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6 FAMILY SYSTEMS THEORIES

OF PSYCHOTHERAPY

DAVID R. CHABOT

This review of the developments in systems psychotherapy is organized into two sections. The first section covers the initial period up to the classical period (1980s), when there was a shift from an individual perspective to a sys- tems perspective. This shift represented a theoretical revolution with a cor- responding radically different way of approaching the therapeutic process. This revolution was begun in the 1950s by small groups of mental health profession- als working separately and in disparate places who made the family unit a primary focus of research and clinical intervention. Much of the early work was charac- terized by efforts to avoid thinking in traditional individual terms, which would have been reflective of existing theories. Rather, these pioneers explained behavior by using new, ecologically valid interpersonal concepts. For this initial period, I present those theoretical concepts that have received consensual vali- dation and that form the foundation of the family systems psychotherapy.

The second section covers conceptual changes that built on the original concepts but expanded them in response to two main forces. Some of these con- ceptual changes and additions were directly related to changing social and cul- tural conditions. Other conceptual changes resulted from integrating the core concepts of the original theories with one another as well as combining them with established social and psychological theories.

http://dx.doi.org/10.1037/12353-006 History of Psychotherapy: Continuity and Change (2nd Ed.), edited by J. C. Norcross, G. R. VandenBos, and D. K. Freedheim Copyright © 2011 American Psychological Association. All rights reserved.

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174 DAVID R. CHABOT

THE INITIAL PERIOD

The early clinical researchers in family systems were well versed in the prevailing individual theories of their day. Foremost among these theories were psychoanalytic (Freud) and humanistic (Rogers) theories, within one of which most of the early pioneers had been professionally trained. To be sure, these individual theories recognized the role that negative family relation- ships played in the development of individual pathology. However, the treat- ment of these problems tended to avoid direct involvement with family members; rather, treatment focused on the dysfunctional or distressed indi- vidual, emphasizing a “corrective emotional experience” with the therapist.

The early family pioneers asked these questions: “What would happen if we were to focus on the family relationships in a direct manner to conceptualize and treat problems that presented in an individual?” “What concepts would we need to both understand how problems develop and to intervene successfully?” “To what extent would we have to reject and/or accept prevailing theoretical concepts and techniques from individual theories to succeed?” Their answers to this last question in particular provided a basis for a classification framework that organizes the diverse early contributions to family therapy theory.

An early classification of family systems theories (Guerin, 1979) pro- posed a metaphor of two branches of a tree: those practitioners who based their clinical methods on traditional psychoanalytic (individual) theory and those practitioners who attempted to formulate a systems conceptual frame- work using new, nonpsychoanalytic concepts. This latter approach was first represented in the early 1950s by the Bateson Project with its emphasis on the communication process between family members. It continued with the work of Jackson and Weakland (1961) and Haley (1976) and extended to the Brief Therapy Project of Watzlawick, Weakland, and Fisch (1974). Later, Ackerman’s brief therapy and the work of the Milan Associates (Selvini- Palazzoli, Boscolo, Cecchin, & Prata, 1978) also branched from this, as did Minuchin’s (1974) structural therapy.

The psychoanalytic branch of the early family theory tree involved a wide range of relatively independent groups, all of whom retained some psy- choanalytic elements in their concepts. This branch included theorists who maintained a direct connection to psychoanalytic theory (Ackerman, 1958; Boszormenyi-Nagy & Framo, 1965), theorists who approached family systems from a group process framework (Bell, 1961; Wynne, 1988), and a group that embraced multigenerational systems (Bowen, 1966, 1976, and his descen- dents, Guerin, Fogarty, and Kerr). It also included a more experiential group of pioneers who shared a common humanistic framework overlaying prima- rily psychoanalytic beginnings. This group was typically more interested in technique rather than theory (Satir, 1967; Whitaker, 1976).

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FAMILY SYSTEMS THEORIES OF PSYCHOTHERAPY 175

Communication Theorists

The communication theorists began their work with the Bateson project at Palo Alto, California. In addition to the original members of this project, there were other significant early theorists who remained true to communica- tion concepts but who went on to produce additional seminal concepts within communication theory.

Bateson Project and Mental Research Institute

In 1954, Gregory Bateson, a cultural anthropologist, studied patterns of communication in schizophrenics. He was joined in the research by Jay Haley (communication), John Weakland (chemical engineering), and Don Jackson (psychiatry). In the early phases of their work, they interviewed individual hospitalized patients at the Palo Alto Veterans Hospital. A few years later (1959) Jackson founded the Mental Research Institute (MRI) and invited Virginia Satir (social work) to join him. After Jackson’s death in 1968, Watzlawick (psychology) and Weakland were joined by Richard Fisch (psychiatry) to form the Brief Therapy Project at the MRI.

From these interdisciplinary researches emerged several seminal concepts of family systems. One of the most basic concepts was family homeostasis, a con- cept borrowed from biology. The concept of family homeostasis described how families resist change, and how, when challenged, these relationship systems strive to maintain the status quo even at considerable emotional cost to one of their members. Jackson was among the first to observe the camouflaging func- tion that a child’s symptoms provide for covert parental conflict. Thus, the child becomes the identified patient instead of the dysfunctional family process.

Another core idea that emerged from these projects was the concept of the double bind. It was based on the family homeostasis and multiple, often contradictory, levels of communication in relationships. In certain relation- ship situations, an overt and explicit meaning of a communication is contra- dicted by the implied or metamessage. The six basic characteristics of the double bind may be summarized as follows (Nichols, 2008):

1. Two or more persons are involved in an important relationship. 2. The relationship is a repeated experience. 3. A primary negative injunction is given, such as “do not do X,

or I will punish you.” 4. A second injunction is given that conflicts with the first but at

a more abstract level. This injunction is also enforced by a per- ceived threat. This second injunction is often nonverbal and frequently involves one parent’s negating the injunction of the other.

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5. A third-level negative injunction exists that prohibits escape from the field while also demanding a response.

6. Once the victim is conditioned to perceive the world in terms of a double bind, the necessity for every condition to be present disappears, and almost any part is enough to precipitate panic or rage.

In 1967, Watzlawick, Beavin, and Jackson published Pragmatics of Human Communication. In this text they explained a “calculus” of human communications, that is, a series of principles about communication and metacommunication. They defined disturbed behavior as a communicative reaction to a particular family relationship rather than evidence of a disease of the individual mind. Further, they emphasized both the pathological and potentially therapeutic aspect of paradox in human communications and the value of the therapeutic double bind, an intervention wherein the therapist attempts to use the natural oppositional forces within the family system to resist continuing dysfunctional behavior. They demonstrated no interest in triangles, the transmission of anxiety, or the role of situational stress.

In 1974, Watzlawick, Weakland, and Fisch reported on their work at the MRI’s Brief Therapy Center. Core concepts were problem formation, problem resolution, first-order change, second-order change, and reframing. A summary of the principles of first-order and second-order change reveals the importance of this contribution:

1. First-order change occurs within a given system, which itself remains unchanged. It is a logical, commonsense solution to a problem. If Johnny is failing in school, mother must supervise his schoolwork more closely.

2. Second-order change is applied when the first-order change (the logical, commonsense solution) is clearly demonstrated to be at the center of an escalating problem. In other words, use second-order change when first-order change is making the problem worse. The mother’s hovering in the previous example is the escalating problem.

3. Second-order change based on reframing and paradox flies in the face of logic and common sense and usually is perceived as weird and unexpected. The second-order change in the preced- ing example is defining the mother’s escalating behavior as desirable and as required in greater amounts to produce the desired result.

4. The use of second-order changes lifts the situation out of the trap created by the commonsense solution and places it in a dif- ferent frame. The entrapping, repetitive cycle of mother’s pres-

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sure and son’s responsive passivity is replaced by a new sequence of behaviors, which eliminates the symptoms.

The work of the interdisciplinary Bateson Project and the MRI produced groundbreaking contributions to family systems thinking. The concepts of homeostasis, double bind, reframing, paradoxical injunctions, first- and second- order change, metacommunication, and prescribing the symptom owe their ori- gins to these overlapping groups. Of the persons contributing to these research programs, those most directly influential on the clinical behavior of succeeding generations of family therapists have been Haley and Satir. Satir’s contribution is presented in the section on experiential systems theorists.

