Family Therapy - Models and Techniques - Chapter1 - The History of Family Therapy
Family Therapy - Models and Techniques - Chapter1 - The History of Family Therapy
Family Therapy - Models and Techniques - Chapter1 - The History of Family Therapy
understanding that emotional disorders were of intrapsychic origin by postulating the rather innovative and then novel hypothesis that these disorders were symptomatic of troubled family relationships. It was then up to a group of innovative clinicians in the 1960s who applied this research to psychotherapeutic work with families. Based on their creative and groundbreaking work with families, family therapy truly emerged in the 1970s as a clinical method to address issues of emotional suffering in families. The history of family therapy also reveals profound paradigm shifts in understanding the causative factors that contribute to emotional disorders. In the following discussion, these paradigm shifts will become evident as we examine the many theoretical and clinical influences on the formation of the varied family therapy models. As we will see in this discussion, the historical development of family therapy reveals initially a challenge to the notion of the autonomous self with the systems-based concepts of the relational self. We will also see how some contemporary family therapy models are now grounded in the notion of the narrative self. It is without saying that one of the earliest and enduring paradigms for understanding the human self is based on the notion of individualism, self-reliance, or what can be labeled as the autonomous self. This notion of the autonomous self as containing the psychological and structural property of self-agency coupled with the belief in the selfs ability to stand independently over and against other selves and its environment has been the foundational assumption of much of the psychology treatment models especially in the first half of the 20th century. Based on the paradigm of the autonomous self, emotional disorders were viewed as symptomatic of a disordered (inner) self. Even though the family unit has always been valued as a basic social institution in society, the family was seen as a collection of individuals or an institution that could either support or impede the development of the autonomous self. There were two significant sociological theories, symbolic interactionism and later structural functional theories that challenged the notion of the autonomous self with the understanding that the human self was embedded in a system of human relationships. With the emergence of systems and communication theories, those theorists and researchers who were giving attention to understanding mental disorders such as schizophrenia confirmed that the human self was indeed a relational and communicating being. And this self is embedded in a system of relational networks, the primary one being the family. This concept of the human self as embedded or as the relational self was to be the guiding paradigm for early family therapy. For early family therapists, the source of human emotional suffering was seen as symptomatic of disordered family relationships and/or disordered family communication patterns.
The third paradigm, which reflects a more contemporary and postmodern perspective of the self, is the narrative self. This postmodern understanding of the self provides a unique insight into understanding families by giving attention to how family members construct their intrafamilial experiences through language. Language is the means of organizing and structuring life experiences. It is the narrative that individuals construct about their lives that provides them with a sense of personal identity. Narratives further reveal the significance of individuals lived experience within the context of their social worlds (Gergen, 1999; Polkinghorne, 1988). Here the focus shifts from examining relational interactions and communication patterns to examining the meaning embedded in narrative forms of expression. Human actions and relationships as expressed through narratives or stories are seen as efforts to create meaning out of personal experiences. These efforts at meaning construction are reflected in narratives or stories that give organization and structure to a person or family (Kilpatrick & Holland, 2009). Thus family problems are located within narrative constructions of meaning. The narrative emphasis on meaning is further supplemented by a focus on ways in which broader sociopolitical influences impact family and individual narratives. As the history of family therapy unfolds in this chapter it will be apparent that the following account will be both chronological and thematic. The chronological account will attempt to locate key events and movements in the history of family therapy in terms of a timeline. Yet, as will be seen, there were research efforts, social movements, and clinical initiatives that occurred at the same point in time and were independent of each other. These efforts, movements, and initiatives are joined together by a thematic connection as they were addressing the same clinical, research, or conceptual issues often without mutual awareness. It is the confluence of these events and themes that forms the historical narrative of family therapy.
urbanization. Social problems such as poverty, increasing social dislocation, immigration, illiteracy, disease, exploited labor, and slum housing adversely impacted the lives of increasing numbers of individuals and families. Many of these families often found themselves living in crowded tenements with more than one family living in small and rodent-infested quarters. Many individuals, including children, also found themselves working in the highly dangerous, unsafe, and exploitative conditions in the emerging factory system. Living in such marginally economic and otherwise vulnerable conditions these individuals were without the benefit of health protection and coverage for themselves and their families. These conditions along with the increasing number of European and Asian immigrants generated concern among many Americans about the seeming deterioration of the social and moral fabric of American society. There were those individuals who viewed these changing social conditions with a sense of moral concern and social responsibility. These individuals, later to be labeled as Progressives, engaged in an array of efforts to bring about social reform in such areas as child labor, worker compensation, health care services, and the responsiveness of local governments to the needs of urban residents.
