Family therapy gained its initial legitimacy during the 1950's by

Family Therapy ConCepts and Methods

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iii

Family Therapy ConCepts and Methods

eLeVenth edItIon

Michael P. Nichols College of William and Mary

with Sean D. Davis Alliant International University

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Library of Congress Cataloging-in-Publication Data Nichols, Michael P., author. Family therapy : concepts and methods / Michael P. Nichols, College of William and Mary with Sean D. Davis, Alliant International University. — Eleventh edition. pages cm Includes bibliographical references and index. ISBN 978-0-13-382660-9 — ISBN 0-13-382660-0 1. Family psychotherapy. I. Davis, Sean D., author. II. Title. RC488.5.N53 2016 616.89’156—dc23 2015032118

10 9 8 7 6 5 4 3 2 1

Student Edition ISBN 10: 0-13-382660-0

ISBN 13: 978-0-13-382660-9

eText ISBN 10: 0-13-382681-3 ISBN 13: 978-0-13-382681-4

Package ISBN 10: 0-13-430074-2 ISBN 13: 978-0-13-430074-0

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v

The Stages of the Family Life Cycle xiii Major Events in the History of Family Therapy xv Foreword xxi Preface xxiii

PART One THE CONTEXT OF FAMILY THERAPY

Introduction The Foundations of Family Therapy 1 The Myth of the Hero 3 Psychotherapeutic Sanctuary 4 Family versus Individual Therapy 5 Thinking in Lines, Thinking in Circles 6 The Power of Family Therapy 6

1 The Evolution of Family Therapy 8 The Undeclared War 8

Small Group Dynamics 9 The Child Guidance Movement 11 Marriage Counseling 12

Research on Family Dynamics and the Etiology of Schizophrenia 13 Gregory Bateson—Palo Alto 13 Theodore Lidz—Yale 15 Lyman Wynne—National Institute of Mental Health 15 Role Theorists 16

From Research to Treatment: The Pioneers of Family Therapy 16 John Bell 16 Palo Alto 17 Murray Bowen 19 Nathan Ackerman 21 Carl Whitaker 21 Ivan Boszormenyi-Nagy 22 Salvador Minuchin 22 Other Early Centers of Family Therapy 23

The Golden Age of Family Therapy 24 SUMMARY 25

ConTEnTS

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vi Contents

2 Basic Techniques of Family Therapy 27 Getting Started 27

The Initial Telephone Call 27 The First Interview 28 The Early Phase of Treatment 30 The Middle Phase of Treatment 32 Termination 33 Termination Checklist 34

Family Assessment 34 The Presenting Problem 34 Understanding the Referral Route 35 Identifying the Systemic Context 35 Stage of the Life Cycle 36 Family Structure 36 Communication 36 Drug and Alcohol Abuse 37 Domestic Violence and Sexual Abuse 37 Extramarital Affairs 37 Gender 38 Culture 38

The Ethical Dimension 39 The Marriage and Family Therapy License 42

Family Therapy with Specific Presenting Problems 42 Marital Violence 42 Sexual Abuse of Children 45

Working with Managed Care 46 Fee-for-Service Private Practice 48

SUMMARY 49

3 The Fundamental Concepts of Family Therapy 50 Cybernetics 51 Systems Theory 54

General Systems Theory 55 Social Constructionism 55

Constructivism 56 The Social Construction of Reality 56

Attachment Theory 57 The Working Concepts of Family Therapy 60

Interpersonal Context 60 Complementarity 60 Circular Causality 60 Triangles 61 Process/Content 62 Family Structure 62 Family Life Cycle 63

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Contents vii

Family Narratives 64 Gender 65 Culture 66

SUMMARY 67

PART TWO THE CLASSIC SCHOOLS OF FAMILY THERAPY

4 Bowen Family Systems Therapy 69 Sketches of Leading Figures 70 Theoretical Formulations 70

Differentiation of Self 71 Emotional Triangles 71 Multigenerational Emotional Processes 72 Emotional Cutoff 72 Societal Emotional Process 73

Family Dynamics 73 Normal Family Functioning 73 Development of Behavior Disorders 74

Mechanisms of Change 76 Goals of Therapy 76 Conditions for Behavior Change 77

Therapy 77 Assessment 77 Therapeutic Techniques 80

Evaluating Therapy Theory and Results 85 SUMMARY 87

5 Strategic Family Therapy 89 Sketches of Leading Figures 89 Theoretical Formulations 91 Family Dynamics 93

Normal Family Functioning 93 Development of Behavior Disorders 93

Mechanisms of Change 94 Goals of Therapy 95 Conditions for Behavior Change 95

Therapy 95 Assessment 95 Therapeutic Techniques 97

Evaluating Therapy Theory and Results 107 SUMMARY 109

6 Structural Family Therapy 111 Sketches of Leading Figures 112 Theoretical Formulations 112

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viii Contents

Family Dynamics 115 Normal Family Functioning 115 Development of Behavior Disorders 116

Mechanisms of Change 118 Goals of Therapy 118 Conditions for Behavior Change 118

Therapy 119 Assessment 119 Therapeutic Techniques 121

Evaluating Therapy Theory and Results 127 SUMMARY 129

7 Experiential Family Therapy 131 Sketches of Leading Figures 132 Theoretical Formulations 132 Family Dynamics 133

Normal Family Functioning 133 Development of Behavior Disorders 133

Mechanisms of Change 134 Goals of Therapy 134 Conditions for Behavior Change 135

Therapy 135 Assessment 135 Therapeutic Techniques 136

Evaluating Therapy Theory and Results 146 SUMMARY 147

8 Psychoanalytic Family Therapy 149 Sketches of Leading Figures 150 Theoretical Formulations 150

Freudian Drive Psychology 151 Self Psychology 152 Object Relations Theory 152

Family Dynamics 154 Normal Family Functioning 155 Development of Behavior Disorders 156

Mechanisms of Change 158 Goals of Therapy 158 Conditions for Behavior Change 159

Therapy 159 Assessment 159 Therapeutic Techniques 160

Evaluating Therapy Theory and Results 165 SUMMARY 166

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Contents ix

9 Cognitive-Behavioral Family Therapy 167 Sketches of Leading Figures 167 Theoretical Formulations 169 Family Dynamics 169

