while constructivists emphasized the subjective mind of the individual, social con- structionists place more emphasis on the intersub- jective influence of language and culture (Lock & Strong, 2010). According to constructivism, people have problems not merely because of the objec- tive conditions of their lives but also because of their interpretation of those conditions. What social constructionism adds is a recognition of how such meanings emerge in the process of talking with other people.

Therapy then becomes a process of deconstruction— freeing clients from the tyranny of entrenched beliefs. How this plays out in practice is illustrated in two of the most influential new versions of family therapy: the solution-focused model and narrative therapy.

Inherent in most forms of therapy is the idea that before you can solve a problem, you must figure out what’s wrong. This notion seems self-evident, but it’s a construction—one way of looking at things. Solution-focused therapy turns this assumption on its head, using a totally different construction—namely, that the best way to solve problems is to discover what people do when they’re not having the problem.

Suppose a woman complains that her husband never talks to her. Instead of trying to figure out what’s wrong, a solution-focused therapist might ask the woman if she can remember exceptions to this complaint. Perhaps she and her husband do have good conversations when they go for a walk or out to dinner. In that case, the therapist might sim- ply suggest that they do more of that. We’ll see how solution- focused therapy builds on the insights of constructivism in Chapter 11.

Like their solution-focused colleagues, narrative therapists create a shift in their clients’ experience by helping them reexamine how they look at things. But whereas solution-focused therapy shifts attention from current failures to past successes in order to mobilize behavioral solutions, narrative therapy’s aim is broader and more attitudinal. The decisive technique in this approach—externalization—involves the truly radical reconstruction of defining problems not as properties of the persons who suffer them but as alien oppressors. Thus, for example, while the parents of a boy who doesn’t keep up with his homework might define him as lazy or a procrastinator, a narrative therapist would talk instead about times when “Procrastination” gets the better of him—and times when “It” doesn’t.

Notice how the former construction—“The boy is a procrastinator”—is relatively deterministic, while the latter—“Procrastination sometimes gets the better of him”—frees the boy from a negative identity, and turns therapy into a struggle for liberation. We’ll talk more about narrative therapy in Chapter 12.

attachment Theory

As the field matured, family therapists showed a re- newed interest in the inner life of the individuals who make up the family. Now, in addition to theo- ries about the broad, systemic influences on family

M03_NICH6609_11_SE_C03.indd 57 9/25/15 7:08 PM

58 Part One: The Context of Family Therapy

members’ behavior, attachment theory has emerged as a leading tool for describing the deeper roots of close relationships.

Attachment theory has been especially fruitful in couples therapy (e.g., Johnson, 2002), where it helps explain how even healthy adults need to depend on each other. In the early years of family therapy, couples treatment was a therapy without a theory. With few exceptions, therapists treated couples with models designed for families (e.g., Minuchin, 1974; Haley, 1976; Bowen, 1978). The exception was behaviorists, who implied that intimacy was a product of reinforcement. Nobody talked much about love or longing. Dependency might be okay for children, but in adults, we were told, it was a sign of enmeshment.

In emotionally focused couples therapy, Susan Johnson uses attachment theory to deconstruct the familiar dynamic in which one partner criticizes and complains while the other gets defensive and with- draws. What attachment theory suggests is that the criticism and complaining are protests against disrup- tion of the attachment bond—in other words, the nag- ging partner may be more insecure than angry.

The notion that how couples deal with each other reflects their attachment history can be traced to the pioneering studies of John Bowlby and Mary Ainsworth. When Bowlby graduated from Cambridge in the 1940s, it was assumed that infants became attached to their mothers as a consequence of being fed. But Konrad Lorenz (1935) showed that baby geese become attached to parents who don’t feed them, and Harry Harlow (1958) found that, un- der stress, infant monkeys prefer the cloth-covered “mothers” that provided contact comfort to the wire- mesh “mothers” that provided food. Human babies, too, become attached to people who don’t feed them (Ainsworth, 1967).

In the 1940s and 1950s, a number of studies found that young children who were separated from their mothers go through a series of reactions that can be described as protest, despair, and finally detachment (e.g., Burlingham & Freud, 1944; Robertson, 1953). In attempting to understand these reactions, Bowlby (1958) concluded that the bond between infants and their parents was based on a biological drive for proximity that evolved through the process of natural selection. When danger threatens, infants

who stay close to their parents are less likely to be killed by predators. Bowlby called this bond “attachment.”

Attachment means seeking closeness in the face of stress. Attachment can be seen in cuddling up to mother’s warm body and being cuddled in return, looking into her eyes and being looked at fondly, and holding on to her and being held. These experiences are profoundly comforting.