Jay Haley

Jay Haley emerged from his work on the Bateson Project with a two-fold conviction that clinical symptoms were a by-product of context and that a power struggle for control was behind relationship patterns. A logical conse- quence of his thinking was the view that a person’s symptom is a strategy for obtaining control within a relationship. The covert nature of the process, its being out of awareness, and the function it serves for the symptomatic individ- ual and the family homeostasis render direct confrontation of the symptom and attempts to make the process explicit fruitless. Therefore, counterstrategies that bypass or confuse the homeostatic mechanism, creating chaos and allowing for spontaneous reorganization, represent the optimal clinical methodology. From the beginning of his work, Haley paid close attention to hierarchal struc- ture as it relates to power distribution and advocated therapeutic strategies to defeat entrenched patterns of dysfunctional behavior.

Haley’s work with Minuchin and Montalvo at the Philadelphia Child Guidance Clinic helped fashion structural family therapy, a method described later in this chapter. In the 1970s, Haley left Philadelphia and with Cloe Madanes established the Family Institute in Washington, DC. From then on his focus shifted away from structural family therapy to the pursuit of a more refined understanding of hierarchy, power, and strategic intervention. By the 1980s, Haley’s (1984) and Madanes’s (1981) contributions to strategic fam- ily therapy made it the most popular approach to family therapy.

Two predominant characteristics of Haley’s methods are his firm belief in the uselessness of direct educational techniques and his corollary commit- ment never to explain himself but rather to operate covertly on the process of power by giving directives to the family that are specific to the presenting problem. Together, Haley (1984) and Madanes developed a clinical method for working strategically with severe marital dysfunction called ordeal ther- apy. In this method, a strategic ordeal is fashioned that provides, on the one hand, a ritual of penance and absolution, and on the other, a bond formed

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between the two people who experience an ordeal together. A recent shift in the Haley and Madanes form of therapy involves strategic humanism. Here, directives are still given by the therapist, but these directives are designed to help family members be more loving to each other rather than to gain greater control over others.

Milan Associates

The Milan Associates (Selvini-Palazzoli et al., 1978) consisted in its early years of four principals: Selvini-Palazzoli, Boscolo, Cecchin, and Prata. The Milan model is an interesting method, with fibers from the work of the Bateson Project, the strategic therapists, and Minuchin all woven together into a creative fabric. The early work of this group involved seeing families typically once a month to avoid dependency on the therapist and used tech- niques that were direct derivatives of the earlier communication theorists. Family problems were framed with a positive connotation—a positive refram- ing of the symptomatic behavior without the earlier connotation that some- one else in particular was benefiting from the symptom. This was done by the therapist to lower family resistance to the reframing. Circular questioning was used by the therapist to address differences in perceptions about events and relationships. This technique was designed to help the family member see their behavior as interpersonal. The Milan group stressed the importance of defining the family rules, an approach similar to that of Jackson in his early work. Rituals (initially involving paradox) were directed to the family to more clearly manifest these family rules and counter their negative consequences.

Later the group stopped using paradoxical prescriptions and replaced this technique with invariant prescriptions. This technique assumed that a child’s symptomatic behavior was the result of his or her being caught in the power struggle between the parents with the child trying to side with one par- ent over the other. The invariant prescription involved having the parents tell the child that they had a secret (not available to the child). In addition, the parents were to spend more alone time with one another to foster the parental dyad and detriangulate the child. In this country, the Milan Associ- ates’ methods were built on and modified at the Ackerman Institute, which led to an American version of the Milan method.

Salvatore Minuchin

Minuchin began to develop his family theory in 1962 at the Wiltwyck School for Boys in New York. The staff of the Wiltwyck Project included E. H. (Dick) Averswald, Richard Rabkin, Bernice Russman, and Braulio Montalvo. Averswald was strongly influenced by Bateson’s ideas, and Rabkin brought a certain irreverence for traditional psychotherapy theories and

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methods best documented in his text Inner and Outer Space (Rabkin, 1970) and in an essay titled “Is the Unconscious Necessary?” (Rabkin, 1968).

Minuchin formed his model of the family as a relationship system. His model rests heavily on the notion that most symptoms, whether they present as a dysfunction in an individual (such as anorexia) or as a conflict in a rela- tionship, are a byproduct of structural failings within the family organization. The family is normally determined by structure, power, function, boundaries between subsystems, and degrees of functional attachment among individu- als. The family, as defined by Minuchin, is the nuclear family or household. Minuchin would include the grandparental generation in his observational lens only when the grandparent was a part of the household.

His description of the family system as a whole relates to the degree to which a family structure demonstrates appropriate boundaries. Those fami- lies with dysfunctional structures are grouped into two categories. Enmeshed is the term used for those families characterized by overly permeable or absent boundaries, and the term disengaged is used for families with rigid boundaries between individuals that do not allow enough flexibility or attachment. The structure of structural family therapy can be best understood by examining boundaries and triangles or conflict detouring triads, as triangles have been termed within this model. After joining with the family and having them enact their typical process, the therapist maps out the structure of the family high- lighting specific interactions and then attempts to unbalance the interactions to create healthier boundaries.

Minuchin’s (1974) model was a major breakthrough in the history of family therapy. His video training tapes demonstrated the systemic aspects of clinical problems formerly conceptualized as residing within the individual. The impact was to turn the attention of the mental health movement toward the developing field of family therapy. One of the most admirable aspects of Minuchin’s work has been the ability to make his conceptual formulations and clinical methodology effective with underprivileged populations.

The early work described previously initially resulted in a communication school of family systems therapy. The concepts were so important, so funda- mental that they were readily incorporated into other major schools of family therapy. As a result, the communication school lost its separate identity. By the 1980s, the two major schools of family therapy that contained these original ideas were the strategic and the structural schools, which were the most popu- lar theories at that time. A central characteristic of all this work was its empha- sis on overt behaviors between family members rather than internal processes (thinking and feeling) within individual family members. The family systems theorists described in the section that follows emphasized emotional processes consistent with their psychoanalytic foundations but extended them to more fully account for the family from a systems point of view.

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Psychoanalytic Theorists

The next group of early theorists to be considered is implicitly defined by their relative weddedness to psychoanalytic formulations. This is not surpris- ing for two major reasons: First, most of these theorists were trained in psycho- analytic theory, which was the dominant clinical theory in the 1950s when their family theory efforts were initiated. Second, much of psychoanalytic knowledge about how and why people behave had already been incorporated into the mental health field. Thus, one did not have to be a psychoanalyst to be using psychoanalytic thinking. Although this group started by drawing from psychoanalytic theory, its core contributions viewed the family from a systems perspective. The psychoanalytic group can be divided into three subcategories: those with a group therapy focus (Bell and Wynne), an object relations group (Ackerman, Framo, and Boszormenyi-Nagy), and the Bowen group (Bowen, Guerin, Fogarty, and Kerr).

Group Focus

It was only natural for some early theorists to draw on group therapy and add it to their psychoanalytic base in their efforts to formulate family systems theory. Serious work dating back to the 1920s had already been completed regarding the process of organized groups. Gestalt psychology had demon- strated how the group was more than the sum of its parts, thus necessitating that individual concepts alone would not suffice in understanding family functioning. Role theory was already well established. More important, the process–content distinction had gained wide acceptance, indicating that it may be more important to focus on how something is said rather than what is said. The contributions of John Bell and Lyman Wynne are particularly important here.

Bell was a psychologist at Clark University who began his clinical work with families in the early 1950s. He is important because many con- sider him to be one of the founders of family therapy along with Ackerman, Bowen, and Jackson. Bell’s (1961) work focused on pragmatic ways to deal with the power differential between parents and children when seeing them all in family sessions. He orchestrated a three-phase therapeutic process in which he first focused on the children to prepare them for con- joint family meetings, then focused on the parents, and finally, the entire family. His stages to therapy demonstrate his investment in traditional analytic theory: defining a therapeutic contract, testing limits, shifting of power within the group, achieving success on a common task, and termi- nation issues. Reflecting his psychoanalytic base, Bell strongly believed in the importance of maintaining effective boundaries between the therapist and the family group.

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Lyman Wynne received his doctor of medicine in psychiatry and his doc- torate in social relations at Harvard. He worked with Bowen at the National Institute of Mental Health, where both shared a commitment to studying schizophrenia from a family process perspective. The development of his major concepts pseudomutuality and pseudohostility (Wynne, Ryckoff, Day, & Hirsch, 1958) described distorted emotional processes within the family. Pseudomu- tuality describes a surface appearance of agreement and attachment among family members, while in reality the family members are tightly locked into dysfunctional roles that did not permit individuation from the family or truly close relationships within it. Behind the pseudomutality is a strong fear of sep- arateness. Although pseudomutuality reflects a deficit in expressing positive affect in the family, pseudohostility reflects a disturbance of negative affect. Pseuodohostility is behavior that also speaks to problems in intimacy, affec- tion, and fear of separateness but masks this deficit by hostility and bickering rather than by false connectedness.