Normal Family Functioning 169 Development of Behavior Disorders 170

Mechanisms of Change 172 Goals of Therapy 172 Conditions for Behavior Change 172

Therapy 173 Behavioral Parent Training 173 Behavioral Couples Therapy 177 The Cognitive-Behavioral Approach to Family Therapy 180 Treatment of Sexual Dysfunction 184

Evaluating Therapy Theory and Results 185 SUMMARY 187

PART THRee RECENT DEVELOPMENTS IN FAMILY THERAPY

10 Family Therapy in the Twenty-First Century 189 Challenges to Traditional Family Systems Models 189

Erosion of Boundaries 189 Postmodernism 190 The Feminist Critique 190 Feminist Family Therapy 191 Social Constructionism and the Narrative Revolution 194 Multiculturalism 195 Race 195 Poverty and Social Class 196 Gay and Lesbian Rights 197

New Frontiers 198 Advances in Neuroscience 198 Sex and the Internet 199 Spirituality and Religion 203

Tailoring Treatment to Populations and Problems 204 Single-Parent Families 205 African American Families 207 Gay and Lesbian Families 209 Home-Based Services 212 Psychoeducation and Schizophrenia 213 Medical Family Therapy 215 Relationship Enrichment Programs 215

SUMMARY 216

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x Contents

11 Solution-Focused Therapy 219 Sketches of Leading Figures 219 Theoretical Formulations 220 Family Dynamics 221

Normal Family Development 221 Development of Behavior Disorders 221

Mechanisms of Change 221 Goals of Therapy 222 Conditions for Behavior Change 222

Therapy 222 Assessment 222 Therapeutic Techniques 224 Taking a Break and Giving Feedback 232 Later Sessions 233 Interviewing Children 235

Evaluating Therapy Theory and Results 236 SUMMARY 237

12 narrative Therapy 239 Sketches of Leading Figures 240 Theoretical Formulations 240 Family Dynamics 242

Normal Family Development 242 Development of Behavior Disorders 242

Mechanisms of Change 243 Goals of Therapy 243 Conditions for Behavior Change 244

Therapy 245 Assessment 245 Therapeutic Techniques 246

Evaluating Therapy Theory and Results 254 SUMMARY 255

PART FOUR THE EVALUATION OF FAMILY THERAPY

13 Comparative Analysis 257 Theoretical Formulations 257

Families as Systems 257 Stability and Change 258 Process/Content 259 Monadic, Dyadic, and Triadic Models 259 Boundaries 260

Family Dynamics 261 Normal Family Development 261

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Contents xi

Development of Behavior Disorders 262 Inflexible Systems 262 Pathologic Triangles 263

Therapy 264 Assessment 264 Decisive Interventions 264

Integrative Models 268 Eclecticism 268 Selective Borrowing 268 Specially Designed Integrative Models 269

Integrative Problem-Centered Metaframeworks (IPCM) Therapy 269 The Narrative Solutions Approach 270 Integrative Couples Therapy 271 Dialectical Behaviorism 272 Other Integrative Models 273 Community Family Therapy 274

SUMMARY 275

14 Research on Family Intervention 276 Research and Practice: Worlds Apart 276 Methodological Issues in Studying the Effectiveness of Family Therapy 277 Research Findings on the Effectiveness of Family-Focused Interventions 279

Family Interventions for Childhood Problems 279 Family Interventions for Adult Disorders 281 Family Interventions for Relationship Difficulties 283

Family Therapy Process Research 284 Common Factors 285 The Therapeutic Alliance 285 Critical Change Events in Family Therapy 286

Future Directions 288

Appendix A Chapter-by-Chapter Recommended Readings 290

Appendix B Selected Readings in Family Therapy 296

Appendix C Glossary 298

References 305

Index 342

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xiii

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 ado- lescent 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 (grand-

parents)

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 expe-

rience of the elderly, supporting the older generation without overfunctioning for them

d. Dealing with loss of spouse, siblings, and other peers and preparation for death

ThE STAgES oF ThE FAMIlY lIFE CYClE

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xv

Social and Political Context Development of Family Therapy

1945 F.D.R. dies, Truman becomes president World War II ends in Europe (May 8) and the

Pacific (August 14)

Bertalanffy presents general systems theory

1946 Juan Perón elected president of Argentina Bowen at Menninger Clinic Whitaker at Emory Macy Conference Bateson at Harvard

1947 India partitioned into India and Pakistan

1948 Truman reelected U.S. president State of Israel established

Whitaker begins conferences on schizophrenia

1949 Communist People’s Republic of China established

Bowlby: “The Study and Reduction of Group Tensions in the Family”

1950 North Korea invades South Korea Bateson begins work at Palo Alto V.A.

1951 Julius and Ethel Rosenberg sentenced to death for espionage

Sen. Estes Kefauver leads Senate probe into organized crime

Ruesch & Bateson: Communication: The Social Matrix of Society

Bowen initiates residential treatment of mothers and children

Lidz at Yale

1952 Eisenhower elected U.S. president Bateson receives Rockefeller grant to study communication in Palo Alto Wynne at NIMH

1953 Joseph Stalin dies Korean armistice signed

Whitaker & Malone: The Roots of Psychotherapy

1954 Supreme Court rules school segregation unconstitutional

Bateson project research on schizophrenic communication

Bowen at NIMH

1955 Rosa Parks refuses to move to the back of the bus; Martin Luther King, Jr., leads boycott in Montgomery, Alabama

Whitaker in private practice, Atlanta, Georgia. Satir begins teaching family dynamics in Chicago

1956 Nasser elected president of Egypt Soviet troops crush anti-Communist rebellion

in Hungary

Bateson, Jackson, Haley, & Weakland: “Toward a Theory of Schizophrenia”

Bowen at Georgetown

MAjoR EvEnTS In ThE hISToRY oF FAMIlY ThERAPY

(continued)

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xvi Major events in the History of Family Therapy

Social and Political Context Development of Family Therapy

1957 Russians launch Sputnik I Eisenhower sends troops to Little Rock,

Arkansas, to protect school integration

Jackson: “The Question of Family Homeostasis” Ackerman opens the Family Mental Health Clinic of

Jewish Family Services in New York Boszormenyi-Nagy opens Family Therapy

Department at EPPI in Philadelphia

1958 European Common Market established Ackerman: The Psychodynamics of Family Life

1959 Castro becomes premier of Cuba Charles de Gaulle becomes French president

MRI founded by Don Jackson

1960 Kennedy elected U.S. president Family Institute founded by Nathan Ackerman (renamed the Ackerman Institute in 1971)

Minuchin and colleagues begin doing family therapy at Wiltwyck

1961 Berlin Wall erected Bay of Pigs invasion

Bell: Family Group Therapy Family Process founded by Ackerman and Jackson

1962 Cuban Missile Crisis Bateson’s Palo Alto project ends Haley at MRI

1963 Kennedy assassinated Haley: Strategies of Psychotherapy

1964 Johnson elected U.S. president Nobel Peace Prize awarded to Martin Luther

King, Jr.