Photo 1.1 Many families at the turn of the 20th century were beginning to experience the impact of the industrial revolution and rapid urbanization
Source: Brand X Pictures//Thinkstock
These reformers, influenced if not inspired by an ideological commitment to the ideas of the potential for social progress, believed that through their reform efforts and initiatives the ills of urban society could be ameliorated. Their efforts were a further expression of a modernist view of society. Modernism was descriptive of a period in European culture from the late 19th to the mid 20th century. As an expression of 18th-century European Enlightenment philosophy, modernist thought emphasized a faith in reason, freedom, and social progress. Imbued with an optimistic spirit there was this sense during the Progressive Era that through human reason, science, technology, and political initiatives the ills of society could be understood and ameliorated.
As the initial work of the friendly visitors was marked by goodwill informed by a parochial and moralistic understanding of human behavior, Mary Richmond, a director of the COS, sought a more systematic method for assessing and understanding family and individual needs. In giving attention to a more in-depth assessment or social diagnosis of individual or family needs (Richmond, 1917), she also emphasized the need for supportive counseling of the individuals within their family context. Though Richmond brought the family to the foreground of attention for early social casework diagnosis, her writings did not suggest involving family members as a group in the intervention activities. Still the focus of change remained on the individual though acknowledging that understanding the individual within the context of his or her family was important in developing a social diagnosis. Settlement House Movement Whereas the focus of the Charity Organization Society was on the individual within the family, the Settlement House Movement gave attention to the family within the broader environment. The Hull House founded by Jane Addams and Ellen Gates Starr in 1889 viewed family problems as resulting from debilitating environmental conditions. Contrary to the moral treatment orientation of the friendly visitors, those within the Settlement House Movement sought to change those societal, city, and neighborhood conditions that had a deleterious impact on family life. As such, this movement shifted the intervention orientation from a sense of moral responsibility to one of social responsibility (Hull & Mather, 2006). In other words, the concern of the Settlement House workers emphasized increased social and public responsiveness to family and human need rather than addressing defective individual moral character. Settlement Houses were often set up in immigrant neighborhoods. These community-based settings provided a venue for both individuals and families to learn those life skills that would enable the participants to support their families. These life skills were taught through educational programs, recreation activities, and other forms of social and community involvement. In these various activities the Settlement Houses provided the opportunity for individuals and families to come together for mutual support and assistance. It is important to note that the focus of these activities was more on providing the participants with those life skills that would enable them to better assimilate into a dominant culture that reflected White middle-class values and cultural habits (Hull & Mather, 2006).
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workers, and college professors often presented itself to the public as a group of family life specialists. It was not unlikely that these professionals were perceived as specialists in family life, for it was often these professions that couples turned to at significant times in the life of a familytimes that included birth, marriage, illness, and death. Many of the couples who sought the services of these counselors were primarily seeking guidance about the everyday facts of marriage and family life rather than help in resolving relationship issues. These counseling efforts included premarital counseling, guidance to newlywed and married couples who were seeking it, and support and information on the legal and social obligations pertaining to marriage (Barker, Kessler, & Lehn, 1984). Much of this marital counseling utilized a range of psycho-educational approaches rather than focusing on an exploration of individual psychological dynamics (Broderick & Schrader, 1981). As marriage counseling began to gain more public recognition and professional status, two physicians, Abraham and Hannah Stone, opened up a marriage consultation center in 1929 and offered professional marriage counseling at the Community Church in New York City. The next efforts at institutionalizing marriage counseling occurred in the 1930s with the formation of the American Institute of Family Relations, the Marriage Counsel of Philadelphia, the Groves Conference on Marriage and Family, and the National Council on Family Relations. Leaders from these two latter organizations formed the American Association for Marriage and Family Therapy in 1942. While the profession of marriage counseling underwent its own professional development into what is now referred to as marriage or couples therapy, this treatment modality shares some of the same history with family therapy.
