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By Tom Smith, Ph.D.
Posted with permission from Tom Smith, Ph.D. Dr. Smith holds the copyright to this article.
Table of Contents
I. The Current Status in a Nutshell
II. Where We Have Come From:
A. Systemic Approaches to Family Therapy
1. The Late 40s through the Early 90s
III. The Current Status
A. From the ’90s to the Twenty-first Century
IV. References
I. The Current Status in a Nutshell
It is sometimes helpful to take a break from the day to day conduct of “therapy” to review, remind ourselves and perhaps redefine our own therapeutic philosophies and models of marriage and family therapy. In the course of this evaluation, we may find that we have abandoned our roots as Family Therapists. We may discover that we are, more often than not, leaving the family behind to pursue therapeutic avenues with couples or just individuals.
There are many reasons why this may occur. Most of all, perhaps, economics and the “business” of doing therapy can have a profound impact on treatment decisions. Managed Care has greatly influenced the landscape and opportunities for doing what we were taught to do. We will return to consider these issues when we discuss the changes that began to occur in mental healthcare at the end of the 80s and beginning of the 90s when therapists began to address the issues of the oppressive power of social institutions on the family and the emergence of the post modern approach.
What is the nature of this “oppressive power of social institutions”? Briefly, in many cases, therapists are not able to obtain reimbursement from insurance companies or are paid a substandard fee. Often, families in trouble do not have the financial resources — due to lack of money or reimbursable “medical necessity” — or time to take care of themselves. Frequently, the family is fragmented and rarely together as a unit so therapy can happen. And so, they suffer from lack of communication and intimacy, confusion of authority and boundaries (physical and psychic), substance abuse, domestic violence, acting out behavior, and hopelessness. They do not know where to turn for help or even what kind of help they need; and when they do, it is out of reach.
Under these circumstances, the therapist may be frustrated and compromised regarding what to do and simply takes the easiest and financially feasible action, tweaking diagnoses and treatment plans for purposes of reimbursement, seeing just the “identified patient”, focusing on the marriage before looking at the family system, taking a smaller fee or referring out to a social service agency. By and by, we find ourselves not doing what we set out to do in the first place: To heal families and make them whole again.
It could be said that the roots of family therapy go back all the way to the early social work of the late 19th and early 20th century. For a paper that provides a detailed literary and historical account of the earliest beginnings of family theory and practice by social workers, beginning in the 1880’s, see “The Theory and Practice of Family Social Work Since 1880.”
During the 1920’s and 30’s, new psychological models of behavior and practice emerged in addition to the child guidance movement of the 20s as well as the research on family dynamics as the etiology of schizophrenia in the late 40s and early 50s. However, family therapy did not find its identity as a discipline until the 50s with Gregory Bateson’s work with Jay Haley, Don Jackson and John Weakland (1956) studying schizophrenic communication in the family and the development of the double-bind theory at the Mental Research Institute in Palo Alto, California, founded by Jackson. Also, Nathan Ackerman’s (1954) work in New York said that to clearly understand the problems of the child, one must understand the family. It matured in the 60s — when in 1964, California issued its first Marriage, Family and Child Counselor’s license — and had a firm foundation by the 70s. During that time, many different approaches developed and competed with each other for some kind of franchise on the “truth” of doing family therapy and a piece of the marketplace. From the mid 70s through the 80s was the “golden age” of family therapy when the general models became well established, taught and practiced.
The established models that are generally accepted are the Transgenerational, Experiential/Communications, Structural, Strategic/Milan School and most recently, in a departure from the systemic approach, the Collaborative/Social Constructivist/Postmodern approach that gave birth to the Narrative method.
The Transgenerational approach, with its roots in psychodynamic theory, emphasizes that family problems occur over generations. Murray Bowen (1976), later followed by Monica McGoldrick (1998) and Betty Carter, pointed out that the family was a system from which one must differentiate themselves. Understanding the family system using the genogram facilitated that process. Ivan Boszormenyi-Nagy (1981), who was once a student of Satir, said that it was the context within which the family lives that is critical to their functioning. By discerning what the family’s responsibilities and moral imperatives were one could discover the pressures, necessities and constraints that compelled the family to behave as they did. Balancing the above led to family health. Boszormenyi-Nagy would not work with families unless he could have at least more than one generation present and at best three!
The therapists most identified with Humanistic Experiential family therapy are Virginia Satir and Carl Whitaker. In her succinct and cogent book, Conjoint Family Therapy (1964), she outlines her theory and technique of therapy that emphasizes communications theory, clarity, genuineness and authenticity of communication and love in the family to overcome blocks to personal growth. Ten years later she declared that unconditional love and acceptance in therapy would save the world. At that time, some of her colleagues thought she was going overboard and was out of step with accepted thinking. Whitaker (1976), felt that just “being yourself” and caring led to a more effective therapy than just depending on theory. The interpersonal encounter and spontaneity were crucial interventions.