Wynne’s third major concept, the “rubber fence,” describes how dysfunc- tional families are socially isolated and only open a tight boundary around themselves to permit minimal extrafamilial involvement with others. Thus, an “outside” person, such as a psychotherapist seeking to engage family mem- bers, might feel a certain ease of entry into the family, only to be bounced out later as if by a rubber fence if certain unwritten rules were violated. Developed in a research program, these important concepts have yet to be interpreted into a more elaborate clinical model of family therapy

Although important contributions were made to family therapy by early pioneers espousing group therapy model, there are inherent limitations in how much one could transfer group concepts to family systems. These limi- tations are largely due to the fact that group therapy involves an ad hoc group, whereas family therapy involves a natural group. “Continuity, commitment and shared distortions all make family therapy different from group therapy” (Nichols, 2008, p. 16).

Object Relations

As mentioned earlier, Freudian theory has long been influential in under- standing the impact of family relationships on the psychological functioning of its individual members. In the early days of family therapy, attempts to formulate a separate theory for family were resisted by the psychoanalytic community. Family therapy was viewed as a method or technique, similar to group therapy, which had successfully adapted traditional Freudian theory.

Clinical work with families, from the perspective of the analytic commu- nity, was indicated in two situations. One situation was when family members needed education about the ways in which they were potentially defeating the transferential therapy of an individual. The other situation was one in which

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there was a need to open communications around tension-filled conflicts within the family. Initially there was considerable skepticism about seeing fam- ilies because of the possible effects on the transference, but eventually a group committed to psychoanalytic theory began to experiment with such methods. The child psychoanalyst Nathan Ackerman, who many consider to be one of the founders of family therapy, began to see families as early as the mid 1940s. He used the traditional psychoanalytic model of drives and defenses as a frame- work for his clinical efforts with the family. Later, those in the analytic commu- nity who maintained both an allegiance to analytic theory and an interest in family therapy moved toward object relations as their primary conceptual base.

The theoretical underpinnings of the object relations approach to family therapy rest on the work of Klein (1946) and Fairbairn (1952). The Kleinian concept of good breast/bad breast refers to infantile ambivalence about the mother derived from the developmental experiences of nurturance and dep- rivation. Fairbairn developed the idea of internalized relationship structures. Contained within these proposed structures were partial objects, that is, a portion of the ego and the affect associated with the relationship. The external object was perceived as either all good, all bad, or both, in alternating cycles, which Fairbairn referred to as splitting. Fairbairn believed that when the splitting process was not resolved, the individual’s ability to objectify relationships was impaired. This concept of splitting has been developed further in the notion of projective identification.

Projective identification is defined as a process whereby an individual first projects onto another person certain denied behaviors or characteristics of his or her own personality. Then, in the interaction, the person behaves in ways that either provoke such behaviors from the other or reacts as if the other pos- sesses these characteristics, which thereby reinforces the projective perception. A simple example from a marital relationship is when a wife with an internal- ized judgmental and negative image of herself projects the perception of a harsh, critical, unloving person onto her husband and then behaves in ways that pre- dictably bring forth critical and withholding behaviors on his part.

Family therapists working with these concepts can track this interac- tional process within the session and interpret the object relation forces that are driving the conflict. These methods closely resemble those used early on in psychoanalytically based family therapy wherein the existence of naturally occurring transferences in the family was hypothesized and interpreted clini- cally to explain relationship conflict and dysfunction.

The most prominent individual in the early years to blend psychoana- lytic theory with family therapy theory was Nathan Ackerman. A man of broad interests, Ackerman was a prolific writer on a variety of topics. Early in his medical career he published on the psychological aspects of hyperten- sion and on the impact of the economic depression of the 1930s on coal min-

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ers’ families. A psychoanalyst, he maintained his commitment to psycho- analytic thought and practice. Ackerman’s belief in the primacy of analytic theory resulted in his not developing a conceptual model for his clinical work with families. A study of his filmed clinical interviews suggests three themes in his work consistent with his use of analytic theory: nurturance and dependency, control and anger, and sexuality and aggression. These themes can be viewed as corresponding to the different stages of psychosexual devel- opment of the individual: oral, anal, and phallic. Operationalizing the oral theme, Ackerman would challenge family members on their excessive need to be fed, on their “sucking” behavior, and on their desire to be a baby. He would provoke them into expressing their anger and would openly discuss their unconscious oedipal strivings. Ackerman quickly took charge and made contact with each family member after playfully teasing the children, flirting with the women, and challenging the men in a fairly aggressive style. He was an activist stirring up emotion by a process he called “tickling the defenses.” He believed it was healthy to let emotion out, especially to express anger openly.

Today, Ackerman’s contribution to family systems is experienced by many as remote, in much the same way most people experience the process in their own extended families—interesting but irrelevant to the present. Nonetheless, Ackerman’s contribution remains relevant to the major issues in family therapy. For one example, he was sensitive to the impact of the social context on families far earlier than most. His study of the families of coal miners enduring the lingering depression of the late 1930s remains a model for studying the impact of social context on the internal dynamics of the family. It raises questions still pertinent today, such as what constitutes a functional adaptation versus a maladaptation? What are the premorbid or preevent characteristics of those families that adapt well as opposed to those families that are thrown into chaos and fragmentation? For another example, Ackerman contributed a typology of families. In his 1958 book The Psycho- dynamics of Family Life, Ackerman presented a preliminary typology: distur- bance of marital pairs, disturbance of parental pairs, disturbance of childhood, disturbance of adolescence, and psychosomatic families. A clinical typology, even one that is symptom focused as is this one, is essential to the development of corresponding clinical methodologies.

Ivan Boszormenyi-Nagy, a psychiatrist, and James Framo, a psycholo- gist, edited a volume titled Intensive Family Therapy: Theoretical and Practical Aspects (Boszormenyi-Nagy & Framo, 1965) that brought together papers from most of the leading family researchers at that time. Framo adopted Fairbairn’s object relations theory as the basis for his work. In his practice, this position led to his inviting significant extended family members into the sessions, espe- cially when dealing with marital conflict. Framo also expended considerable

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effort in integrating his work with that of others whose theoretical stance derived primarily from psychoanalytic theory.

Boszormenyi-Nagy also maintained his psychoanalytic orientation when he changed from the study of schizophrenia to the study of loyalty in families, particularly as it influences coalitions and alliances over multiple generations. This work is described in his book Invisible Loyalties: Reciprocity in Intergenerational Family Therapy, written with his colleague Geraldine Spark (Boszormenyi-Nagy & Spark, 1973). Boszormenyi-Nagy offered the concept of the family ledger, an invisible ledger of mutigenerational accounts of obligations, debts, and events perceived as relationship atrocities. These firmly entrenched emotional wounds require retribution of some kind over the generations. If a problem’s genesis is reframed in terms of old wounds and loyalties, family members have a face-saving mechanism that allows them to give up their present-day conflict (Hoffman, 1981).

In 1987 Boszormenyi-Nagy made additional contributions with his con- textual therapy, which places ethical behavior between family members cen- ter stage for adaptive family functioning. His reminder that relationships have to be fair to be functional is most important. Around the same time, the Washington School of Psychiatry was refining the psychoanalytic method of treating families. David Scharff and his wife, Jill Scharff (1987), published their work in a book titled Object Relations Family Therapy.

The Bowen Group

Bowenian family systems therapy evolved directly from psychoanalytic principles and practices. It is the most comprehensive model of family systems insofar as it consists of a defined number of concepts with a corresponding clinical methodology. Murray Bowen, its originator and major contributor, began with an interest in studying the problem of schizophrenia and brought to his study of the family extensive training in psychoanalysis, including 13 years of personal training analysis.

In the early years of the family therapy movement, many of the pioneers trod lightly in the area of theory. Bowen was the exception to this rule, both in his emphasis on the importance of theory and in his belief that his ideas could form a new theory of human emotional functioning. He hoped his the- ory would be viewed as evolving from Freudian theory but be seen as dis- tinctly different from it in its systems orientation. Bowen kept an essential element of psychoanalytic theory, emotional process, but moved it beyond an intrapersonal domain to a transgenerational domain. In this sense his theory does evolve from Freudian theory but becomes something distinctively differ- ent. Because of the emphasis on the emotional process in the system rather than in the individual, the techniques of Bowenian therapy are substantially different from psychoanalytic therapy techniques in spite of their similar

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beginnings. Bowen (1978) believed that the task of the theorist was to find the smallest number of congruent concepts that could fit together as a working blueprint for understanding the human experience. He designated eight con- cepts as central to his theory: differentiation of self, triangles, nuclear family emotional system, family projection process, emotional cutoff, multigeneration transmission process, sibling position, and societal regression. He repeatedly warned of the pitfalls of lowest common denominator eclecticism.