Satir: Conjoint Family Therapy Norbert Wiener dies (b. 1894)

1965 Passage of Medicare Malcolm X assassinated

Minuchin becomes director of Philadelphia Child Guidance Clinic

Whitaker at University of Wisconsin

1966 Red Guards demonstrate in China Indira Gandhi becomes prime minister of

India

Brief Therapy Center at MRI begun under director- ship of Richard Fisch

Ackerman: Treating the Troubled Family

1967 Six-Day War between Israel and Arab states Urban riots in Cleveland, Newark, and Detroit

Watzlawick, Beavin, & Jackson: Pragmatics of Human Communication

Dicks: Marital Tensions

1968 Nixon elected U.S. president Robert Kennedy and Martin Luther King, Jr.,

assassinated

Don Jackson dies (b. 1920) Satir at Esalen

1969 Widespread demonstrations against war in Vietnam

Bandura: Principles of Behavior Modification Wolpe: The Practice of Behavior Therapy

1970 Student protests against Vietnam War result in killing of four students at Kent State

Masters & Johnson: Human Sexual Inadequacy Laing & Esterson: Sanity, Madness and the Family

1971 Twenty-Sixth Amendment grants right to vote to 18-year-olds

Nathan Ackerman dies (b. 1908)

1972 Nixon reelected U.S. president Bateson: Steps to an Ecology of Mind Wynne at University of Rochester

1973 Supreme Court rules that states may not prohibit abortion

Energy crisis created by oil shortages

Center for Family Learning founded by Phil Guerin Boszormenyi-Nagy & Spark: Invisible Loyalties

1974 Nixon resigns Gerald Ford becomes 39th president

Minuchin: Families and Family Therapy Watzlawick, Weakland, & Fisch: Change

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Major events in the History of Family Therapy xvii

Social and Political Context Development of Family Therapy

1975 Vietnam War ends Mahler, Pine, & Bergman: The Psychological Birth of the Human Infant

Stuart: “Behavioral Remedies for Marital Ills”

1976 Carter elected U.S. president Haley: Problem-Solving Therapy Haley to Washington, D.C.

1977 President Carter pardons most Vietnam War draft evaders

Family Institute of Westchester founded by Betty Carter

American Family Therapy Academy (AFTA) estab- lished

1978 Camp David Accords between Egypt and Israel

U.S. and People’s Republic of China establish diplomatic relations

Hare-Mustin: “A Feminist Approach to Family Therapy”

Selvini Palazzoli et al.: Paradox and Counterparadox

1979 England’s Margaret Thatcher becomes West’s first woman prime minister

Iranian militants seize U.S. Embassy in Tehran and hold hostages

Founding of Brief Therapy Center in Milwaukee Bateson: Mind and Nature

1980 Reagan elected U.S. president U.S. boycotts summer Olympic Games in

Moscow

Haley: Leaving Home Milton Erickson dies (b. 1901) Gregory Bateson dies (b. 1904)

1981 Sandra Day O’Connor becomes first woman justice of Supreme Court

Egyptian president Sadat assassinated

Hoffman: The Foundations of Family Therapy Madanes: Strategic Family Therapy Minuchin & Fishman: Family Therapy Techniques

1982 Equal Rights Amendment fails ratification Falklands war

Gilligan: In a Different Voice Fisch, Weakland, & Segal: Tactics of Change The Family Therapy Networker founded by Richard Simon

1983 U.S. invades Grenada Terrorist bombing of Marine headquarters in

Beirut

Doherty & Baird: Family Therapy and Family Medicine

Keeney: Aesthetics of Change

1984 Reagan reelected U.S. president U.S.S.R. boycotts summer Olympic Games in

Los Angeles

Watzlawick: The Invented Reality Madanes: Behind the One-Way Mirror

1985 Gorbachev becomes leader of U.S.S.R. de Shazer: Keys to Solution in Brief Therapy Gergen: “The Social Constructionist Movement in

Modern Psychology”

1986 Space shuttle Challenger explodes Anderson et al.: Schizophrenia and the Family Selvini Palazzoli: “Towards a General Model of

Psychotic Family Games”

1987 Congress investigates the Iran–Contra affair Tom Andersen: “The Reflecting Team” Guerin et al.: The Evaluation and Treatment of

Marital Conflict Scharff & Scharff: Object Relations Family Therapy

1988 George H. W. Bush elected U.S. president Kerr & Bowen: Family Evaluation Virginia Satir dies (b. 1916)

(continued)

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xviii Major events in the History of Family Therapy

Social and Political Context Development of Family Therapy

1989 The Berlin Wall comes down Boyd-Franklin: Black Families in Therapy

1990 Iraq invades Kuwait Murray Bowen dies (b. 1913) White & Epston: Narrative Means to Therapeutic

Ends

1991 Persian Gulf War against Iraq Harold Goolishian dies (b. 1924)

1992 Clinton elected U.S. president Family Institute of New Jersey founded by Monica McGoldrick

1993 Ethnic cleansing in Bosnia Los Angeles police officers convicted in

Rodney King beating

Israel Zwerling dies (b. 1917) Minuchin & Nichols: Family Healing

1994 Republicans win majority in Congress Nelson Mandela elected president of South

Africa

David and Jill Scharf leave Washington School of Psychiatry to begin the International Institute of Object Relations Therapy

1995 Oklahoma City federal building bombed Carl Whitaker dies (b. 1912) John Weakland dies (b. 1919) Salvador Minuchin retires Family Studies Inc. renamed The Minuchin Center