One of the most well known and respected of family therapists is Salvador Minuchin (1974) His structural approach emphasizes the importance of boundaries, subsystems, hierarchies of power, coalitions and roles. He would jump in and join the family to reframe and thus, change ossified family structures. His is a useful perspective when working with families of various cultural backgrounds. In his way of thinking, the family is functional or dysfunctional depending on its ability to adapt to the various stressors of life. It is a thrilling experience to watch him do family therapy as he actively manipulates the family patterns of behavior to foster understanding and change. Minuchin is still very active in family therapy. In the issue of the Journal of Marital and Family Therapy (1998), he has the opening essay, a discussion of narrative family therapy.
The Strategic school developed by Jay Haley (1968), Paul Watzlawick (1974) from the MRI days in Palo Alto and later Cloe Madanes (1981), now in La Jolla, California and still actively developing her ideas, focused on brief therapy that examined power issues and the use of symptoms to control others in the family that resulted in dysfunctional repetitive behaviors. Active interventions and the use of paradoxical intent are used to reduce or eliminate problematic symptoms. Basically, you cannot solve the family’s problems by repeating the same old failed behaviors. The point is to learn new solutions through changes in family interactions. This led to the Milan school.
The Milan systemic approach, known particularly through the thought of the cheeky, but gentle, Gianfranco Cecchin (1987) who died in February 2004, and the complementary work of Luigi Boscolo (1987) with the psychiatrist Mara Selvini-Palazzoli (1986), who died in 1999, points out that dysfunctional families get caught up in playing futile, crazy “family games” that are circular in nature and that follow rules that do not fit the family’s current reality. What is important is the concept of mind as system and system as mind. Key interventions use circular questioning and hypothesizing (“What would you do if…?”) to transform family patterns of relating.
For a general summary of the above theoretical models that also briefly addresses characteristics of the dysfunctional family, interventions and goals of family treatment and counseling techniques see “Counseling Families from a Systems Perspective.”
At the end of the 80s and the beginning of the 90s, many therapists, faced with a multiplicity of problems that were emerging from the fast changing social structures, mores and demographics understood that they must go beyond the limited techniques of a single theoretical approach. In an eclectic fashion they began to select the technique or intervention that was most appropriate or effective regardless of the school from which they emerged. For a list and discussion of these various techniques customized to fit the unique situation presented to the therapist see “Basic Techniques in Marriage and Family Counseling.”
III. The Current Status
A. From the 90s to the Twenty-first Century
During the 90s there were many questions regarding the systemic approaches. Does family therapy work? What evidence is there for the effectiveness of family therapy? Does it help eating disorders in adolescence, schizophrenia in the family, mood disorders, conduct problems in children, drug or alcohol misuse or marital difficulties? For a discussion of these questions see “Outcome Research in Family Therapy.”
Additionally, therapists began to modify their approaches to the traditional models. An example is Family-Directed Structural Therapy (FDST); it is an approach to family therapy built on traditional concepts of Salvador Minuchin’s Structural Family Therapy, and Group Work Theory. For a discussion of this modified approach see “Family-Directed Structural Therapy.”
Additionally, as the 1980s drew to a close, a deep skepticism about the universal validity of any single narrative composition, or theoretical version of any human situation emerged (Lyotard 1979), giving rise to the Collaborative/Social Constructivist/Postmodern approach embraced and developed by Michael White (1989) the guiding light who started out as a mechanical draftsman, David Epston (1989), Steve deShazer (1994), who died in 2005 and Insoo Kim Berg (1993). They called their method Narrative Therapy. It is a brief solution-focused process that seeks to understand how families create “stories” filled with assumptions about themselves and how to deconstruct them and then design new ones that redefine problems as external and oppressive and provide for better outcomes. This postmodern approach is a reaction to the so-called scientific theories (grand narratives) that preceded it and posits that there are no fixed truths and there are multiple versions of reality.
For a comprehensive discussion that focuses on the essential aspects and core dimensions of Michael White’s and David Epston’s Narrative Therapy Approach from a unique perspective utilizing the analogy of a dance, in which a practice grid is described to highlight key therapy steps see “The Narrative Dance – A Practice Map for White’s Therapy.”
After a time, people wondered if Narrative therapy was really family therapy. Most of the time in Narrative therapy the individual was encouraged to rescript her version of the family and the family as a whole unit was rarely present. For a provocative criticism by Salvador Minuchin that focuses on this issue regarding Narrative therapy, see “Where is the family in narrative family therapy?”