Bowen dated the beginning of his theory to his clinical work with schiz- ophrenia at the Menninger Clinic from 1946 to 1954. During that time he studied mothers and their schizophrenic offspring who lived together in small cottages on the Menninger campus. From this clinical research he was hoping to gain a better understanding of mother–child symbiosis. Observations from these studies led to the formation of his concept of differentiation (Bowen, 1972). Bowen’s concept of differentiation consists of two interrelated parts, an interpersonal differentiation and an intrapsychic differentiation. To be differ- entiated on the interpersonal level one has to achieve a balance between a well-defined sense of self while simultaneously being able to be in an intimate relationship with another. To the extent that one fails to do this, one is either fused to the other at the expense of having a well-defined sense of self or one is without a functional close relationship because one is attempting to acquire or preserve a well-defined sense of self. When one has a poor level of differen- tiation interpersonally it is accompanied by a poor level of differentiation intrapsychically. A poor level of differentiation on the intrapsychic level involves a lack of integration between one’s feelings and one’s thinking. An individual who is poorly differentiated intrapsychically does not behave in a functional manner because of excessive emotionality or the lack thereof. Bowen’s concept of differentiation has been well received by family therapists and researchers. There are a number of scales that measure interpersonal dif- ferentiation. Chabot has developed an intrapsychic scale of Bowen’s concept (Licht & Chabot, 2006).

From the Menninger Clinic, Bowen moved to the National Institute of Mental Health, where he formed a project to hospitalize and study whole fam- ilies with a schizophrenic member. It was this project that expanded the con- cept of mother–child symbiosis to involve fathers that inevitably led to the Bowen concept of triangulation. Triangulation is another central concept in Bowen theory and has become an essential concept in any systems theory of psychotherapy. Triangles get created when there is a lack of differentiation interpersonally and intrapsychically. As one is unable to achieve a balance between a well-defined sense of self and a simultaneous functional close rela- tionship anxiety is experienced. One seeks to stabilize the anxious situation by moving off the relationship and involving a third person or thing. A tri- angle is an abstract way of thinking about a structure in human relationships,

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and triangulation is the reactive emotional process that goes on within that triangle.

For example, when a couple presents for treatment, the triangle with their son may have become relatively fixed so that the mother and the son are overly close and the father is in the distant, outside position. This align- ment may occasionally shift so that there are times when either the mother or the son is in the outside position and the father has some closeness with his son or his wife, but then it shifts back to its usual dysfunctional structure. Triangulation is the emotional process that occurs among the three people who make up the triangle. For example, in the triangle just described the father might desire a connection with his son and resent his wife’s monopoly of the boy’s affection; the mother may be angry at the father’s distance from her and compensate by substituting closeness with her son. The child, in turn, may resent his father’s inattention and criticism and may move toward his mother but, at the same time, be anxious about his overly close relationship with her. As the emotional process of triangulation moves around the trian- gle it can produce changes in its structure.

In 1959, Bowen left the National Institute of Mental Health and went to Georgetown Medical School, where he was a professor of psychiatry until his death in the fall of 1990. In his 31 years at Georgetown, Bowen refined his theory by applying it to less dysfunctional populations and developing a clinical methodology that he could pass on to the psychiatric residents at Georgetown. Bowen saw the need for a corresponding method that would assist the psychotherapist in the development of his or her own personal autonomy. For this purpose, Bowen began to research and experiment with the emotional process within his own personal family system. A documenta- tion of his research on his own family of origin was first presented at a national family therapy conference in 1967 and published in 1972; in the published study Bowen spelled out his method and its four steps in detail. First, know the facts about your family relationship system. Bowen encouraged his trainees to construct comprehensive family diagrams to document the structural relation- ships among members of the family and to gather facts about the timing of important events such as deaths and births. Second, he coached his trainees to become better observers of their families and to learn to control their emotional reactivity to these people. Third, he taught them how to detriangulate them- selves from emotional situations. This part of the method entails developing an ability to stay nonreactive during periods of intense anxiety within one’s own family. Last, he advocated the development of person-to-person relation- ships with as many family members as possible.

Over the years Bowen trained many psychiatrists. Among the most influential are Phil Guerin, Tom Fogarty, and Mike Kerr. Kerr remained at Georgetown as Bowen’s closest associate, and his theoretical contributions

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are reflective of that association. One of his major contributions has been the further development of the role of anxiety in the family system. Fogarty (1976a, 1976b, 1984) has become most widely known for his contributions detailing the repetitive patterns of pursuit and distance (with the correspon- ding concepts of the emotional pursuer and the emotional distancer). These patterns reflect the preferred styles that individuals manifest in a relation- ship as they struggle to achieve a balance between autonomy and closeness. Chabot (1996) has operationalized these concepts into a brief test useful for both clinical work and research. Guerin, Fay, Burden, and Kautto’s (1987) most important contributions to family therapy are the clarifications and elaborations of Bowen’s concepts as well as the application of the theory to the treatment of marital conflict and child and adolescent centered families. In his work Guerin has focused on the development of the individual’s “adap- tive level of functioning” to operationalize the more fixed and innate aspects of differentiation as described by Bowen.

Experientialist Theorists

Experiential family therapy is characterized by its emphasis on intuition, feelings, unconscious processes, and an atheoretical stance. The foundations of this approach stem from the existential–humanistic tradition, which emphasizes personal freedom, honest expression of emotion, and the underlying natural goodness of individuals. The two major figures in this branch of the family therapy movement are Carl Whitaker (Whitaker & Keith, 1981) and Virginia Satir (1967). Both of them drew on quite different epistemologies for their therapies, but they shared a common set of experiential assumptions and tech- niques in their clinical work that parallels the work of Carl Rogers in individual therapy in its underlying assumptions.

Carl Whitaker’s approach to family therapy was predicated on the belief that family problems are due to emotional suppression of individuals. Thus, his goal was to help individuals better express themselves emotionally as a way of improving family functioning. His approach was pragmatic and athe- oretical (to the point of being antitheoretical). Whitaker (1976) considered theory to be useful only for the beginning therapist. He believed that the real role of theory for the novice therapist is to control his or her anxiety about managing the clinical situation. Whitaker preferred to use the support of a cotherapist and a supervisor to deal with these stresses rather than relying on theory. When a family functions well it is cohesive which, in turn, fosters individual growth. Honest affective expression is critical both for individual growth and for family cohesion.

The basic goal of therapy for Whitaker is to facilitate individual autonomy and a sense of belonging within the family. The emphasis is on the emotional

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experience, not conceptual understanding. Above all, the process of therapy is a very personal experience for the therapist. The more expressive and genuine the connection between the therapist and the family members in the session, the more successful the therapy is considered to be.

Existential encounter is believed to be the most important therapeutic process for both the therapist and the family. Early in his career Whitaker tended to present himself in a provocative manner as he attempted to break through the clients’ defenses and relate to them in an emotionally honest manner. In his own interviews, Whitaker’s highest stated priority was to “get something out of it for myself.” What he did clinically, on a fairly consistent basis, was to seize on a per- ception of the family’s “craziness” and attempt to escalate this state of affairs to the level of the absurd. One can see an example of Whitaker’s method in his statement to a young man who had recently made a suicide gesture. Whitaker turned to the young man and said to him that he should consider taking his ther- apist with him the next time he felt suicidal. Whitaker explained this maneuver as an attempt at augmenting the pathology of the family until the symptoms disappeared (Hoffman, 1981). Although Whitaker’s contributions to the fam- ily therapy movement have been considerable (Whitaker, 1976; Whitaker, Felder, & Warkentin, 1965), his contribution to a formalized system of family psychotherapy has been minimal. He was, however, a master at being able to get the family to improve by engaging each family member in the session and help- ing family members to express themselves emotionally more fully. In this way he worked at changing the family by changing individual members.

Virginia Satir, like Whitaker, represents a clinical method that is highly personalized, experiential, and immensely popular. Satir began her work with families in Chicago and in 1959 came to California to join Don Jackson at the MRI. There she organized what may have been the first formal training pro- gram in family therapy. Although she left the MRI to work at the Esalen Insti- tute, where she further developed her humanistic–experiential therapy, much of her conceptual framework is based on the Bateson Project, especially in the formulations of Jackson concerning the rules that govern relationships and the forces of family homeostasis. Satir speaks of the family as a balanced system and, in her assessment, seeks to determine the price individual family members pay to maintain this balance. She views symptoms as blockages to growth, which help to maintain the family status quo. She is more important as a skilled cli- nician and teacher than as an original theorist. However, her impact on the practices of family therapists was far from minor. Indeed, she may be the most influential of all the family pioneers mentioned in this chapter.