1996 Clinton reelected U.S. president Edwin Friedman dies (b. 1932) Eron & Lund: Narrative Solutions in Brief Therapy Freedman & Combs: Narrative Therapy

1997 Princess Diana dies in auto accident Hong Kong reverts to China

Michael Goldstein dies (b. 1930)

1998 President Clinton impeached by House of Representatives

Minuchin, Colapinto, & Minuchin: Working with Families of the Poor

1999 President Clinton acquitted in impeachment trial

Neil Jacobson dies (b. 1949) John Elderkin Bell dies (b. 1913) Mara Selvini Palazzoli dies (b. 1916)

2000 George W. Bush elected U.S. president Millennium Conference, Toronto, Canada

2001 September 11 terrorist attacks James Framo dies (b. 1922)

2002 Sex abuse scandal in Catholic Church Corporate corruption at Enron

Lipchik: Beyond Techniques in Solution-Focused Therapy

2003 U.S. invades Iraq Greenan & Tunnell: Couple Therapy with Gay Men

2004 George W. Bush reelected U.S. president Gianfranco Cecchin dies (b. 1932)

2005 Hurricane Katrina devastates New Orleans Steve de Shazer dies (b. 1940)

2006 Democrats regain control of U.S. House and Senate

Minuchin, Nichols, & Lee: Assessing Families and Couples

2007 Shootings at Virginia Tech Jay Haley dies (b. 1923) Lyman Wynne dies (b. 1923) Insoo Kim Berg dies (b. 1934) Albert Ellis dies (b. 1913) Thomas Fogarty dies (b. 1927)

2008 Barack Obama elected U.S. president Michael White dies (b. 1949)

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Major events in the History of Family Therapy xix

Social and Political Context Development of Family Therapy

2009 Worldwide economic recession Sprenkle, Davis, & Lebow: Common Factors in Couple and Family Therapy

2010 Earthquake in Haiti LaSala: Coming Out, Coming Home Dattilio: Cognitive-Behavioral Therapy with Couples

and Families

2011 Earthquake and tsunami in Japan Cose: The End of Anger

2012 Mass shootings in Newton CT Barack Obama reelected U.S. president

Betty Carter dies (b. 1929)

2013 Death of Nelson Mandela Affordable Healthcare Act

Alan Gurman dies (b. 1945)

2014 Ebola epidemic in West Africa Donald Bloch dies (b. 1923)

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xxi

In this volume, Mike Nichols tells the story of family therapy—and tells it very well. It’s hard to imagine a more readable and informative guide to the field.

Born in the late 1950s, family therapy seemed to spring fully formed out of the heads of a group of seminal thinkers. Over six decades later, both theory and practice show the uncertainties and doubts that define maturity. But in the beginning—as the story- tellers say—there was Gregory Bateson on the West Coast, a tall, clean-shaven, angular intellectual, who saw families as systems, carriers of ideas. On the East Coast was Nathan Ackerman, short, bearded, portly, the quintessential charismatic healer, who saw fam- ilies as collections of individuals struggling to bal- ance feelings, irrationalities, and desires. Bateson and Ackerman complemented each other perfectly, the Don Quixote and Sancho Panza of the family systems revolution.

For all the diversity of the 1960s that saw the new clinical practice called family therapy take a variety of names—systemic, strategic, structural, Bowenian, experiential—there was also a remarkable solidarity in the shared beliefs that defined the field.

As family therapy succeeded and expanded, it was extended to encompass different client popula- tions, with specific interventions for various special groups—clients with drug addictions, hospitalized psychiatric patients, the welfare population, violent families, and so on. All posed their own complexities. Practitioners responded to this expanded family ther- apy with an array of new approaches, some of which even questioned the fundamental allegiance to sys- tems thinking.

The challenges to systems theory (the official sci- ence of the time) took two forms. One was purely the- oretical: a challenge to the assumption that systemic thinking was a universal framework, applicable to the

functioning of all human collectives. A major broad- side came from feminists who questioned the absence of concepts of gender and power in systems thinking and pointed to the distorting consequences of gender- less theory when focusing on family violence. The other challenge concerned the connection between theory and practice: a challenge to the imposition of systems theory as the basis for therapeutic practice. The very techniques that once defined the field were called into question. Inevitably, the field began to re- open for examination of its old taboos: the individual, intrapsychic life, emotions, biology, the past, and the particular place of the family in culture and society.

As is always characteristic of an official science, the field tried to preserve established concepts while a pragmatic attention to specific cases was demand- ing new and specific responses. As a result, today we have an official family therapy that claims direct de- scendance from Bateson and a multitude of excellent practitioners doing sensitive and effective work that is frequently quite different from what systems theory prescribes.

I see the therapeutic process as an encounter between distinct interpersonal cultures. Real respect for clients and their integrity can allow therapists to be other than fearfully cautious, can encourage them to be direct and authentic—respectful and compassionate— but also at times honest and challenging.

This conception of the therapist as an active knower—of himself or herself and of the different family members—is very different from the neutral therapist of the constructivists. But, of course, these two prototypes are entirely too simplified. Most prac- titioners fall somewhere between these two poles of neutrality and decisiveness.

The choice between action and interventionism, on the one hand, and meaning and conversation,

FoREwoRd

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xxii Foreword

on the other, is but one of the questions the field is grappling with today; there are many others. Are the norms of human behavior universal, or are they cultur- ally constructed products of political and ideological constraint? How do we become experts? How do we know what we know? Can we influence people? Can we not influence them? How do we know that we are not simply agents of social control? How do we know that we are accomplishing anything at all?

These questions and the rich history and contem- porary practice of family therapy are explored in Family Therapy: Concepts and Methods. It is a thor- ough and thoughtful, fair and balanced guide to the

ideas and techniques that make family therapy such an exciting enterprise. Dr. Nichols has managed to be comprehensive without becoming tedious. Per- haps the secret is the engaging style of his writing, or perhaps it is how he avoids getting lost in abstrac- tion while keeping a clear focus on clinical practice. In any case, this superb book has long set the standard of excellence as the best introduction and guide to the practice of family therapy.

Salvador Minuchin, M.D.