In response to Minuchin and for an expanded and balanced discussion that addresses the point that it’s not the level of focus (intrapsychic versus family versus culture) that leads to trouble, but it’s the way that level is focused on and that privileging any level as the most important or only possibility constrains therapists and clients alike and that clients are embedded in interrelated constraints at each of those levels, see “Narrative therapy expands and contracts family therapy’s horizons.”
And finally, two articles, “Innovations in Family Practice: Context Matters” and “Afterword: Challenges for Family Practitoners” taken from the Michigan Family Review (MFR), a peer-reviewed interdisciplinary publication of the Michigan Council on Family Relations (MiCFR) focused on professional application and scholarly inquiry that publish articles and reviews about critical contemporary problems confronting families and those who provide service to them addresses future issues of concern to a wide range of professionals and others interested in strengthening family life. Readers and contributors include educators at many levels in several fields, social service staff, researchers, attorneys, medical and health personnel, clergy, and public policy makers, as well as practitioners in community and citizen-action groups, and family members themselves.
Where we go from here is for each therapist to evaluate their own methods in the light of current historical, socioeconomic and political developments.
Now, more than ever, do families — in all their various manifestations — need help. The Norman Rockwell, nostalgic portrait of the American nuclear family of four with the same biological parents — usually middle class and white — is a thing of the past. We live in a very diverse society and the very definition of family is contentious and continues to change.
Change is occurring at a faster and faster pace. Telecommunications, from the internet to cell phones, information and entertainment media from iPods to plasma television and aerospace are causing unprecedented changes in social and by definition, family structures. We can communicate with anyone, anonymously if we wish, in real time anywhere in the world and we can go anywhere in the world in about 24 hours! This has brought with it its own set of problems of alienation, internet addiction, easy access to drugs, increased threat of child molestation and more. Just think about it and you will come up with issues on your own.
By reviewing and reconnecting with our philosophical and psychotherapeutic roots, becoming aware of current trends and contemplating future possibilities in an ever changing economy, society and demographic we may decide to do something different.
Ackerman, N. W. 1954. Interpersonal disturbances in the family: some unresolved problems in psychotherapy. Psychiatry. 17:359-368.
Bateson, G., Jackson, D. D., Haley, J., and Weakland, J. 1956. Toward a theory of schizophrenia. Behavioral Sciences. 1:251-264.
Berg, I. K., and de Shazer, S. 1993. Making numbers talk: Language in therapy. In The new language of change. S. Friedman, ed. New York: Guilford Press.
Boscolo, L., Cecchin, G., Hoffman, L., and Penn, P. 1987. Milan systemic family therapy. New York: Basic Books.
Boszormenyi-Nagy, I., and. Ulrich, D. N. 1981. Contextual family therapy. In Handbook of family therapy, A. S. Gurman and D. P. Kniskern, eds. New York: Brunner/Mazel.
Bowen, M. (1978). Family Therapy in clinical practice. New York: Aronson.
Cecchin, G. 1987. Hypothesizing, circularity and neutrality revisited: An invitation to curiosity. Family Process. 26:405-413.
de Shazer, S. 1994. Words were originally magic. New York: Norton.
Haley, J., and Hoffman, L., (Eds.) 1968. Techniques of family therapy. New York: Basic Books.
Lewis, E. (2005). “Innovations in Family Practice: Context Matters.” Michigan Family Review, Ann Arbor, Michigan: University of Michigan Library.
Lewis, E. (2005). “Afterword: Challenges for Family Practitioners.” Michigan Family Review, Ann Arbor, Michigan: University of Michigan Library.
Lyotard , J-F . 1984. The Postmodern Condition: A Report on Knowledge. Transl.. Bennington G & Massumi B., Foreword by Jameson F. Minneapolis: University of Minnesota Press & Manchester: University of Manchester Press.
Madanes, C. 1981. Strategic family therapy. San Francisco: Jossey-Bass.
McGoldrick, M., Gerson, R., & Schellenberger, S. (1998). Genograms in family assessment (2nd ed.), New York: Norton.
Minuchin, S. 1974. Families and family therapy. Cambridge, MA: Harvard University Press.
Satir, V. M. 1964. Conjoint family therapy, Palo Alto: Science and Behavior Books.
Selvini-Palazzoli, M. 1986. Towards a general model of psychotic games. Journal of Marital and Family Therapy. 12:339-349.
Whitaker. C. A. 1976. The hindrance of theory in clinical work. In Family therapy: Theory and practice, P. J. Guerin, ed. New York: Gardner Press.
White, M. 1989. Selected papers. Adelaide, Australia: Dulwich Centre Publications.
White, M. & Epston, D., 1989. Literate means to therapeutic ends, Adelaide, Dulwicb Centre Publications.