The child who has secure attachment experiences will develop a sense of basic security and will not be subject to morbid fears of being helpless, abandoned, and alone in the world. But the opposite is also true. Insecure attachment poisons a child’s self-confidence. When threats arise, infants in secure relationships are able to direct attachment behavior (approaching, cry- ing, reaching out) to their caregivers and take comfort in their reassurance (Bowlby, 1988). Infants with se- cure attachments are confident in the availability of their caregivers and, consequently, confident in their interactions in the world.

If a child’s caregivers are generally unavailable or unresponsive to the child’s needs, that child de- velops a sense of shame around those needs; such children doubt the validity of their needs, and feel bad for having them. They also come to believe that others cannot be depended on. They develop an in- secure attachment (Bowlby, 1988). Insecure attach- ment generally falls into two categories: anxious and avoidant.

Anxiously attached children tend to have overly protective and intrusive parents. These children learn that the validity of their needs must be approved by their caregivers. As a result, over time, these children find it increasingly difficult to identify what they truly feel. Anxiously attached children cling to their care- givers; the message from the caregivers’ intrusiveness is that the world is a dangerous place—you need me to manage it (Ainsworth, 1967). As an adult, anx- iously attached individuals often suffer from depres- sion and anxiety as they habitually give in to others’ demands and work hard to please people. When their emotional security is threatened in adult romantic relationships, anxiously attached individuals try to restore a comfortable level of emotional closeness by frantically pulling their partner closer out of fear of losing them (Bowlby, 1973). Fear of abandonment—

M03_NICH6609_11_SE_C03.indd 58 9/25/15 7:08 PM

Chapter 3 The Fundamental Concepts of Family Therapy 59

“terror” might be the better term in order to convey how all-consuming it is—haunts some people like nothing else.

Avoidantly attached children tend to have emo- tionally unavailable parents. The child will make initial attempts at seeking comfort from his or her caregiver, but when it becomes apparent that the care- giver will not respond, the child eventually gives up. A similar pattern happens with exploring—the child may start to venture out, but often gives up when faced with challenges (Ainsworth, 1967). These chil- dren learn that others will not be responsive to their needs, and in an attempt to avoid the pain of rejection, they try to cut off or otherwise not feel those unmet needs. When faced with insecurity in their intimate attachment relationships, avoidantly attached adults will often become distant and aloof in an effort to not need their partners and therefore not feel hurt by their rejection (Bowlby, 1973).

One of the things that distinguishes attach- ment theory is that it has been extensively studied. What is clear is that it is a stable and inf luential trait throughout childhood. The type of attach- ment shown at twelve months predicts: (1) type of attachment at eighteen months (Waters, 1978; Main & Weston, 1981); (2) frustratability, per- sistence, cooperativeness, and task enthusiasm at eighteen months (Main, 1977; Matas, Arend, & Sroufe, 1978); (3) social competence of pre- schoolers (Lieberman, 1977; Easter brook & Lamb, 1979; Waters, Wippman, & Sroufe, 1979); and (4) self-esteem, empathy, and classroom deportment (Sroufe, 1979). The quality of relationship at one year is an excellent predictor of quality of relating up through five years, with the advantage to the securely attached infant.

What is less clearly supported by research is the proposition that styles of attachment in childhood are correlated with attachment styles in adult relation- ships. Nevertheless, the idea that romantic love can be conceptualized as an attachment process (Hazan & Shaver, 1987) remains a compelling if as yet un- proven proposition. What the research has established is that individuals who are anxious over relationships report more relationship conf lict, suggesting that some of this conflict is driven by basic insecurities over love, loss, and abandonment. Those who are

anxious about their relationships often engage in co- ercive and distrusting ways of dealing with conflict, which are likely to bring about the very outcomes they fear most (Feeney, 1995).

Thus attachment theory offers a deeper under- standing of the dynamics of familiar interactional problems. For example, a common pursue/withdraw pattern emerges when an anxiously attached part- ner pursues closeness while an avoidantly attached partner withdraws emotionally. Even though the un- derlying motivation for each partner is to establish emotional safety and closeness, their attachment fears of rejection lead them to act in a way that pushes their partner away, thus giving each of them less of what they long for (Johnson, 2002). Their solution has be- come the problem.

Being able to see behind a person’s pursuing or distancing behavior to the underlying desire for connection and security can be one of a therapist’s most useful insights. Interactions soften and shift when couples are helped to see and express their anxious pursuing as a fear of losing their partners, or their avoidant withdrawal as a fear of failure. A similar shift can occur between parents and children as parents are helped to understand some of their children’s disruptive behavior as stemming from the child’s anxiety about the parents’ availability and responsiveness.