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the psychiatric hospitals that provided short-term inpatient care and child guidance clinics that emphasized community-based prevention and treatment of children within the context of their parental relationships (Friedman, 2002). Viewing the parent-child relationship as the nexus for mental health intervention was indeed a clinical precursor for examining relational dynamics within the family system. The initial goal of the child guidance movement was to address juvenile delinquency through teaching parents how to understand their children and respond to them with the appropriate use of love and discipline. Based on the child development theory of Alfred Adler and later the Adlerian psychiatrist Rudolf Dreikurs, early child guidance practitioners viewed the concept of the inferiority complex as one of the determinate factors in childhood psychological disturbances. Thus early psychological intervention with a child focused on helping the child overcome feelings of inferiority and inadequacy that could in turn deter the child from manifesting behavioral problems. The most important outcome of such interventions was that the child would therefore become a productive and successful adult. One of the significant outcomes of this movement as it relates to the future development of family therapy was as child guidance practitioners began to understand the child they began to examine the ways in which both social and family dynamics might influence the childs psychological difficulties. For example, these practitioners began to recognize the importance of intervening with the entire family units around child-focused issues. In addition there was a shift in understanding the causative factors in childhood psychological disorders. The childs emotional stability was increasingly being understood as reflective of parental, especially maternal, child-rearing behaviors. While much of this understanding was informed by psychoanalytic theory there was an increased focus on the relational dynamics within the family.
FROM THE AUTONOMOUS SELF TO THE RELATIONAL SELF: CHANGING PERSPECTIVES IN PSYCHODYNAMIC THEORY
Freud and Psychoanalytic Theory
Even though the child guidance movement represented in part a movement away from traditional orthodox Freudian psychoanalytic theory, this perspective had a dominant influence on ways of understanding human behavior. Freud (1956) took the position that much of human behavior is motivated by unconscious sexual and aggressive instincts and that the expressions of these instincts are shaped by early childhood relationships between children and their parents.
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Freudian psychoanalytic theory was based on the concept of the embodied and autonomous self. Attention given to family dynamics was only in terms of exploring the extent to which family members, primarily the parents, had an impact on the development of the patients inner life. In fact it was the belief by those influenced by traditional psychoanalytic theory that the involvement of family members as a part of analysis or analytically informed psychotherapy would impede the development of the transference relationship between the analyst and the patient. Such an influence would thereby sabotage treatment. Thus there was a strong taboo against seeing family members of the patient while allowing the family to be symbolically represented within the context of the therapy hour. Here the patient was given the opportunity to relive the family drama or key family relationships through the projection of those relationships onto the therapist via transference.
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Harry Stack Sullivan (18921949). Influenced by Adler, Sullivans (1953) theory of psychiatry, interpersonal analysis, was based on the theory that both interpersonal relationships and social forces play a critical role in the formation of the self. In his study of the social sciences, especially the sociological theories of George Herbert Mead, Sullivan understood that human behavior was motivated not only by the desire for physical satisfaction but more important by a drive to attain a sense of security in relationships. This sense of security, which is key to Sullivans understanding of the self, develops and is reinforced by the nature of the interpersonal relationship with the caregiver, primarily the mother. The childs sense of security is shaped by those aspects of his or her behavior that the caregiver responds to either positively or negatively. According to Sullivan, maternal anger or disapproval can contribute to childhood insecurities and anxiety and perhaps future emotional disturbances such as schizophrenia. Thus for Sullivan, parental disapproval and approval within the network of family relationships was key to understanding psychopathology. Beginning in 1935 Frieda Fromm-Reichmann, a student and colleague of Sullivan, worked in a hospital for mentally disturbed patients. Through her work she began to give attention to the etiology of schizophrenia from an interpersonal orientation. As she states in 1948: The schizophrenic is painfully distrustful and resentful of other people due to the severe early warp and rejection he encountered in important people of his infancy and childhood, as a rule, mainly in a schizophrenic mother. (p. 265) In her research Fromm-Reichmann concluded that schizophrenia, especially male schizophrenia, was the result of a cold, domineering, and rejecting yet overprotective mother. She introduced the term schizophrenogenic mother to describe this type of maternal behavior. This mother in combination with a passive, detached, and ineffectual father can cause the male child to feel confused, inadequate, and ultimately schizophrenic (Schultz, 1984). Both Sullivans interpersonal approach to personality development and FrommReichmanns research on schizophrenia heavily influenced the thinking and work of some of the early family therapists. Both Sullivan and Fromm-Reichmann contributed to the shift in thinking about the self as autonomous to the self that was intractably embedded in a network of relationships. For Sullivan and Fromm-Reichmann an understanding of interactions between people rather than the intrapsychic domain was critical to understanding the etiology of emotional disorders. Finally their work, especially the work of Fromm-Reichmann, gave rise to a number of family pathology studies, which extended into the 1950s. These studies gave attention to the relationships between the dysfunctional behavior of individuals
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and their familys interpersonal patterns. It was the outcome of these studies that formed the conceptual framework for early family therapy treatment models (Atwood, 1992).