Despite the fact that Satir did not primarily concern herself with the- ory, there are several theoretical premises in her work. First, there is a strong emphasis on individual growth stemming from positive self-esteem. Second, Satir emphasizes communication patterns among family members. Third, she

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addresses the rules by which the family members interact with one another, and fourth, she emphasizes the family linkage to society.

These four aspects of family life are viewed as universal needs and forces operating in all families. In Satir’s definition of healthy families, the individ- ual member has positive self-esteem and communication is clear, emotionally honest, and direct. The family rules by which the system maintains itself are conducive to individual growth. Thus, family rules are human, flexible, and appropriate to the situation at hand.

A fifth premise is that the family does not function as a closed emotional system but is open to larger systems in society and hopeful in its outlook. As a counterpoint, Satir believes that troubled families do not foster positive self- worth; communication patterns are indirect and vague; rules are not flexible but absolute; and the family functions as a closed emotional system in a defen- sive and negative manner.

Satir (1972) stated her goals in family therapy,

We attempt to make three changes in the family system. First, each mem- ber of the family should be able to report congruently, completely, and obviously on what he sees and hears, feels and thinks, about himself and others, in the presence of others. Second, each person should be addressed and related to in terms of his uniqueness, so that decisions are made in terms of exploration and negotiation rather than in terms of power. Third, differentness must be openly acknowledged and used for growth. (p. 120)

Although Satir conceptualized the family in these ways, her therapy technique involved heavy use of herself in a direct, pragmatic, and support- ive way. She described herself both as a “mirror,” allowing the family to see how it was functioning, and as a “teacher” suggesting ways to grow by offer- ing specifics on how to improve self-esteem and communication patterns.

There is some suggestion that Satir may have overworked self-esteem and communication in her attempts to account for both normal and patho- logical family functioning. Again, like Whitaker, her highly individual and powerful persona makes reproducibility a problem for descendant genera- tions. On the other hand, her optimistic view of the potential for growth in families and her dynamic teaching of many other family therapists make her a major personality in family therapy.

Conclusions From the Initial Period

Even though the work of the early systems theorists started from different vantage points, the end result was agreement on a number of core assumptions about how to understand family functioning. Perhaps the most fundamental assumption is that the whole is greater than the sum of its parts. Related to this is the assumption that pathology is not only within the individual, but is in the

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system (often across multiple generations). Functional behavior is character- ized by development of healthy individual differentiation as well as appropriate dyadic relationships. The dysfunctional aspects of a family can be understood by considering the structure and process of triangles, boundaries, communica- tions, power, and rules. Causality is not linear but circular among family mem- bers. The tendency to maintain homeostasis involves feedback loops. Effective improvement of functioning often necessitates second-order change.

Although a single comprehensive theory did not emanate from this early work, three major models emerged with a strong systemic perspective: the strategic (Haley and colleagues), the structural (Minuchin), and the multi- generational (Bowen). Each of these models had its strengths as well as its weak- nesses. The strategic model, although clearly demonstrating the power of context and the magic of paradox and reframing, failed to consider the inter- nal developmental struggles of the individual. Therefore, it overvalued context in much the same way that a theory of the individual undervalues it.

The structural model of Minuchin (1974) was the clearest and most eas- ily understood of the three. However, it was much more a model of doing therapy than a comprehensive theory of family psychotherapy. In addition, although it was eminently teachable and reproducible, it was almost entirely a method for working with child-focused families. It offered little assistance for working with the problems of a relationship conflict between adults and/or working with an individual.

The multigenerational model of Bowen and his descendents represented the most consistent effort at developing a broad-based theory of family psy- chotherapy, including attention to the development of individual autonomy. However, Bowen’s models became somewhat murky in attempts to define and describe differentiation and triangulation. In addition, their clinical tech- nique can become overly ritualized and constricted.

CONCEPTUAL CHANGES IN SYSTEMS THEORY

Since the initial period (and the emergence of these three dominant theories), family therapy has profited from a number of important contribu- tions. In the next section of this chapter, I summarize these contributions as stemming from two major sources: (a) changing social conditions and (b) the integration of theories.

Changing Social Conditions

The concepts of clinical theory that are used to provide direction for the treatment of families did not get developed in a vacuum but were constantly

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being influenced by changing social and economic conditions. Concepts rel- evant to the psychoeducation, solution-focused, feminist, and multicultural approaches to family therapy have been particularly influenced by changing social and economic conditions.

Psychoeducation

Perhaps the major social force in the 1960s that had an impact on the mental health field was the movement toward deinstitutionalization and com- munity care. Related to these movements was an enlarged focus on well-being, rather than on pathology, and on prevention, rather than on tertiary treat- ment. These changes in social philosophy resulted in the development of the psychoeducational approach to the treatment of emotional dysfunction.

The history of psychoeducation in family therapy goes back at least to the early 1970s. At that time, the Center for Family Learning, directed by Phil Guerin, received a federal grant from the National Institute of Alcohol and Alcohol Abuse to conduct multiple family groups for family members at risk for alcohol abuse. This program, called Family Systems Training, taught families the principles of family systems theory and how families function emotionally. The program targeted families with a history of alcohol abuse. In the same period, at Albert Einstein College of Medicine, family therapists at the Family Studies Section under the direction of Israel Zwerling were formulating a psy- choeducation multifamily group approach for schizophrenics and their families.

The difference between these efforts was that the Center for Family Learning program was primary prevention that attempted to teach family sys- tems principles to those at risk for alcohol abuse as determined by cultural background and family history. The Einstein program, on the other hand, was tertiary prevention created to teach families with a schizophrenic member about the phenomenon of schizophrenia. It aimed to help them cope with the emotional fallout of the disease and to relieve them of misplaced guilt that they had caused the condition in their family member. In addition, it attempted to educate family members in specific ways to relate to the schizophrenic member to promote better functioning in that person and prevent the exacerbation of symptoms that would require rehospitalization.

This latter model is consistent with methods that took hold in the early 1980s and has continued to develop in various centers through the country. Of special note is the work of Carol Anderson (Anderson, Reiss, & Hogarty, 1986) and Michael Goldstein (Goldstein, Rodnick, Evans, May, & Steinberg, 1978). Research showed that multiple family psychoeducation groups for schizophrenics and their families are more effective than medication alone at preventing rehospitalization and more effective than a combination treatment of medication and family sessions with their individual families (McFarlane, Dixon, Lukens, & Luckstead, 2003).

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This early work with schizophrenia was extended to families with chronic medical problems. Medical family therapists such as McDaniel, Hepworth, and Doherty (1992) and Doherty (1996) have mapped out the relationship between the clinical aspects of a specific medical condition and specific family dynamics. These programs drew heavily from concepts contained in Bowenian and structural family theory and combined them with social support theory and expressed emotion. The work with expressed emotion has highlighted the particularly destructive nature of criticism, hostility, and emotional over- involvement. These elements have been consistently correlated with the relapse of schizophrenia (Milkowitz, 1995).

Solution-Focused Therapy

In the mid-1980s, simultaneous with the managed care focus in the health industry, the solution-focused approach to family therapy made a sig- nificant impact on the field (Berg, 1994; de Shazer, 1985; O’Hanlon & Weiner-Davis, 1989).

Managed care was an attempt to equate psychological and counseling treatments to medical treatments. By designating specific treatments for specific disorders, insurance companies sought to save money by limiting ser- vices as much as possible. Practitioners accepting managed care patients were increasingly told who they could see, what services they could provide, and how many sessions would be reimbursed. Treatments that were quick (particularly if they could be demonstrated to be effective) were preferred.

Solution-focused therapy was based on a reemergence of constructivism, a philosophical position dating back to Immanual Kant. An essential feature of constructivism is that individuals “construct” their own reality. They use their individual lens to perceive a problem in a specific way. The solution to a problem is not to analyze how a problem began or how individuals are trapped in recurring behavioral processes but to acquire new ways of solving the problem by challenging assumptions and activating solutions. This reframing is essentially a cognitive activity and has much in common with the earlier work of the communication theorists at the MRI. Unlike the earlier communication theorists, solution-focused therapists do not accept the notion of resistance or ulterior motives for symptomatic behavior but believe that family members want to change.

Here are seven assumptions that solution-focus therapists make as a basis for their interventions (from Selekman, 1993):

1. Resistance is not a useful concept. Clients want change, and the therapist should join with the family in its efforts at change.

2. Change is inevitable. The problem is to be viewed optimistically, and the therapy emphasizes possible solutions to the problems.

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3. Only a small change is necessary. Therapy should proceed in a fashion that links one small change to another.