Boca Raton, Florida

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xxiii

PReFAce

One thing that sometimes gets lost in academic dis- cussions of family therapy is the feeling of accom- plishment that comes from sitting down with an unhappy family and being able to help them. Begin- ning therapists are understandably anxious and not sure they’ll know how to proceed. (“How do you get all of them to come in?”) Veterans often speak in abstractions. They have opinions and discuss big issues—postmodernism, managed care, second- order cybernetics. While it’s tempting to use this space to say Important Things, I prefer to be a little more per- sonal. Treating troubled families has given me the greatest satisfaction imaginable, and I hope that the same is or will be true for you.

New to This edition

In this eleventh edition of Family Therapy: Concepts and Methods, I’ve tried to describe the full scope of family therapy—its rich history, the classic schools, the latest developments—but with increasing empha- sis on clinical practice. There are a lot of changes in this edition:

New Digital Enhancements in the Pearson eText

♦ Videos: Links to video clips of therapists have been embedded for students to view throughout the chapters of the Pearson eText. Students are prompted to reflect on and analyze the videos via an accompanying question.

♦ Chapter Quizzes: At the end of each chapter Summary, students will find two self-assessments marked by a checkmark icon. In the Pearson eText,

they click on the icon and the quiz appears. The first one prompts them to test their knowledge of chapter concepts by taking a multiple-choice quiz.

The second quiz icon prompts them to apply their knowledge of chapter concepts by responding to open-ended questions by typing their response and submitting it for immediate feedback. These self- assessments can reinforce understanding of key chapter concepts and support application of newly learned content.

Content Changes in the New Edition

♦ New section on the impact of the Affordable Care Act ♦ Recommendations for establishing a fee-for- service

private practice ♦ Revised and expanded section on attachment

theory ♦ Questions to ask when doing a genogram ♦ More specific interventions from the MRI

approach ♦ Detailed guidelines for making a structural family

therapy assessment ♦ New section with guidelines on using family

sculpting ♦ More specific techniques used in object relations

family therapy ♦ Expanded section on spirituality and religion ♦ Expanded and updated section on families and

technology ♦ Guidelines for therapeutic letter writing ♦ New research chapter including a discussion of

why research has failed to influence practice and suggestions for bridging the research-practice gap

♦ New case studies

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xxiv Preface

Instructor Supplements

An instructor’s manual, test bank, and PowerPoint slides are available to accompany this text. They can be downloaded at www.pearsonhighered.com/educator.

Acknowledgments

Albert Einstein once said, “If you want to learn about physics, pay attention to what physicists do, not what they say they do.” When you read about therapy, it can be hard to see past the jargon and political packaging to the essential ideas and practices. So in preparing this edition, I’ve traveled widely to visit and observe actual sessions of the leading practitioners. I’ve also invited several master therapists to share some of their best case studies with you. The result is a more prag- matic, clinical focus. I hope you like it.

So many people have contributed to my develop- ment as a family therapist and to the writing of this book that it is impossible to thank them all. But I would like to single out a few. To the people who taught me family therapy—Lyman Wynne, Murray Bowen, and Salvador Minuchin—thank you. Some of the people

who went out of their way to help me prepare this eleventh edition were Yvonne Dolan, Jerome Price, Deborah Luepnitz, William Madsen, Frank Dattilio, Vicki Dickerson, Douglas Breunlin, and Salvador Minuchin. And I owe a huge debt of gratitude to Sean Davis for his extensive and thoughtful contributions to this edition. Sean has the rare combination of ac- ademic smarts and clinical sophistication that makes his perspective so valuable. To paraphrase John, Paul, George, and Ringo, I get by with a lot of help from my friends—and I thank them one and all. I am especially grateful to Julie Peters at Pearson for making a hard job easier.

Finally, I would like to thank my postgraduate instructors in family life: my wife, Melody, and my children, Sandy and Paul. In the brief span of forty-five years, Melody has seen me grow from a shy young man, totally ignorant of how to be a husband and father, to a shy middle-aged man, still bewildered and still trying. My children never cease to amaze me. If in my wildest dreams I had imagined children to love and be proud of, I wouldn’t even have come close to children as fine as Sandy and Paul.

M. P. N.

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1

I n t r o d u c t I o n

The FoundaTions oF Family Therapy Leaving Home

There wasn’t much information on the intake sheet. Just a name, Holly Roberts, the fact that she was a senior in college, and her presenting complaint: “trouble making decisions.”

The first thing Holly said when she sat down was, “I’m not sure I need to be here. You prob- ably have a lot of people who need help more than I do.” Then she started to cry.

It was springtime. The tulips were up, the trees were turning leafy green, and purple clumps of lilacs perfumed the air. Life and all its possibilities stretched out before her, but Holly was naggingly, unaccountably depressed.

The decision Holly was having trouble making was what to do after graduation. The more she tried to figure it out, the less able she was to concentrate. She started sleeping late, missing classes. Finally, her roommate talked her into going to the counseling center. “I wouldn’t have come,” Holly said. “I can take care of my own problems.”

I was into cathartic therapy back then. Most people have stories to tell and tears to shed. Some of the stories, I suspected, were dramatized to elicit sympathy. We seem to give ourselves permission to cry only with some very accept- able excuse. Of all the human emotions we’re ashamed of, feeling sorry for yourself tops the list.

I didn’t know what was behind Holly’s depres- sion, but I was sure I could help. I felt comforta- ble with depression. Ever since my senior year in high school when my friend Alex died, I’d been a little depressed myself.

♦  ♦  ♦

After Alex died, the rest of the summer was a dark blur. I cried a lot. And I got mad whenever any- body suggested that life goes on. Alex’s minister said that his death wasn’t really a tragedy because now “Alex was with God in heaven.” I wanted to scream,

1

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but I numbed myself instead. In the fall, I went off to college, and, even though it seemed disloyal to Alex, life did go on. I still cried from time to time, but with the tears came a painful discovery. Not all of my grief was for Alex. Yes, I loved him. Yes, I missed him. But his death provided me the justification to cry about the everyday sorrows of my own life. Maybe grief is always like that. At the time, though, it struck me as a betrayal. I was using Alex’s death to feel sorry for myself.

♦  ♦  ♦

What, I wondered, was making Holly so sad? In fact, Holly didn’t have a dramatic story. Her feelings weren’t focused. After those first moments in my of- fice, she rarely cried. When she did, it was more an involuntary tearing up than a sobbing release. She talked about the future and not knowing what she wanted to do with her life. She talked about not hav- ing a boyfriend, but she didn’t say much about her family. If the truth be told, I wasn’t much interested. Back then, I thought home was a place you left in or- der to grow up.