Structural/Functional Theory
Structural/functionalism, one of the dominant sociological theories in the 1950s, had a tremendous impact on family studies during that period. The leading thinker of the structural/functionalist school was Talcott Parsons (1951). This sociological perspective holds that societies and social units are held together by cooperation and orderliness. These social units work best when they function smoothly as an organism with all parts working toward the natural or smooth working of the system. Cooperation and orderliness are maintained through adherence to consensually agreed-upon social norms and roles. As natural social units dynamically interact with external or natural environments, such interaction requires ongoing adaptation. In order for balance to be maintained within a social unit there must be a division of labor within that unit to enable each interrelated part to work with the others to create efficiency and harmony. Structural strain caused by disturbance within the social unit must be restored; otherwise it can lead to social disorganization. Likewise if significant conflict emerges between social units then there is the necessity for some form of adaptation to maintain equilibrium between these units (Ingoldsby, Smith, & Miller, 2004).
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For a structural/functionalist the function of the family is to socialize children to fit into overall society. A structural description of the family would refer to the composition of the family as a social institution and its role within the social order. A functional description of the family would detail the services that the family provides to society as well as the tasks and roles required within the family structure to provide for the physical welfare and emotional and psychological needs of the family. For a structural/functionalist, viewing the family as a mediating system within the larger society, the concern would center on understanding ways in which the family maintains both internal harmony and equilibrium Additionally a structural/functionalist would be as concerned about how well a family maintains its structural role of instilling and socializing children with social values and norms. As family therapy models incorporated the language of family dysfunction they were drawing upon a structural/functional base analysis of families. Families that needed therapeutic intervention were in need of change to correct the interrupted function of the family and thereby restore a form of balance, harmony, and equilibrium.
Symbolic Interactionism
More of a microsociological perspective that emerged around the time of structural/functional theory, the core principles of symbolic interactionism revolve around the concepts of social interaction, language, and the formation of self. Grounded in the pragmatic philosophy of the early 1900s, the sociological theories of George Herbert Mead (18631931) and Herbert Blumer (1969), symbolic interactionist theory presents human beings as meaning-generating creatures embedded in social interactions. These interactions are shaped by the meaning people assign to those interactions as meaning is not inherent in the interactions. In the ability to use language to name and generate symbols that have meaning and value, humans have the capacity to assign meaning to people, things, and events. Thus humans do not act toward things as they are but based on the meaning they ascribe to these things. This meaning is not generated based on inward reflection but is based on the social interaction one has with others within his or her interactional field. These meanings are further modified not only by inner reflection but by outward interaction and discourse. One of the key concepts of symbolic interaction that is important for family therapy is the concept of the self. The self is not found solely through the process of inner reflection (the I). Rather it is discovered by taking on the role of the other and imagining how ones sense of self is perceived from anothers perspective (the looking glass self or the me). Thus the self has both inner and outer dimensions, but most important the self is subject to the socializing influences of
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a community (the generalized other) of other selves, in terms of its expectations and responses to the individual self. From this sociological perspective the family is the interactional, communicative, and meaning-generating network that is critical in the formation of self.