♦♦ ♦♦ ♦

After reading this chronology of how theories in family therapy have evolved, the reader may feel overwhelmed by the number of paradigm shifts in the field. It may help to point out a pattern in this apparent discontinuity. The focus of therapy has expanded to- ward ever-wider levels of context. This process started when therapists looked beyond individuals to their families. Suddenly, unexplainable behavior began to make sense. Early family therapists focused on behav- ioral interactions surrounding problems. Next it was recognized that those interactions were manifestations of a family’s underlying structure, and structure be- came the target of change. Then family structure was seen to be a product of multigenerational processes that were governed by belief systems, and therapists aimed their interventions at those underlying beliefs.

M03_NICH6609_11_SE_C03.indd 59 9/25/15 7:08 PM

60 Part One: The Context of Family Therapy

More recently it dawned on therapists that these belief systems don’t arise in a vacuum, hence the current in- terest in cultural influences.

♦♦ ♦♦ ♦

Family therapists, naturalists on the human scene, discovered how behavior is shaped by transactions we don’t always see. Systems concepts—feedback, circularity, and so on—helped make complex inter- actions predictable. In keeping with our emphasis on how ideas are actually applied in clinical practice, we will now consider the fundamental working concepts of family therapy.

The Working Concepts of Family Therapy

Interpersonal Context

The fundamental premise of family therapy is that people are products of their context. Because few people are closer to us than our parents and partners, this notion can be translated into saying that a person’s behavior is powerfully inf luenced by interactions with other family members. Thus the importance of context can be reduced to the importance of family. It can be, but it shouldn’t be.

Although the family is often the most relevant context for understanding behavior, it isn’t always. A depressed college student, for example, might be more unhappy about what’s going on in the dormitory than about what’s happening at home.

The clinical significance of context is that attempts to treat individuals by talking to them once a week may have less influence than their interactions during the remaining 167 hours of the week. Or to put this positively, often the most effective way to help people resolve their problems is to meet with them together with important others in their lives.

Complementarity

Complementarity refers to the reciprocity that is the defining feature of every relationship. In any relation- ship one person’s behavior is yoked to the other’s.

Remember the symbol for yin and yang, the mascu- line and feminine forces in the universe?

Notice how the two parts are complementary and occupy one space. Relationships are like that. If one person changes, the relationship changes. If Tony starts doing more grocery shopping, Anne likely does less.

Family therapists should think of complementarity whenever they hear one person complaining about another. Take, for example, a husband who says that his wife nags. “She’s always complaining.” From the perspective of complementarity, a family therapist would assume that the wife’s complaining is only half of a pattern of mutual influence. When people are perceived as nagging, it probably means that they haven’t received a fair hearing for their concerns. Not being listened to by John makes Mary feel angry and unsupported. No wonder she comes across as nag- ging. If instead of waiting for her to complain, John starts asking her how she feels, Mary will feel like he cares about her. Or at least she’s likely to feel that way. Complementarity doesn’t mean that people in relationships control each other; it means that they in- fluence each other.

A therapist can help family members get past blaming—and the powerlessness that goes with it— by pointing out the complementarity of their actions. “The more you nag, the more he ignores you. And the more you ignore her, the more she nags.”

Circular Causality

Before the advent of family therapy, explanations of psychopathology were based on linear models: medi- cal, psychodynamic, or behavioral. Etiology was con- ceived in terms of prior events—disease, emotional conf lict, or learning history. With the concept of circularity, Bateson helped change the way we think about psychopathology, from something caused by

M03_NICH6609_11_SE_C03.indd 60 9/25/15 7:08 PM

Chapter 3 The Fundamental Concepts of Family Therapy 61

events in the past to something that is part of ongoing, circular feedback loops.

The notion of linear causality is based on the New- tonian model in which the universe is like a billiard ta- ble where the balls act unidirectionally on each other. Bateson believed that while linear causality is useful for describing the world of objects, it’s a poor model for the world of living things, because it neglects to account for communication and mutual influence.

To illustrate this difference, Bateson (1979) used the example of a man kicking a stone. The effect of kicking a stone can be predicted by measuring the force and angle of the kick and the weight of the stone. If the man kicks a dog, on the other hand, the effect would be less predictable. The dog might respond in any number of ways—cringing, running away, biting, or trying to play—depending on the temperament of the dog and how it interpreted the kick. In response to the dog’s reaction, the man might modify his behavior, and so on, so that the number of possible outcomes is unlimited.