Holly was hurting and needed someone to lean on, but something made her hold back, as though she didn’t quite trust me. It was frustrating. I wanted to help.

A month went by, and Holly’s depression got worse. I started seeing her twice a week, but we weren’t getting anywhere. One Friday afternoon, Holly was feeling so despondent that I didn’t think she should go back to her dorm alone. I asked her in- stead to lie down on the couch in my office and, with her permission, I called her parents.

Mrs. Roberts answered the phone. I told her that I thought she and her husband should come to Rochester and meet with me and Holly to discuss the advis- ability of Holly taking a medical leave of absence. Unsure as I was of my authority back then, I steeled myself for an argument. Mrs. Roberts surprised me by agreeing to come at once.

The first thing that struck me about Holly’s parents was the disparity in their ages. Mrs. Roberts looked like a slightly older version of Holly; she couldn’t have been much over thirty-five. Her husband looked sixty. It turned out that he was Holly’s stepfather. They had married when Holly was sixteen.

Looking back, I don’t remember much that was said in that first meeting. Both parents were worried about Holly. “We’ll do whatever you think best,” Mrs. Roberts said. Holly’s stepfather, Mr. Morgan, said they could arrange for a good psychiatrist “to help Holly over this crisis.” But, Holly didn’t want to go home, and she said so with more energy than I’d heard from her in a long time. That was on Saturday. I said that there was no need to rush into a decision, so we arranged to meet again on Monday.

When Holly and her parents sat down in my office on Monday morning, it was obvious that some- thing had happened. Mrs. Roberts’s eyes were red from crying. Holly glared at her and looked away. Mr. Morgan turned to me. “We’ve been fighting all weekend. Holly heaps abuse on me, and when I try to respond, Lena takes her side. That’s the way it’s been since day one of this marriage.”

The story that emerged was one of those sad his- tories of jealousy and resentment that turn ordinary love into bitter, injured feelings and, all too often, tear families apart. Lena Roberts was thirty-four when she met Tom Morgan. He was a robust fifty-six. The sec- ond obvious difference between them was money. He was a stockbroker who’d retired to run a horse farm. She was waitressing to support herself and her daugh- ter. It was a second marriage for both of them.

Lena thought Tom could be the missing father fig- ure in Holly’s life. Unfortunately, Lena couldn’t ac- cept all the rules Tom wanted to enforce, and so he became the wicked stepfather. He made the mistake of trying to take over and, when the predictable ar- guments ensued, Lena sided with her daughter. There were tears and midnight shouting matches. Twice Holly ran away for a few days. This triangle nearly proved the marriage’s undoing, but things calmed down after Holly left for college.

Holly expected to leave home and not look back. She would make new friends. She would study hard and choose a career. She would never depend on a man to support her. Unfortunately, she left home with unfinished business. She hated Tom for the way he treated her mother. He was always demanding to know where her mother was going, who she was going with, and when she would be back. If she was the least bit late, there would be a scene. Why did her mother put up with it?

2 Part One: The Context of Family Therapy

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Blaming her stepfather was simple and satisfying. But another set of feelings, harder to face, was eat- ing at Holly. She hated her mother for marrying Tom and for letting him be so mean to her. What had her mother seen in him? Had she sold out for a big house and a fancy car? Holly didn’t have answers to these questions; she didn’t even allow them into full aware- ness. Unfortunately, repression doesn’t work like put- ting something away in a closet and forgetting about it. It takes a lot of energy to keep unwelcome emo- tions at bay.

Holly found excuses not to go home during col- lege. It didn’t even feel like home anymore. She buried herself in her studies. But rage and bitterness gnawed at her until, in her senior year, facing an uncertain future, knowing only that she couldn’t go home again, she gave in to hopelessness. No wonder she was depressed.

I found the whole story sad. Not knowing about family dynamics and never having lived in a step- family, I wondered why they couldn’t just try to get along. Why did they have so little sympathy for each other? Why couldn’t Holly accept her mother’s right to find love a second time around? Why couldn’t Tom respect the priority of his wife’s relationship with her daughter? And why couldn’t Lena listen to her daugh- ter’s adolescent anger without getting so defensive?

That session with Holly and her parents was my first lesson in family therapy. Family members in therapy talk not about actual events but about re- constructed memories that resemble the original ex- periences only in certain ways. Holly’s memories resembled her mother’s memories very little, and her stepfather’s not at all. In the gaps between their truths, there was little room for reason and no desire to pursue it.

Although that meeting may not have been terribly productive, it did put Holly’s unhappiness in perspec- tive. No longer did I think of her as a tragic young woman all alone in the world. She was that, of course, but she was also a daughter torn between running away from a home she no longer felt part of and being afraid to leave her mother alone with a man she didn’t trust. I think that’s when I became a family therapist.

To say that I didn’t know much about families, much less about how to help them, would be an un- derstatement. But family therapy isn’t just a new set

of techniques; it’s a whole new approach to under- standing human behavior—as fundamentally shaped by its social context.

The myth of the hero

Ours is a culture that celebrates the uniqueness of the individual and the search for an autonomous self. Holly’s story could be told as a coming-of-age drama: a young person’s struggle to break away from child- hood and provincialism, to take hold of adulthood and promise and the future. If she fails, we’re tempted to look inside the young adult, the failed hero.

While the unbounded individualism of the hero may once have been encouraged more for men than women, as a cultural ideal it casts its shadow on us all. Even if Holly cared about connection as well much as autonomy, she may be judged by the prevail- ing image of accomplishment.

We were raised on the myth of the hero: the Lone Ranger, Robin Hood, Wonder Woman. When we got older, we searched for real-life heroes: Eleanor Roosevelt, Martin Luther King Jr., Nelson Mandela. These men and women stood for something. If only we could be a little more like these larger-than-life individuals who seemed to rise above their circumstances.

Only later did we realize that the circumstances we wanted to rise above were part of the human condition— our inescapable connection to our families. The roman- tic image of the hero is based on the illusion that authentic selfhood can be achieved as an autonomous individual. We do many things alone, including some of our most heroic acts, but we are defined and sustained by a network of human relationships. Our need to wor- ship heroes is partly a need to rise above littleness and self-doubt, but it is perhaps equally a product of imag- ining a life unfettered by all those pesky relationships that somehow never quite go the way we want them to.