SYSTEMS, CYBERNETICS, COMMUNICATIONS, AND ECOLOGICAL THEORIES: THEIR IMPACT ON FAMILY THERAPY
While the sociological perspectives of structural/functionalism and symbolic interactionism shaped in part the conceptual milieu for family therapy, the development of family therapy was influenced in the 1950s by four powerful theories general systems theory, cybernetics, communications theory, and ecological theory. These four theories formed the theoretical foundations for the development of family therapy models. Furthermore, cybernetics, systems, and communications theories allowed researchers and later clinicians to free themselves from psychoanalytic formulations for understanding emotional disorders such as schizophrenia and to expand their understanding of these disorders as a function of disturbed relational and communication patterns within families. Ecological theories provide a conceptual framework for understanding the impact of the transactions between a family and its broader environment. Systems, cybernetics, communications, and ecological theories challenged the influences of psychoanalytic thinking, which was the dominant perspective from the early 1920s well into the late 1950s. With the exception of theorists such as Alfred Alder and Harry Sullivan, psychoanalytic theory focused on the individual and intrapsychic conflicts emanating from the experiences of childhood and the fantasy life emanating from the inner psychological world. External family members were only important to the extent that they were symbolic players in the inner drama of the individuals internal psychological world. These new theories acknowledged that a persons behavior is not determined solely by ones internal world but that the social context is a powerful determinant in shaping behavior. Furthermore individual psychopathology cannot be understood without a detailed appreciation of the psychosocial and ecological context of the individual and his or her family. In terms of a direct impact on the historical development of family therapy, systems, cybernetics, and communication theories informed early research studies on families with schizophrenia. The findings from this research sparked many initiatives to translate such findings into therapeutic interventions with families. Ecological theories though not having a profound impact in the early history of family therapy became more influential as
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family therapists began to gain a greater appreciation of the impact of the social, economic, cultural, and political environments on family life. An overview of ecological theory will be presented later in this chapter as the discussion turns to more contemporary conceptual and clinical influences on family.
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Translated to the arena of human relationships, a linear causal model would involve seeking the causal connection between thought, behavior, and emotions. The goal would be to uncover the primary cause for the expressed thoughts, behaviors, or emotions. From a psychodynamic perspective the primary cause of emotional disturbance resides within the inner world of the psyche. And even these inner-world dynamics are impacted by early childhood experiences. The systems view by contrast called for a different perspective on analysis and causality. Entities could be understood not in reductionist isolation from other entities in the observational field but in their relationship and interactions with other elements in the observational field. Causality is nonlinear and more circular. Here it is understood that forces do not simply move in one direction in which each event is caused by a previous event. Rather, seemingly discrete events become part of a causal chain with each event both influencing and being influenced by other events in a nonlinear manner. From this perspective the focus of analysis is shifted to a broader field of observation to understand the dynamic interaction of events rather than seek the linear causal relationship between events. As systems thinking was a new way to think about relationships between entities it provided a conceptual framework that allowed the observer of families to view individuals within families as existing in a web of complex, interacting, and interdependent relationships. Systems thinking further freed the observer from psychoanalytic thinking, which tended to isolate the patient from his or her relational network in order to render a diagnosis. Families could no longer be seen as a collection of autonomous individuals. A systems perspective gave the observer the lens to examine and explore how the individual both influences and is influenced by the dynamics within the interior of a family system. Following in Table 1.1 are some selected concepts from systems theory that have relevance for understanding families from a systems perspective.
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Table 1.1
System A set of orderly and interrelated elements that form a functional whole. Boundaries Repeatedly occurring patterns that characterize the relationship within a system and give that system a particular identity. A boundary is like a membrane surrounding and enclosing a living cell. Subsystem A secondary or subordinate system within a larger system. Homeostasis The tendency for a system to remain relatively stable and in a constant state of balance. If something disturbs the system it will strive to adapt and restore the stability previously achieved. Homeostasis is the status quowhether that condition is positive or negative. Role A socially expected behavior pattern usually determined by an individuals status in a particular society. Relationship The mutual emotional exchange; dynamic interaction; and affective, cognitive, and behavioral connection that exists between two or more persons or systems.