4. Clients have the strength and resources to change. Therapy emphasizes a health perspective.

5. Problems are unsuccessful attempts to resolve difficulties. Fam- ilies need new consultation to get unstuck from old attempts at problem solving.

6. Therapists do not need to know a great deal about the problem in order to solve it. Understanding why the problem initially began is not necessary to finding a solution to the current problem.

7. There are multiple perspectives. There is no one way to view the problem. There is no one solution to the problem.

In addition to focusing on how the clients are framing the problem and assuming that they have the strength to change, solution-focused family ther- apists ask specific questions in concrete behavioral terms to get individuals to take responsibility for new actions in their relationships.

Feminism and Multiculturalism

Changing social and cultural conditions impacted the ways that fam- ily psychotherapy was conceptualized and practiced in a number of signifi- cant ways beyond the psychoeducational approach and solution-focused therapy. Feminism was a major force in getting theorists to reconceptualize family life. Rachel Hare-Mustin and Jeanne Marecek (1988) challenged whether systems theory was intrinsically predicated on concepts that were in opposition to feminist principles. Although some maintained that being a feminist therapist involved more than being sensitive to gender issues and necessitated taking an active political position, there is no question that therapists of all orientations benefited from the insights provided by feminist writings.

Multiculturalism alerted family therapists to the power of culture, race, and ethnicity in influencing family behavior. Therapists could no longer be mere technicians implementing specific techniques but had to be concerned with broader contextual issues. Therapists needed to distinguish between cul- tural, racial, and ethnic differences and pathology. The work of McGoldrick, Giordano, and Pearce (1996) on ethnic patterns and Boyd-Franklin (1993) on racial issues was particularly effective in raising consciousness. Cultural changes that resulted in greater awareness of the plight of marginalized groups in our society (gay and lesbian families, economically disadvantaged families, immigrant families, single-parent families) have influenced therapist thinking and practice significantly.

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Integration of Theories

Once the family therapy field moved beyond its initial period there was a natural integration of these family theories with relevant preexisting psycho- logical theories as well as with other family theories both old and new. As therapists using the new family theories became more secure about their contributions to the mental health field they were less resistant to additions, modifications, and integration of concepts and techniques drawn from multiple sources. A major force driving these changes was the desire to make theory more comprehensive to achieve greater clinical effectiveness. Indeed, integration or eclecticism is the modal position of therapists in the United States.

In this section I comment on the integration of early family therapy the- ories: behavioral family theory, internal family systems therapy, narrative therapy, and developmental theory. Last, I comment on family therapy the- ories that are a combination of elements from various family therapy theories.

Behavioral Family Therapy

Behavior therapists have a long history of applying their principles to a variety of problems that occur within the family. However, early attempt by behavior therapists to address symptoms in the family tended to occur using well-established behavior techniques that kept these efforts contained within behavior theory. Family systems therapists, for the most part, left the estab- lished theoretical groups with which they were originally associated to form their own informal, and later formal, organizations. These organizations were committed to the development of new theoretical formulations of family functioning. Thus, initially, behavior therapists and systems therapists belonged to two different professional groups and tended to use their respec- tive techniques to address family problems. However, with time there has been a beneficial blending of the techniques of behavior therapy and systems therapy. Early on, as behaviorists attempted to move from an individual per- spective to a systemic perspective, they used social exchange theory (e.g., Homans, 1961; Thibaut & Kelly, 1959). Some of the underlying assumptions of this theory include the facts that people are motivated by self-interest, that they will try to maximize their rewards at minimal cost, and that each mem- ber of a group has to expect some reward for maintaining the relationship with the group.

Jacobson and Margolin (1979), building on the earlier work of Stuart (1969), used these principles in constructing a view of reinforcement that is both circular and reciprocal. An example is the following: A wife asks her husband for more time together; the husband is not so inclined and does not respond. The wife begins to become angry and demanding, and the husband says, “There is no way I’m going to spend time with you when you act like

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such a shrew.” This only serves to increase the wife’s anger and behavioral tirade. Finally, in exhaustion, the husband gives in, saying, “Okay, if you just stop, we will go out somewhere to eat.”

In this sequence, the wife has been reinforced for delivering the tirade, and the husband has been reinforced for giving in to the wife’s negative behav- ior by stopping her tirade after he agrees to go out. In behavior exchange, each partner’s behavior is both being affected by and influencing the other. Thus, the model maintains the centrality of behavior modification by intervening to alter the reinforcement contingencies while at the same time attempting to deal with a relationship focus by looking at how both spouses participate in the process of reinforcement.

Further contributions to behavioral family therapy were made when cognitive techniques were added to the original behavioral paradigm to form cognitive–behavioral therapy. The work of Beck (1988) and Dattilio (1998) has been widely received. The basic premise of these theories is that cognitions are essential along with behaviors and emotions in understanding and modi- fying the interactions between individuals. Cognitions, emotions, and behav- iors all interact in a mutually influential manner. Beliefs can be perpetuated across generations and can result in personal schemas about self, others, and the world at large. If these schemas are predicated on false assumptions, the result is dysfunctional behavior.

Gordon and Davidson (1981) were among the first to acknowledge the limitations of behavior therapy and stressed the importance of broad-based assessment and treatments that went beyond traditional behavioral tech- niques. They called for an integrative model that would extend the focus of treatment to other areas of the family system beyond the presenting complaint. Today, there is general agreement that behavioral family therapy not only addresses specific symptoms but also broader systemic concerns of the family to effectively improve family functioning. As behavior therapists began to acknowledge these broad problems in the family, they began to incorporate more traditional family systems concepts and techniques into their efforts (Birchler & Spinks, 1980; Jacobson & Christensen, 1996). Thus, as behavior therapists deal with the complex problems of families, they are not only mod- ifying their procedures but are also incorporating systemic principles, which has made their efforts more successful.

Internal Family Systems Therapy

When the family therapy movement began in the 1950s, there was a strong effort by the early theorists to avoid established individual theory. Indeed, many of the dominant leaders of the family therapy movement were allergic, if not hostile, toward existing individual theory. Those family theo- rists who used a psychoanalytic underpinning to their family psychotherapy

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were the major exception. The relentless focus on an interpersonal perspec- tive, however, resulted in inadequate consideration of internal processes of the individual to the family process. By the mid-1980s, enough time had passed that family theorists could reconsider individual processes without fear that they were losing their systems identity. The self had rejoined the system. A strong example of this is Schwartz’s (1995) internal family systems theory.

Schwartz’s understanding of individuals and their relationship began when he observed that clients talked about parts of themselves. He concep- tualized that each of these parts had a full range of feelings and beliefs and functioned as autonomous personalities, almost independent of the person in whom they existed. The goal of therapy was to help the individual to establish trust and harmony among these parts so that an integrated self could relate in a functional manner to others. These inner parts function as a system, thereby allowing the therapist to use the same principles used to treat family members to treat the subparts of an individual. Therapist tracking of the internal processes across parts is done simultaneously with the tracking of the interpersonal process between people.

Schwartz conceptualized parts of an individual into three categories, each with its own function or role. There are the manager parts, whose role is to be responsible and protective. There are the exile parts, whose role is to be containers of hurt, pain, and wounds. And there are the fire fighter parts, whose role is to put out the fire of the pain and hurt when it surfaces from the exiles. Overuse of fire fighter behavior does not solve the problem, and in fact it creates other problems, such as alcoholism. In addition to the parts of an individual, there is the self. When the self is in charge it can balance and heal the parts of the individual and thereby not be at the mercy of extreme behavior from any one part.

Narrative Therapy

Narrative therapy has its base in symbolic interactionism theory, which began in the early 1900s (Thomas & Znaniecki, 1920) and is one of the most influential theories for studying and understanding the family. These philo- sophical principles were used by Michael White (1991), considered to be the founder of the narrative movement in family therapy. In narrative therapy, pri- mary import is given to the stories that families tell themselves to make sense of their experiences. These stories are core for families and are a primary source of both functional and dysfunctional behavior.

White appeared uninterested in what causes peoples’ problems. Rather, he focused on how the therapist can empower them to overcome “the oppres- sion” of their “negative lives.” In doing this work, White used two main tech- niques. The first is the construction of a new narrative story in which the therapist helps the family members fashion a more functional and more hope-

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ful storyline for their lives. The second technique centers on the externaliza- tion of the problem outside of the individual and the family in a way that makes the problem the external common enemy. In this way, the family as a group can join forces and become empowered to change.