When we do think about families, it’s often in negative terms—as burdens holding us back or as de- structive elements in the lives of our patients. What catches our attention are differences and discord. The harmonies of family life—loyalty, tolerance, solace, and support—often slide by unnoticed, part of the taken-for-granted background of life. If we would be heroes, then we must have villains.

Introduction The Foundations of Family Therapy 3

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4 Part One: The Context of Family Therapy

These days there’s a lot of talk about dysfunctional families. Unfortunately, much of this amounts to lit- tle more than parent bashing. People suffer because of what their parents did: their mother’s career, their fa- ther’s unreasonable expectations—these are the causes of their unhappiness. Perhaps this is an advance on stewing in guilt and shame, but it’s a long way from understanding what really goes on in families.

One reason for blaming family sorrows on the personal failings of parents is that it’s hard for the av- erage person to see past individual personalities to the structural patterns that make them a family—a system of interconnected lives governed by strict but unspo- ken rules.

People feel controlled and helpless not because they are victims of parental folly and deceit but be- cause they don’t understand the forces that tie hus- bands and wives and parents and children together. Plagued by anxiety and depression, or merely trou- bled and uncertain, some people turn to psychother- apy for help. In the process, they turn away from the irritants that propel them into therapy. Chief among these are unhappy relationships—with friends and lovers, and with our families. Our disorders are pri- vate ailments. When we retreat to the safety of a synthetic relationship, the last thing we want is to take our families with us. Is it any wonder, then, that when Freud ventured to explore the dark forces of the mind, he locked the family outside the consulting room?

psychotherapeutic sanctuary

Psychotherapy was once a private enterprise. The con- sulting room was a place of healing, yes, but it was equally a sanctuary, a refuge from a troubled and trou- bling world.

Buffeted about in love and work, unable to find solace elsewhere, adults came to therapy to find sat- isfaction and meaning. Parents, worried about their children’s behavior, sent them for guidance and di- rection. In many ways, psychotherapy displaced the family’s role in solving the problems of everyday life.

Freud excluded the family from psychoanalysis to help patients feel safe to explore the full range of their thoughts and feelings.

It’s possible to look back on the days before fam- ily therapy and see those who insisted on segregating patients from their families as exponents of a fos- silized view of mental disorder, according to which psychiatric maladies are firmly embedded inside the heads of individuals. Considering that clinicians didn’t begin treating families together until the mid- 1950s, it’s tempting to ask, “What took them so long?” In fact, there were good reasons for conducting therapy in private.

The two most influential approaches to psycho- therapy in the twentieth century, Freud’s psycho- analysis and Rogers’s client-centered therapy, were both predicated on the assumption that psychological problems arise from unhealthy interactions with oth- ers and can best be alleviated in a private relationship between therapist and patient.

Freud’s discoveries indicted the family, first as a breeding ground of childhood seduction and later as the agent of cultural repression. If people grew up a lit- tle bit neurotic—afraid of their own natural instincts— who should we blame but their parents?

Given that neurotic conflicts were spawned in the family, it seemed natural to assume that the best way to undo the family’s influence was to isolate relatives from treatment, to bar their contaminating influence from the psychoanalytic operating room. Because psychoanaly- sis focused on the patient’s memories and fantasies, the family’s presence would only obscure the subjective truth of the past. Freud wasn’t interested in the living family; he was interested in the family-as-remembered.

Freud excluded the family from psychoanalysis to help patients feel safe to explore the full range of their thoughts and feelings.W

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Introduction The Foundations of Family Therapy 5

By conducting treatment in private, Freud safe- guarded patients’ trust in the sanctity of the therapeu- tic relationship and thus maximized the likelihood that they would repeat, in relation to the analyst, the understandings and misunderstandings of childhood.

♦  ♦  ♦

Carl Rogers also believed that psychological prob- lems stemmed from destructive family relations. Each of us, Rogers said, is born with an innate tendency toward self-actualization. Left to our own devices, we tend to follow our own best interests. Unhappily, said Rogers, our instinct for actualization gets subverted by our craving for approval. We learn to do what we think others want, even though it may not be what’s best for us.

Gradually, this conflict between self-fulfillment and need for approval leads to denial of our authen- tic selves—and even the feelings that signal them. We swallow our anger, stif le our exuberance, and bury our lives under a mountain of expectations.

The therapy Rogers developed was designed to help patients uncover their real feelings. The Rogerian therapist listens sympathetically, offering compassion and understanding. In the presence of such an accept- ing listener, patients gradually get in touch with their own inner promptings.

Like the psychoanalyst, the client-centered ther- apist maintains absolute privacy in the therapeutic relationship to avoid any possibility that patients’ feelings might be subverted to win approval. Only an objective outsider could be counted on to provide the unconditional acceptance to help patients rediscover their real selves. That’s why family members had no place in the process of client-centered therapy.

Family versus individual Therapy

As you can see, there were valid reasons for conduct- ing psychotherapy in private. Although a strong claim can be made for individual psychotherapy, equally strong claims can be made for family therapy.

Individual psychotherapy and family therapy each offer an approach to treatment and a way of

understanding human behavior. Both have their virtues. Individual therapy provides the concentrated focus to help people face their fears and learn to become more fully themselves. Individual therapists have always recognized the importance of family life in shaping personality, but they have assumed that these influences are internalized and that intrapsychic dynamics become the dominant forces controlling behavior. Treatment can and should, therefore, be di- rected at the person and his or her personal makeup. Family therapists, on the other hand, believe that the dominant forces in our lives are located externally, in the family. Therapy, in this framework, is directed at changing the organization of the family. When family organization is transformed, the life of every family member is altered accordingly.

This last point—that changing a family changes the lives of its members—is important enough to elaborate. Family therapy isn’t predicated merely on changing the individual patient in context. Fam- ily therapy exerts change on the entire family; there- fore, improvement can be lasting because each family member is changed and continues to exert synchro- nous change on other family members.

Almost any human difficulty can be treated with either individual or family therapy, but certain prob- lems are especially suited to a family approach, among them problems with children (who must, re- gardless of what happens in therapy, return home to their parents), complaints about a marriage or other intimate relationship, family feuds, and symptoms that develop in an individual at the time of a major family transition.