Source: Adapted from Ingoldsby, Smith, & Miller (2004). Used with permission.
and interpersonal interaction patterns within the families of schizophrenics. Their work at the Mental Research Institute (MRI) in Palo Alto, California, challenged the assumption that communication within families is motivated by individual motives and personality characteristics. Out of this work on communication and systems came a model of human communication that incorporated a systems perspective (Watzlawick, Beavin, & Jackson, 1967). In 1952 while affiliated with the Mental Research Institute, Gregory Bateson recruited Jay Haley who was a graduate student in communications. Along with John Weakland, a former chemical engineer trained in cultural anthropology, they became aware of double-bind communication patterns, which represented a contradiction between levels of messages in that what might be communication on one level by one person may be contradicted on another level by the same person. As they observed families with schizophrenic members they found such pathogenic
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communication patterns. This pathogenic or double-bind element in this communication reflected the parental invitation for closeness along with an injunction to stay away. This led to the speculation that schizophrenia was the result of disturbed interpersonal communication rather than an intrapsychic disorder. These researchers concluded that contradictory communication patterns and injunctions within a family contributed to the etiology of schizophrenia. The contributions of those affiliated with the Mental Research Institute extend well beyond the early research on the relationship between communication patterns and family schizophrenia. Many of the early practitioners in family therapy,
Table 1.2 Principles of Interpersonal Communication Systems Theory
1. One Cannot Not Communicate: Interpersonal communication occurs on multiple levels including both verbal and nonverbal. An attempt to avoid communication, for example through silence, nonetheless communicates the senders intent and feelings to the receiver. 2. Human Beings Communicate Both Digitally and Analogically: Language is digital communication in that words have no similarity to the things or ideas they describe yet they refer to these things or ideas by name. Analogical communication on the other hand represents things and ideas by likeness. For example, nonverbal communication through tone of voice, facial expression, and touch mirrors gradations of feeling. For example, problems in communication occur when one uses digital communication to label nonverbal communication such as facial expressions, thus leading to difficulties in understanding the range, scope, and depth of the feeling conveyed by the facial expression. 3. Communication Equals Both Content and the Relationship: Communication involves the content of what is said, but the relationship shapes and provides the context that virtually surrounds the content and impacts the interpretation of the content. The tone of voice, an emphasis on certain words, and other nonverbal forms such as facial clues direct how the message is to be interpreted. The relationship level influences metacommunication, which is communication about communication. 4. The Nature of the Relationship Depends on How Both Parties Punctuate the Communication Sequence: Though communication patterns appear to be sequential, these patterns occur within the context of dynamic and interactive relationships. Drawing upon the systems concept of circular causality one party in a given communication sequence may punctuate the sequence and view him- or herself as either the cause or the reactor to a perceived sequence of interpersonal interactions. 5. All Communication Is Either Symmetrical or Complementary: While an understanding of relationships speaks to issues of belongingness, intimacy, and trust, communication theory addresses issues of control, status, and power as each relationship contains elements of control, status, and power. Symmetrical communication is based on equal power; complementary communication is based on a differential in power.
Source: Adapted from Griffin (1997).
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including Virginia Satir, Jay Haley, and Don Jackson, were affiliated with the MRI during its early years. It is without saying that the work at MRI has been profoundly influential in the historical development of family therapy. It is also important to note that many of the contemporary models of family therapy including the MRI brief therapy model, solution-focused therapy, and the Milan systemic therapy orientation trace their heritage to the early work at the MRI. Some of these models will be discussed in more detail later in this text.
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up like the other parent. The other marital pattern that Lidz observed were those marriages that, while not threatened with possible dissolution, were nonetheless reflective of a mutual destructive pattern within the relationship wherein the psychological disturbance of one partner dominates the emotional climate of the house. In those situations he found the dependent spouse accepting and normalizing the situation and not being sensitive to the impact of these destructive behaviors on the children. Such parental attitudes created a sense of distortion and denial on the part of the children. One of contributions that Lidz made to the study of schizophrenia was the attention given to the fathers role in the etiology of schizophrenia. Lidz, Cornelison, Fleck, and Terry (1957) identified patterns of pathological fathering of schizophrenics. These patterns involved fathers who, when in constant and severe conflict with their wives, ally themselves with their daughters; fathers of sons who turn their hostility toward their sons rather than their wives; fathers with grandiose and paranoid thinking who create a pathological atmosphere within the family; fathers who have failed in life while becoming nonentities in their home; and passive fathers who demand little for themselves and act like siblings (Schultz, 1984).
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with the emotional stuck-togetherness (fusion) of family members with schizophrenia. His theory, later to be called Bowenian family therapy, incorporates important intergenerational processes, allowing family therapists to explore critical historical events and intergenerational patterns affecting current family functioning. Problems related to unresolved family issues of past generations are conceptualized as having a potential emotional impact in subsequent generations.