The manner in which narrative therapists work with families takes its cues from the earlier work of Anderson and Goolishiam (1988) known as the collaborative-conversational model. This method is reminiscent of the 1970s when Carl Whitaker challenged therapists to abandon “dummy–expert” the- ories and use more collaborative methods in which family and therapist come together in a joint effort at healing. This idea of working collaboratively and supportively has been extended by many narrative family therapists (e.g., Epston, 1994; Madigan & Epston, 1995), who emphasize the need for the family to acquire supportive communities after therapy to help them sustain their new narratives.

Developmental Theory

Soon after the basic concepts of family psychotherapy became established, theorists began to study the family from a clinical perspective over time. They drew on developmental theory based on psychological and sociological theo- ries of the family, which came into their own in the 1950s. One of the first con- tributions to developmental theory was made by Duvall and Hill (1948), who took the systems position that families developed as a dynamic unit not merely as a collection of individuals. In this early work, the distinction was made between the functioning of the family at a particular stage of development and the functioning of the family as they experienced the transition period between stages. Duvall’s eight stages of the family life cycle, beginning with a married couple has been the most widely accepted format for family development. Each of his stages involves roles and developmental tasks for the various family mem- bers. Others have expanded the life cycle to a life course (e.g., Bengtson & Allen, 1993), which adds the social context in which change occurs as well as the individual meaning family members gave to the changes occurring in their life course. These contributions take into account that all families do not fol- low the same path on the same time table.

Contributions by family therapists to family theory have been substan- tial since the early 1970s. Wynne (1988) proposed an epigenetic model of family process that involved four processes: attachment, communication, joint problem solving, and mutuality. He pointed out that relational processes usually proceed at a pace that is different from individual life cycle changes. Breunlin (1988) helped to explain why families experience stress during transi- tion periods during their life cycle. His oscillation theory proposes that transi- tions are not made clearly from one stage to the next but involve a period of time in which there is oscillation between levels of functioning. This back-and-forth

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involvement between levels of functioning is frustrating for family members. Olson has shown how his core dimensions of cohesion and adaptability need to change in a family depending on external stress and developmental stage. A family starting out with infant children may need to have a higher level of cohesion to be functional than a family that is at the stage of launching its children. Carter and McGoldrick (1980), working from their multigenera- tional Bowenian beginnings, have contributed substantially in demonstrat- ing how anxiety develops in families over time particularly in response to major life transitions.

Integrative Family Psychotherapy

The preceding integrative developments draw heavily from theories outside the mainstream of family psychotherapy, such as individual psychology and developmental theory. But many developments have resulted directly from integrating different theories and techniques of family psychotherapy. Some of these integrative therapies have been in existence for a considerable period of time, and others have recently been proposed. Over the past 30 years, integrative approaches to family therapy have combined elements from the early models (structural, strategic, Bowenian, experiential) with each other as well as with elements from relatively newer models (behavioral, narrative, solution focused). It is to be expected that no one model could do full justice to the complexity of the human condition or the difficulties inherent in clinical problems. As such, approaches that integrate elements from various theories are indicated provided that they reflect conceptual integrity and clinical relevance.

An exemplar of well-developed integration is the problem-centered therapy of Pinsof (1995) and his colleagues. Working from a strategic family theory base, Pinsof added emotional expressive procedures from the experi- entialists, family-of-origin procedures from Bowen, or intrapsychic procedures from psychoanalytic family therapy as the course of treatment warrants. He often employed a team of therapists, each of whom had his or her own com- petencies to provide the needed services to a given family.

Eron and Lund (1996) proposed a well-developed therapy protocol that has been developed over the past 20 years. Their approach combines strate- gic elements from the earlier MRI model with narrative techniques. The use of this combination of techniques can be more easily mastered by a single therapist than can the wide range of techniques used in the Pinsof model. In combining the behavioral focus of the strategic model with the cognitive approach (organizing story line or preferred view of oneself) of the narrative approach, Eron and Lund broadened their focus of the therapy to more fully account for the multiple dimensions of the family problem.

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Other problem-centered integrative approaches have been developed from major research program designed to address specific clinical problems. Henggeler and Borduin (1990) developed a multisystemic model that is designed to treat juvenile offenders and their families. In addition to using established procedures aimed at improving family relationships they extended their efforts to school and peer systems, two critical systems beyond the fam- ily. They also paid close attention to relevant developmental issues that may be critical to the presenting problem. The movement toward integrative ther- apies is a dominant characteristic of current family psychotherapy. Often these integrated models are the results of pragmatic concerns about which combination will work for a specific presenting problem. Recent experimen- tation with combinations is highlighting the strengths of the respective the- ories. This can eventually result in the identification of overarching principles of treatment interventions. Knowledge about these principles and which techniques from specific therapies can best address them should result in more effective treatments.

CONCLUSION

Family systems therapy has grown over the past 60 years in theory, research, and application. Overall, this growth has been quite positive. There has been a general acceptance of family therapy by both the public and profes- sionals in the mental health field and beyond. The broader context of family functioning (e.g., ethnicity, gender, race) continues to be addressed and incor- porated into clinical practice. The range of clinical issues that are addressed by family therapy continues to be expanded. Research continues to refine proce- dures so that treatments can be more effective.

Although there are many positives about this growth, there is no con- sensus on a comprehensive theory of family. If family systems theory is to continue as a comprehensive model for understanding the individual’s emo- tional, cognitive, and behavioral functioning in relationship context, sev- eral eventualities must occur. There must be a continued sophistication and refinement of the characteristics of functional compared with dysfunctional systems, a systemic model of the individual including a continuum linking his or her “inner and outer space,” and a model for tracking dyadic inter- action and triangle formation. Guerin, Fogarty, Fay, and Kautto (1996) in their book Working With Relationship Triangles proposed one such model. The goal of these refined family concepts is to reach the point where the pioneers of family therapy began: to develop an integrated system of inter- ventions that would enhance better functioning for individuals as well as the family system as a whole.

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REFERENCES

Ackerman, N. (1958). The psychodynamics of family life. New York, NY: Basic Books. Anderson, C. M., Reiss, D., & Hogarty, G. E. (1986). Schizophrenia and the family: A practi-

tioner’s guide to psychoeducation and management. New York, NY: Guilford Press. Anderson, H., & Goolishian, H. (1988). Human systems as linguistic systems: preliminary and

evolving ideas about the implications for clinical theory. Family Process, 27, 371–393. doi:10.1111/j.1545-5300.1988.00371.x

Beck, A. T. (1988). Cognitive therapy and the emotional disorders. New York, NY: International Universities Press.

Bell, J. E. (1961). Family group therapy. Public Health Monograph No. 64. Washington, DC: U.S. Government Printing Office.

Bengtson, V. I., & Allen, K. R. (1993). The life course perspective applied to families over time. In P. G. Boss, W. J. Doherty, R. LaRossa, W. J. Schumm, & S. K. Steinmetz (Eds.), Sourcebook of family theories and methods: A contextual approach (pp. 469–499). New York, NY: Plenum Press.

Berg, I. K. (1994). Family-based services: A solution focused approach. New York, NY: Norton. Birchler, G. R., & Spinks, S. H. (1980). Behavioral-systems marital therapy: Integration and

clinical application. The American Journal of Family Therapy, 8, 6–28. doi:10.1080/ 01926188008250354

Boszormenyi-Nagy, I. (1987). Foundations of contextual therapy. New York, NY: Brunner/Mazel. Boszormenyi-Nagy, I., & Framo, J. (Eds.). (1965). Intensive family therapy: Theoretical and prac-

tical aspects. New York, NY: Harper & Row. Boszormanyi-Nagy, I., & Spark, G. (1973). Invisible loyalties: Reciprocity in intergenerational fam-

ily therapy. New York, NY: Harper & Row. Bowen, M. (1966). The use of family theory in clinical practice. Comprehensive Psychiatry,

7, 345–374. doi:10.1016/S0010-440X(66)80065-2 Bowen, M. (1972). On the differentiation of self. In J. Framo (Ed.), Family interaction: A dialogue

between family researchers and family therapists (pp. 111–173). New York, NY: Springer. Bowen, M. (1976). Theory in the practice of psychotherapy. In P. Guerin (Ed.), Family therapy:

Theory and practice (pp. 42–90). New York, NY: Gardner Press. Bowen, M. (1978). Family therapy in clinical practice. New York, NY: Jason Aronson. Boyd-Franklin, N. (1993). Race, class, and poverty. In F. Walsh (Ed.), Normal family processes

(pp. 260–279). New York, NY: Guilford Press. Breunlin, D. C. (1988). Oscillation theory and family development. In C. Falicov (Ed.), Family tran-

sitions: Continuity and change over the life cycle (pp. 133–155). New York, NY: Guilford Press. Carter, E. A., & McGoldrick, M. (1980). The family life cycle: A framework for family therapy.