The dog’s actions (e.g., biting) loop back and af- fect the man’s next moves (e.g., taking the Lord’s name in vain), which in turn affect the dog, and so on. The original action prompts a circular sequence in which each subsequent action recursively affects the other. Linear cause and effect is lost in a circle of mutual influence.

This idea of mutual or circular causality is enor- mously useful for therapists because so many families come in looking to find the cause of their problems and determine who is responsible. Instead of join- ing the family in a logical but unproductive search for who started what, circular causality suggests that problems are sustained by an ongoing series of ac- tions and reactions.

Triangles

Most clients express their concerns in linear terms. It might be a four-year-old who is “unmanageable” or perhaps an ex-wife who “refuses to cooperate” about visitation rights. Even though such complaints sug- gest that the problem resides in a single individual, most therapists would think to look for relationship issues. “Unmanageable” four-year-olds often turn out to have parents who are ineffective disciplinarians,

and ex-wives who are “unreasonable” probably have their own sides of those stories. So a therapist, cer- tainly a family therapist, would probably want to see the four-year-old together with her parents and to meet with both the angry father and his ex-wife.

Let’s suppose that the therapist who meets with the four-year-old and her parents sees that indeed the real problem is a lack of discipline. The mother com- plains that the girl never does what she’s told, the fa- ther nods in agreement, and the child runs around the room ignoring her mother’s requests to sit still. Maybe the parents could use some advice about setting limits. Perhaps. But experience teaches that a child who mis- behaves is often standing on one parent’s shoulders. When children are disobedient, it usually means that their parents are in conflict about the rules or how to enforce them.

Perhaps the father is a strict disciplinarian. If so, his wife might feel that she needs to protect her daughter from her husband’s harshness, and so she becomes more of a friend and ally to her child than a parent-in-charge.

Some parents are so angry with each other that their disagreements are plain to see. But many are less open. Their conflicts are painful, so they keep them private. Maybe they think that their relationship is none of the therapist’s business, or perhaps the father has decided that if his wife doesn’t like how he does things, “then she can damn well do them herself!” The point is this: Relationship problems often turn out to be triangular (Bowen, 1978), even though it may not always be apparent.

A less obvious example of triangular complica- tions often occurs in the case of divorced parents who fight over visitation rights. Most divorces generate enough hurt and anger to make a certain amount of animosity inevitable. Add to that a healthy dose of pa- rental guilt (felt and projected), and you would seem to have a formula for arguments about who gets the kids for holidays, whose turn it is to buy new sneak- ers, and who was late picking them up or dropping them off last weekend. Meeting with the embattled exes is likely to do little to disconfirm the assump- tion that the problem is between the two of them. Yet even two people who are very angry at each other will eventually find a way to work things out—unless third parties mix in.

M03_NICH6609_11_SE_C03.indd 61 9/25/15 7:08 PM

62 Part One: The Context of Family Therapy

What do you suppose happens when a divorced fa- ther complains to his girlfriend about his ex’s “unrea- sonableness”? The same thing that usually happens when one person complains about another. The girl- friend sympathizes with him and, often as not, urges him to get tough with his ex. Meanwhile the mother is equally likely to have a friend encouraging her to become more aggressive. Thus, instead of two people left to work things out between them, one or both of them is egged on to escalate their conflict.

Do all relationship problems involve third parties? No, but most do.

Process/Content

Focusing on the process of communication (how peo- ple talk), rather than its content (what they talk about), may be the single most productive shift a family ther- apist can make. Imagine, for example, that a therapist encourages a moody freshman to talk to her parents. Imagine further that the young woman rarely expresses herself in words but rather in passive-aggressive pro- test and that her parents are, in contrast, all too good at putting their opinions into words. Suppose that the young woman finally begins to express her feeling that college is a waste of time, and her parents counter with an argument about the importance of staying in school. A therapist made anxious by the idea that the young woman might actually drop out of college who intervenes to support the content of the parents’ posi- tion will miss an opportunity to support the process whereby the young woman learns to put her feelings into words, rather than into self-destructive actions.

Families who come for treatment are usually fo- cused on content. A husband wants a divorce, a child refuses to go to school, a wife is depressed. The fam- ily therapist talks with the family about the content of their problems but thinks about the process by which they try to resolve them. While the family discusses what to do about the child’s refusal to go to school, the therapist notices whether the parents seem to be in charge and whether they support each other. A ther- apist who tells the parents how to solve the problem (by making the child go to school) is working with content, not process. The child may start going to school, but the parents won’t have improved their decision-making process.