If problems that arise around family transitions make a therapist think first about the role of the family, individual therapy may be especially useful when people identify something about themselves that they’ve tried in vain to change while their so- cial environment remains stable. Thus, if a woman gets depressed during her first year at college, a therapist might wonder if her sadness is related to leaving home and leaving her parents alone with each other. But if the same woman were to become depressed in her thirties, during a long period of sta- bility in her life, we might wonder if there was some- thing about her approach to life that wasn’t working for her. Examining her life in private—away from

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6 Part One: The Context of Family Therapy

troubled relationships—doesn’t, however, mean that she should believe she can fulfill herself in isolation from other people.

The view of persons as separate entities, with fam- ilies acting on them, is consistent with the way we experience ourselves. We recognize the influence of others—especially as obligation and constraint—but it’s hard to see that we are embedded in a network of relationships, that we are part of something larger than ourselves.

Thinking in lines, Thinking in Circles

Mental illness has traditionally been explained in linear terms—medical or psychological. Both para- digms treat emotional distress as a symptom of inter- nal dysfunction with historical causes.

Linear explanations take the form of A causes B. This works fine for some things. If you’re driv- ing along and your car suddenly sputters to a stop, go ahead and look for a simple explanation. Maybe you’re out of gas. If so, there’s a simple solution. Hu- man problems are usually a bit more complicated.

Individual therapists think in terms of linear cau- sality when they explore what happened to make in- dividuals behave the way they do. If a young woman has low self-esteem, perhaps it’s because her mother constantly criticizes her. Family therapists prefer to think in terms of circular causality and consider peo- ple’s mutual influence on each other. Thus, the young woman’s moping around the house might be a re- sponse to her mother’s fault-finding—and the moth- er’s finding fault might be a response to the young woman’s moping around the house. The more the mother criticizes, the more the young woman with- draws, and the more the young woman withdraws, the more the mother criticizes.

The term circular causality calls attention to the cy- cles of interaction in relationships. But in fact the term is somewhat of a misnomer, because the focus is not on causality—how something got started—but on the on- going transactions that sustain it. In some cases, maybe something in the past did trigger an unhappy pattern of interaction. But the past is over; therapists can only

work with what’s going on in the present. Although the mother in the earlier example may only have started reproaching her daughter when she started avoiding social activities, her continuing attempts to motivate the girl with criticism may only serve to perpetuate a circular pattern of withdrawal-and-criticism.

When things go wrong in relationships, most of us are generous in giving credit to other people. Because we look at the world from inside our own skins, it’s easy to see other people’s contributions to our mutual problems. Blaming is only natural. The illusion of unilateral influence tempts therapists too, especially when they hear only one side of a story. But once we understand that reciprocity is the governing principle of relationships, we can begin to get past thinking in terms of villains and victims.

Suppose that a father complains about his teenage son’s behavior.

Father: It’s my son. He’s rude and defiant.

Therapist: Who taught him that?

Instead of accepting the father’s perspective that he’s a victim of his son’s villainy, the therapist’s ques- tion invites him to look for patterns of mutual influ- ence. The point isn’t to shift blame from one person to another but to get away from blame altogether. As long as he sees the problem as his son’s doing, the fa- ther has little choice but to hope the boy will change. (Waiting for other people to change is like planning your future around winning the lottery.) Learning to think in circles rather than lines empowers us to look at the half of the equation we can control.

The power of Family Therapy

The power of family therapy derives from bringing parents and children together to transform their in- teractions. Instead of isolating individuals from the emotional origins of their conflict, problems are ad- dressed at their source.

What keeps people stuck is their inability to see their own participation in the problems that plague them. With eyes fixed firmly on what recalcitrant oth- ers are doing, it’s hard for most people to see the pat- terns that bind them together. The family therapist’s

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Introduction The Foundations of Family Therapy 7

job is to give them a wake-up call. When a husband complains that his wife nags, and the therapist asks how he contributes to her doing that, the therapist is challenging the husband to see the hyphenated him- and-her of their interactions.

♦  ♦  ♦

When Bob and Shirley came for help with marital problems, her complaint was that he never shared his feelings; his was that she always criticized him. This is a classic trading of complaints that keeps couples stuck as long as they fail to see the reciprocal pattern in which each partner provokes in the other precisely the behavior he or she can’t stand. So the therapist said to Bob, “If you were a frog, what would you be like if Shirley changed you into a prince?” When Bob countered that he doesn’t talk with her because she’s so critical, it seemed to the couple like the same old ar- gument—but the therapist saw this as the beginning of change—Bob starting to speak up. One way to create an opening for change in rigid families is to support the blamed person and help bring him back into the fray.

When Shirley criticized Bob for complaining, he tried to retreat, but the therapist said, “No, continue. You’re still a frog.”

Bob tried to shift responsibility back to Shirley. “Doesn’t she have to kiss me first?”

“No,” the therapist said. “In real life, you have to earn that.”

♦  ♦  ♦

In the opening of Anna Karenina, Tolstoy wrote: “All happy families resemble one another; each un- happy family is unhappy in its own way.” Every un- happy family may be unhappy in its own way, but everyone stumbles over the same familiar challenges of family life. It’s no secret what those challenges are—learning to live together, dealing with difficult relatives, chasing after children, coping with ado- lescence, and so on. What not everyone realizes, however, is that a relatively small number of sys- tems dynamics, once understood, illuminate those challenges and enable families to move successfully through the predictable dilemmas of life. Like all healers, family therapists sometimes deal with bizarre and baffling cases, but much of their work is with or- dinary human beings learning life’s painful lessons. Their stories, and the stories of the men and women of family therapy who have undertaken to help them, are the inspiration for this book.

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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

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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.

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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

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

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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

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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.

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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

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https://www.youtube.com/watch?v=AqiHJG2wtPI&index=2&list=PLT10BSjdk4VOrdigJrT8KQaWFvZ2mGKPh
https://www.youtube.com/watch?v=AqiHJG2wtPI&index=2&list=PLT10BSjdk4VOrdigJrT8KQaWFvZ2mGKPh
https://www.youtube.com/watch?v=AqiHJG2wtPI&index=2&list=PLT10BSjdk4VOrdigJrT8KQaWFvZ2mGKPh
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.