New York, NY: Gardner Press. Chabot, D. R. (1996). Chabot pursuer—Distancer movement scale. Unpublished manuscript,

Fordham University, New York, New York. Dattilio, F. M. (1998). Case studies in couple and family therapy: Systemic and cognitive perspectives.

New York, NY: Guilford Press. de Shazer, S. (1985). Keys to solutions in brief therapy. New York, NY: Norton. Doherty, W. (1996). The intentional family. Reading, MA: Addison-Wesley. Duvall, E. M., & Hill, R. L. (1948). Reports of the committee on the dynamics of family interaction.

Washington, DC: National Conference on Family Life. Epston, D. (1994). Extending the conversation. Family Therapy Networker, 18, 30–37. Eron, J., & Lund, T. (1996). Narrative solutions in brief therapy. New York, NY: Guilford Press. Fairbairn, W. D. (1952). An object-relations theory of the personality. New York, NY: Basic Books.

200 DAVID R. CHABOT

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

Fogarty, T. F. (1976a). Marital crisis. In P. J. Guerin (Ed.), Family therapy: Theory and practice (pp. 325–334). New York, NY: Gardner Press.

Fogarty, T. F. (1976b). Systems concepts and the dimensions of self. In P. J. Guerin (Ed.), Family therapy: Theory and practice (pp. 144–153). New York, NY: Gardner Press.

Fogarty, T. F. (1984). The individual and the family. In E. Pendagast (Ed.), Compendium II: The best of the family, 1978–1983 (pp. 71–77). New Rochelle, NY: Center for Family Learning.

Goldstein, M. J., Rodnick, E. H., Evans, J. R., May, P. R., & Steinberg, M. (1978). Drug and family therapy in the aftercare treatment of acute schizophrenia. Archives of General Psy- chiatry, 35, 1169–1177.

Gordon, S. B., & Davidson, N. (1981). Behavioral parent training. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy (pp. 517–555). New York, NY: Brunner/Mazel.

Guerin, P. (1979). System, system, who’s got the system? In E. Pendagast (Ed.), Compendium I: The best of the family, 1973–1978 (pp. 9–16). New Rochelle, NY: Center for Family Learning.

Guerin, P., Fay, L., Burden, S., & Kautto, J. (1987). The evaluation and treatment of marital con- flict: A four-stage approach. New York, NY: Basic Books.

Guerin, P. Fogarty, T. F., Fay L. & Kautto, J. (1996). Working with relationship triangles: The one-two-three of psychotherapy. New York, NY: Guilford Press.

Haley, J. (1976). Problem solving therapy. San Francisco, CA: Jossey-Bass. Haley, J. (1984). Ordeal therapy. San Francisco, CA: Jossey-Bass. Hare-Mustin, R. T. (1978). A Feminist approach to family therapy. Family Process, 17,

181–194. Hare-Mustin, R. T., & Mareck, J. (1988). The meaning of difference: Gender theory, post-

modernism, and psychology. American Psychologist, 43, 455–464. Henggeler, S., & Borduin, C. (1990). Family therapy and beyond: A multisystemic approach to

treating the behavior problems of children and adolescents. Pacific Grove, CA: Brooks/Cole. Hoffman, L. (1981). Foundations of family therapy. New York, NY: Basic Books. Homans, G. (1961). Social behavior: Its elementary forms. New York, NY: Harcourt, Brace &

Jovanovich. Jackson, D. D., & Weakland, J. H. (1961). Conjoint family therapy: Some considerations on

theory, technique and results. Psychiatry, 24, 30–45. Jacobson, N., & Christensen, A. (1996). Integrative couple therapy. New York, NY: Norton. Jacobson, N., & Margolin, G. (1979). Marital therapy: Strategies based on social learning and behav-

ioral exchange principles. New York, NY: Brunner/Mazel. Klein, M. (1946). Notes on some schizoid mechanisms. The International Journal of Psycho-

Analysis, 27, 99–110. Licht, C., & Chabot, D. (2006). The Chabot emotional differentiation scale: A theoreti-

cally and psychometrically sound instrument for measuring Bowen’s intrapsychic aspect of differentiation. Journal of Marital and Family Therapy, 32, 167–180. doi:10.1111/ j.1752-0606.2006.tb01598.x

Madanes, C. (1981). Strategic family therapy. San Francisco, CA: Jossey-Bass. Madigan, S., & Epston, D. (1995). From “spychiatric gaze” to communities of concern: From

professional monologue to dialogue. In S. Friedman (Ed.), The reflecting team in action: Collaborative family practice (pp. 257–276). New York, NY: Guilford Press.

McDaniel, S. Hepworth, J., & Doherty, W. (1992). Medical family therapy. New York, NY: Basic Books.

McFarlane, W. R., Dixon, L., Lukens, E., & Luckstead, A. (2003). Family psychoeducation and schizophrenia: A review of the literature. Journal of Marital and Family Therapy, 29, 223–245.

FAMILY SYSTEMS THEORIES OF PSYCHOTHERAPY 201

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .

McGoldrick, M. Giordano, J., & Pearce, J. (1996). Ethnicity and family therapy (2nd ed.). New York, NY: Guilford Press.

Milkowitz, D. J. (1995). The evolution of family-based psychopathology. In R. H. Mikesell, D. D. Lusterman, & S. H. McDaniels (Eds.), Integrating family therapy: Handbook of fam- ily psychology and systems theory (pp. 183–197). Washington, DC: American Psychological Association.

Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Nichols, M. (2008). Family therapy: Concepts and methods. Boston, MA: Allyn & Bacon. O’Hanlon, W., & Weiner-Davis, M. (1989). In search of solutions: A new direction in psychotherapy.

New York, NY: Norton. Pinsof, W. (1995). Integrative problem-centered therapy. New York, NY: Basic Books. Rabkin, R. (1968). Is the unconscious necessary? American Journal of Psychiatry, 125, 313{3n}319.

doi:10.1176/appi.ajp.125.3.313 Rabkin, R. (1970). Inner and outer space. New York, NY: Norton. Satir, V. (1967). Conjoint family therapy. Palo Alto, CA: Science & Behavior Books. Satir, V. (1972). Peoplemaking. Palo Alto, CA: Science & Behavior Books. Scharff, D., & Scharff, J. (1987). Object relations family therapy. New York, NY: Jason Aronson. Schwartz, R. C. (1995). Internal family systems therapy. New York, NY: Guilford Press. Selekman, M. D. (1993). Solution-oriented brief therapy with difficult adolescents. In

S. Friedman (Ed.), The new language of change: Constructive collaboration in psychotherapy (pp. 138–157). New York, NY: Guilford Press.

Selvini Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. (1978). Paradox and counterparadox. New York, NY: Jason Aronson.

Stuart, R. B. (1969). An operant-interpersonal treatment for marital discord. Journal of Consulting and Clinical Psychology, 33, 675–682. doi:10.1037/h0028475

Thibaut, J., & Kelly, H. H. (1959). The social psychology of groups. New York, NY: Wiley. Thomas, W. I., & Znaniecki, F. (1920). The polish peasant in Europe and America (Vol. 5).

Boston, MA: Badger. Watzlawick, P., Beavin, J., & Jackson, D. (1967). Pragmatics of human communication. New

York, NY: Norton. Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Principles of problem formation and

problem resolution. New York, NY: Norton. Whitaker, C. (1976). The hindrance of theory in clinical work. In P. J. Guerin (Ed.), Family

therapy: Theory and practice. New York, NY: Gardner Press. Whitaker, C., Felder, R., & Warkentin, J. (1965). Counter-transference in the family treat-

ment of schizophrenia. In I. Boszormenyi-Nagy & J. Framo (Eds.), Intensive family therapy (pp. 323–342). New York, NY: Harper & Row.

Whitaker, C., & Keith, D. (1981). Symbolic experiential family therapy. In A. Gurman & D. Kniskern (Eds.), Handbook of family therapy (pp. 187–225). New York, NY: Brunner/Mazel.

White, M. (1991). Deconstruction of family therapy. Dulwich Center Newsletter, 3, 21–40. Wynne, L. (1988). An epigenetic model of family process. In C. Falicov (Ed.), Family transi-

tions: Continuity and change over the life cycle (pp. 81–106). New York, NY: Guilford Press. Wynne, L., Ryckoff, I., Day, J., & Hirsch, S. (1958). Pseudomutuality in the family relations

of schizophrenics. Psychiatry, 21, 205–220.

202 DAVID R. CHABOT

Co py

ri gh

t Am

er ic

an P sy

ch ol og ic al A ss oc ia ti on . No t fo r fu

rt he

r di

st ri

bu ti

on .