Sometimes, of course, content is important. If a wife is drinking to drown her worries or a husband is molesting his stepdaughter, something needs to be done. But to the extent that therapists focus exclu- sively on content, they’re unlikely to help families become better functioning systems.

Family Structure

Family interactions are predictable—some might say stubborn—because they are embedded in pow- erful but unseen structures. Dynamic patterns, like pursuer/distancer, describe the process of interac- tion; structure defines the organization within which those interactions take place. Initially, interactions shape structure; but once established, structure shapes interactions.

Families, like other groups, have many options for relating. Soon, however, interactions that were initially free to vary become regular and predictable. Once these patterns are established, family members use only a fraction of the full range of alternatives available to them (Minuchin & Nichols, 1993). Families are structured in subsystems—determined by generation, gender, and function—which are demarcated by interpersonal boundaries, invisible barriers that regulate the amount of contact with oth- ers (Minuchin, 1974).

Like the membranes of living cells, boundaries safeguard the integrity of the family and its subsys- tems. By spending time alone together and exclud- ing friends and family from some of their activities, a couple establishes a boundary that protects their relationship from intrusion. Later, if they marry and have children, that boundary is preserved by making time to be alone together without the children. If, on the other hand, the couple includes their children in all of their activities, the boundary separating the generations wears thin and the couple’s relationship is sacrificed to parenting. Moreover, if their parents are involved in all of their activities, children won’t develop autonomy or initiative.

Psychoanalytic theory also emphasizes the need for interpersonal boundaries. Beginning with “the psy- chological birth of the human infant” (Mahler, Pine, & Bergman, 1975), psychoanalysts describe the pro- gressive separation and individuation that culminates

M03_NICH6609_11_SE_C03.indd 62 9/25/15 7:08 PM

Chapter 3 The Fundamental Concepts of Family Therapy 63

in the resolution of oedipal attachments and eventu- ally in leaving home. But this is a one-sided emphasis on poorly defined boundaries. Psychoanalysts pay in- sufficient attention to the problems of emotional iso- lation stemming from rigid boundaries. This belief in separation as the model and measure of maturity may be an example of male psychology overgeneralized and unquestioned. The danger of people losing them- selves in relationships is no more real than the danger of their isolating themselves from intimacy.

What family therapists discovered is that problems result when boundaries are either too rigid or too diffuse. Rigid boundaries permit little contact with outside systems, resulting in disengagement. Dis- engagement leaves people independent but isolated; it fosters autonomy but limits affection and nurture. Enmeshed subsystems have diffuse boundaries: They offer access to support, but at the expense of indepen- dence. Enmeshed parents are loving and attentive; however, their children tend to be dependent and may have trouble relating to people outside their family. Enmeshed parents respond too quickly to their chil- dren; disengaged parents respond too slowly.

Another important point about boundaries is that they are reciprocal. A mother’s enmeshment with her children is related to the emotional distance between her and her husband. The less she gets from her hus- band, the more she needs from her children—and the more preoccupied she is with her children, the less time she has for her husband.

It should not go unnoticed that these arrangements are gendered. This doesn’t make them any more right or wrong. But it should make us cautious about blam- ing mothers for cultural expectations that perpetuate their role as primary caretakers of children (Luepnitz, 1988). A therapist who recognizes the normative na- ture of the enmeshed-mother/disengaged-father syn- drome but puts the burden on the mother to let go should ask himself why it doesn’t occur to him to challenge the father to take hold.

Family Life Cycle

When we think of the life cycle, we tend to think of individuals moving through time, mastering the chal- lenges of one period, and then moving on to the next. The cycle of human life may be orderly, but it’s not

a steady, continuous process. We progress in stages with plateaus and developmental hurdles that demand change. Periods of growth and change are followed by periods of relative stability during which changes are consolidated.

The idea of a family life cycle adds two things to our understanding of individual development: First, families must reorganize to accommodate to the growth of their members; second, developments in any of the family’s generations may have an im- pact on one or all of the family’s members. When a son or daughter heads off to kindergarten or reaches puberty, not only must the child learn to cope with a new set of circumstances, but the whole family must readjust. Moreover, the developmental transitions that affect children aren’t merely their own but their parents’ as well—in some cases, even their grandpar- ents’. The strain on a fourteen-year-old’s relationship with his parents may be due as much to his father’s midlife crisis or his mother’s worrying about her own father’s retirement as anything the boy himself is go- ing through.

Changes in one generation complicate adjustments in another. A middle-aged father may become disen- chanted with his career and decide to become more involved with his family just as his children are grow- ing up and pulling away. His wish to get closer may frustrate their need to be on their own. Or to cite an- other example becoming more and more familiar, just as a man and woman begin to do more for themselves after launching their children, they may find the chil- dren back in the house (after dropping out of school, being unable to afford housing, or recovering from an early divorce) and therefore be faced with an awk- ward version of second parenthood.

One property that families share with other com- plex systems is that they don’t change in a smooth, gradual process, but rather in discontinuous leaps. Falling in love and political revolutions are examples of such leaps. Having a baby is like falling in love and undergoing a revolution at the same time.

Sociologists Evelyn Duvall and Reuben Hill ap- plied a developmental framework to families in the 1940s by dividing family life into discrete stages with tasks to be performed at each stage (Duvall, 1957; Hill & Rodgers, 1964). Family therapists Betty Carter and Monica McGoldrick (1980, 1999) enriched this

M03_NICH6609_11_SE_C03.indd 63 9/25/15 7:08 PM

64 Part One: The Context of Family Therapy

Family Life-Cycle Stage

Emotional Process of Transition: Key Principles

Second-Order Changes in Family Status Required to Proceed Developmentally

Leaving home: single young adults

Accepting emotional and financial responsibility for self

a. Differentiation of self in relation to family of origin b. Development of intimate peer relationships c. Establishment of self in respect to work and financial

independence

The joining of families through marriage: the new couple

Commitment to new system

a. Formation of marital system b. Realignment of relationships with extended families

and friends to include spouse

Families with young children

Accepting new members into the system

a. Adjusting marital system to make space for children 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 family boundaries to permit children’s independence and grandparents’ frailties

a. Shifting of parent–child relationships to permit adolescent to move into and out of system

b. Refocus on midlife marital and career issues c. Beginning shift toward caring for older generation

Launching children and moving on

Accepting a multitude of exits from and entries into the family system

a. Renegotiation of marital system as a dyad b. Development of adult-to-adult relationships c. Realignment of relationships to include in-laws and

grandchildren d. Dealing with disabilities and death of parents

(grandparents)

Families in later life Accepting the shifting generational roles

a. Maintaining own and/or couple functioning and 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

experience 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

tabLe 3.1 stages of the Family life Cycle

framework by adding a multigenerational point of view, recognizing culturally diverse patterns and con- sidering stages of divorce and remarriage (Table 3.1).

It’s important to recognize that there is no uni- versal version of the family life cycle. Not only do families come in a variety of forms—single- parent fam- ilies, same-sexed couples, stepfamilies—but various religious, cultural, and ethnic groups may have different norms for various stages. The real value of the life- cycle concept isn’t so much defining what’s normal or ex- pected at particular stages but recognizing that families often develop problems at transitions in the life cycle.

Problems develop when a family encounters a challenge—environmental or developmental—and is unable to accommodate to the changed circum- stances. Thus problems are usually assumed to be a sign not of a dysfunctional family but simply of one that’s failed to readjust at one of life’s turning points.

Family Narratives

The first family therapists looked beyond individ- uals to their relationships to explain how prob- lems were perpetuated. Actions, it turned out, were

M03_NICH6609_11_SE_C03.indd 64 9/25/15 7:08 PM

Chapter 3 The Fundamental Concepts of Family Therapy 65

embedded in interactions—and, of course, the most obvious interactions are behavioral. Double binds, problem-maintaining sequences, aversive con- trol, triangles—these concepts all focused on behav- ior. But in addition to being actors in each other’s lives, family members are also storytellers.

By reconstructing the events of their lives in coher- ent narratives, family members are able to make sense of their experience (White & Epston, 1990). Thus, it is not only actions and interactions that shape a fam- ily’s life but also the stories they construct. The par- ents of a two-year-old who tell themselves that he’s “defiant” will respond very differently than parents who tell themselves that their little one is “spunky.”

Family narratives organize and make sense of ex- perience. They emphasize certain events that rein- force the plot line and filter out events that don’t fit. The parents who see their two-year-old as defiant are more likely to remember times she said no than times she said yes.

Interest in family narrative has become identified with one particular school, Michael White’s narrative therapy, which emphasizes the fact that families with problems come to therapy with defeatist narratives that tend to keep them from acting effectively. But a sensi- tivity to the importance of personal narrative is a useful part of any therapist’s work. However much a therapist may be interested in the process of interaction or the structure of family relationships, he or she must also learn to respect the influence of how family members experience events—including the therapist’s input.

Gender

When family therapists first applied the systems metaphor—an organization of parts plus the way they function together—they paid more attention to the or- ganization than to the parts. Families were understood in terms of abstractions like boundaries, triangles, and parental subsystems, while family members were sometimes treated as cogs in a machine. The parts of a family system never cease being individual human beings, but the preoccupation with the way families were organized tended to obscure the personhood of the individuals who made up the family, including their psychodynamics, psychopathology, personal responsibility—and gender.

Common sense tells us that gender is a fact of life (though no one should underestimate social scientists’ ability to transcend common sense). As long as society expects the primary parenting to be done by mothers, girls will shape their identities in relation to some- one they expect to be like, while boys will respond to their difference as a motive for separating from their mothers. The result is what Nancy Chodorow (1978) called “the reproduction of mothering.”

Traditionally, women have been raised to have more permeable psychological boundaries, to de- velop their identities in terms of connection, to cul- tivate their capacity for empathy, and to be at greater risk for losing themselves in relationships. Men, on the other hand, tend to emerge with more rigid psy- chological boundaries and disown their dependency needs, fear being engulfed, and often have greater difficulty empathizing with others. We all know men who are nurturing and women who are not, but these are exceptions that prove the rule.

Awareness of gender and gender inequity has long since penetrated not only family therapy but our en- tire culture. Translating this awareness into concrete clinical practice, however, is complicated.

There is room for disagreement between those who strive to maintain clinical neutrality and those who be- lieve that failing to raise gender issues in treatment— money, power, child care, fairness, and so on—runs the risk of reinforcing traditional roles and social arrange- ments (Walters, Carter, Papp, & Silverstein, 1988). However, it is not possible to be a fair and effective therapist without being sensitive to how gender issues pervade the life of the family. A therapist who ignores gender may inadvertently show less interest in a wom- an’s career, assume that a child’s problems are primarily the mother’s responsibility, have a double standard for extramarital affairs, and expect—or at least tolerate—a father’s nonparticipation in the family’s treatment.

If patriarchy begins at home, a gender-sensitive therapist must recognize the enduring significance of early experience and of unconscious fantasies. How children respond to their parents has significance not only for how they get along but also for the men and women they will become. When a girl speaks deri- sively about her “bitchy” mother, she may inadver- tently be disparaging the female in herself. In addition to identification with the same-sex parent, the child’s

M03_NICH6609_11_SE_C03.indd 65 9/25/15 7:08 PM

66 Part One: The Context of Family Therapy

relationship with the other parent is part of what pro- grams future experience with the opposite sex.

A gender-sensitive therapist must also avoid po- tential inequities in some of the basic assumptions of family therapy. The notion of circular causality, for example, which points to mutually reinforcing patterns of behavior, when applied to problems such as batter- ing, incest, or alcoholism, tends to bypass questions of responsibility and makes it hard to consider influences external to the interaction, such as cultural beliefs about appropriate gender behavior. The concept of neutrality suggests that all parts of a system contribute equally to its problems and thus obscures differences in power and influence. The same is true of complementarity, which suggests that in traditional relationships between men and women, the roles are equal though different. Reconciling these contradictions is not always easy, but ignoring them isn’t the answer.

Culture

Among the influences shaping family behavior few are more powerful than the cultural context. A fam- ily from Puerto Rico, for example, may have very

different expectations of loyalty and obligation from their adult children than, say, a white middle-class family from Minnesota. One reason for therapists to be sensitive to cultural diversity is to avoid im- posing majority values and assumptions on minority groups. There are a host of excellent books and arti- cles designed to familiarize therapists with families from a variety of backgrounds, including African American (Boyd-Franklin, 1989), Latino (Falicov, 1998), Haitian (Bibb & Casimir, 1996), Asian Amer- ican (Lee, 1996), and urban poverty (Minuchin, Colapinto, & Minuchin, 2007), to mention just a few. These texts serve as guides for therapists who are about to  venture into relatively unknown territory. However, the best way to develop an un- derstanding of people from other cultures is to spend time with them.

Although they are sometimes used interchange- ably, there is a difference between culture and ethnic- ity. Culture refers to common patterns of behavior and experience derived from the settings in which people live. Ethnicity refers to the common ancestry through which individuals have evolved shared values and customs—especially among groups that are not

Among Latino families, family loyalty is often a paramount virtue.

M on

ke y

B us

in es

s Im

ag es

/S hu

tt er

st oc

k

M03_NICH6609_11_SE_C03.indd 66 9/25/15 7:08 PM

Chapter 3 The Fundamental Concepts of Family Therapy 67

white Anglo-Saxon Protestants. Culture is the more generic term, and we have chosen it here to empha- size that cultural context is always relevant, even with a family who comes from a background similar to the therapist’s.

Although cultural influences may be most obvi- ous with families from foreign backgrounds, it is a mistake to assume that members of the same culture necessarily share values and assumptions. A young Jewish therapist might, for example, be surprised at the unsympathetic attitudes of a middle-aged Jewish couple about their children’s decision to adopt an Af- rican American baby.

Appreciating the cultural context of families is complicated by the fact that most families are in- fluenced by multiple contexts, which makes gener- alization difficult. For example, as noted by Nancy Boyd-Franklin (1989), middle-class African Amer- ican families stand astride three cultures. There are cultural elements that may be traced to African roots, those that are part of the dominant American culture, and finally the adaptations that people of color have to make to racism in the dominant culture. Moreover, the cultural context may vary among family mem- bers. In immigrant families, for example, it’s not un- common to see conflicts between parents who retain a strong sense of ethnic identity and children who are more eager to assimilate the ways of the host country. First-generation parents may blame their children for abandoning the old ways and dishonoring the family, while the children may accuse their parents of being stuck in the past. Later, the children’s children may develop a renewed appreciation for their cultural traditions.

Watch this video of a therapist exploring a couple’s ethnic heritage. What effect does their

ethnicity have on the dynamics in their marriage?

The first mistake a therapist can make in working with clients from different backgrounds is to pathol- ogize cultural differences. Although a lack of bound- aries between a family and their neighbors and kin might seem problematic to a middle-class white therapist, such more inclusive family networks are not atypical for African American families.

The second mistake is to think that a therapist’s job is to become an expert on the various cultures he or she works with. While it may be useful for therapists to familiarize themselves with the customs and values of the major groups in their catchment area, an attitude of respect and curiosity about other people’s cultures may be more useful than imposing ethnic stereotypes or assuming an understanding of other people. It’s important to acknowledge what you don’t know.

The third mistake therapists make in working with families from other cultures is to accept every- thing assumed to be a cultural norm as functional. An effective therapist must be respectful of other people’s ways of doing things without giving up the right to question what appears to be counter- productive. Although fluid boundaries may be typ- ical among urban poor families, that doesn’t mean it’s inevitable for poor families to be dependent on various social services or for agency staff to pre- sume that a family’s need entitles workers to enter, unannounced and uninvited, into the family’s space, physically or psychologically (Minuchin, Lee, & Simon, 1996).

summary

We’ve covered a lot of ground in this chapter—from cybernetics to social constructionism, complemen- tarity to culture. Some of these ideas may be famil- iar, while some may be new to you. Here’s a brief summary.

Cybernetics is the study of how feedback is used to regulate mechanical systems. Applied to families, cybernetics teaches that when a family functions like a closed system the response to a problem may actu- ally perpetuate it. To employ this concept clinically, therapists simply identify how family members have been responding to their problems and then get them to try something different.

According to systems theory, it’s impossible to understand the behavior of individual family mem- bers without considering how the family system as a whole operates. To do so it may be necessary to look at process (how family members interact), and structure (how the family is organized).

M03_NICH6609_11_SE_C03.indd 67 9/25/15 7:08 PM

68 Part One: The Context of Family Therapy

Constructivism reintroduced cognition to family therapists. Family systems may be regulated by in- terpersonal interactions, but those interactions are shaped by how family members interpret each other’s behavior. Social constructionism reminds us that fam- ilies are open systems—our interpretations are shaped by assumptions we absorb from the culture.

The trajectory of these concepts broadened our focus beyond the individual to relationships, to the family as a whole, and finally to society at large. Attachment theory can be seen as part of an effort to restore our grounding in psychology. Attachment theory emphasizes the basic need for security in close relationships, both in childrearing and intimate partnership.

In the section on “The Working Concepts of Family Therapy,” we tried to show how therapists can apply the insights of these various theories in clinical prac- tice. Beyond the specifics, what we’d hope to get across is that families are more than a collection of individuals; they have superordinate properties that may not always be apparent. It may be obvious, for example, that there are always two parties to a relationship—and that problems, as well as solutions,

are a function of both parties. But even this reality can get lost in the heat of emotion. This is as true for therapists as for the people involved. Each of the var- ious other working concepts offers its own particular insights into understanding family joys and sorrows.

In the following chapters, we’ll see how the var- ious schools of family therapy approach the task of understanding and treating family problems. But even as the models get specific, it’s a good idea to keep in mind the general principles of family functioning explained in this chapter.

Click here to apply your knowledge of chapter concepts.

Click here to test your application and analysis of the content found within this chapter.

M03_NICH6609_11_SE_C03.indd 68 9/25/15 7:08 PM