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lead to panic. Though schizophrenia was viewed as a thought disorder, Wynne saw communication patterns within the family as a vehicle for transmitting thought disorders (Nichols & Schwartz, 2008).
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salient aspects of a familys systemic interactions in order to bring about change and problem resolution (Becvar & Becvar, 2000). These first-generation clinicians in fact subscribed to either a structural/functional or a communicative/interactive perspective. This latter perspective was clearly influenced by symbolic interactionist theory. In many respects the first-generation therapists, by adhering to the rather conservative and status quo theories of structural/functionalism and symbolic interactionism, only gave minimal recognition to factors of gender, race, and culture in their theories or intervention strategies. This lack of attention to issues of gender, race, and ethnicity generated much critique regarding the applicability of family therapy to diverse populations. Ironically the only possible exceptions to this critique were those approaches influenced by Minuchins (1974) structural family therapy model and ecological theory. The second-generation clinicians have provided a postmodern critique of the first-generation system-based approaches (Nichols & Schwartz, 2008). The nature of the critique is that the systems approach represents a mechanist view of families to be manipulated and changed by the expert therapist. Such an approach ignores the impact of the therapists presence on the family system, the dynamics of gender and power, and the larger ecological, historical, and cultural context in which the family is embedded (Nichols & Schwartz, 2008). From this secondgeneration perspective the families, not the family therapist, are the experts of their own lives. The second-generation clinician sees the family as constituting a language system or narrative with family difficulties constructive in language. In the development of a new Photo 1.2 The marriage counseling movement language, the clinician is a participant- emerged in the 1920s to provide couples with manager of the conversation about the guidance and support in coping with the demands problem. In the second-generation of married life approaches, the individual identity is Source: Thinkstock/Comstock/Thinkstock
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embodied in a personal narrative about self. Additionally these self-narratives are context dependent, thus allowing for different versions of the self. As a person moves through the different arenas of her or his life, a different narrative presentation of self may emerge. In the reality of practice many therapists may move between first- and second-generation approaches. As a corrective measure to systems theories the postmodern critiques do address some of the major limitations of family systems theories. Yet these critiques do not necessitate a rejection of systems-based theories. The focus of the structural/functional practice and communicative/ interactive models can provide a framework for understanding the actual structure of the family, and the postmodern language and narrative-based approaches can allow for the therapist to understand the meaning and interpretation of that structure by family members as impacted by ethnic, cultural, historical, economic, and sociopolitical factors. Whether a family therapists theoretical perspective falls within a first- or a second-generation framework the level of change sought by family therapists is a fundamental revision of the familys structure, function, interaction patterns, or language system (Goldenberg & Goldenberg, 2008). This level of change, described by Watzlawick, Weakland, and Fisch (1974) as second-order change, is focused on helping the family reach a different level of functioning rather than engage in superficial behavioral or first-order changes. Such first-order changes, while bringing about the possible cessation of the presenting family problem, will fail to address the underlying systemic rules that sustain the presence of the presenting problem. For Watzlawick (1978) family therapy should focus on secondorder changes. Given this focus of intervention the family can engage in reconstituting itself in a different way (Goldenberg & Goldenberg, 2008).
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at various developmental stages. Another family systems paradigm defines a family as a system that operates independently and from which individual psychodynamics, including those that created symptoms, emerge. Another orientation is when family is defined as a system that shares isomorphic characteristics with all natural systems in a hierarchy according to classesfrom quarks to universes with higher systems containing those lower in the hierarchy. The relevance of these approaches from a structural/functionalist orientation lies with their emphasis on the family as a boundary-maintaining social system in constant transaction with the environment or other systems. The internal family system is composed of individual members who define both the family as a whole and the various subsystems within the wholethat is, the marital, parent-child, and sibling units. In transacting with the environment, individual members are viewed primarily as reactors who are subject to influences and impingement from the greater social system. The healthy functioning of a family system can be measured by its adaptive boundary-maintenance ability following stressful situations caused by pressures from transactions with other environmental systems or with society as a whole. Hence, therapy as guided by this conceptualization suggests interventions that strengthen the boundary-maintaining ability of the family for adaptive purposes and that serve stability or equilibrium needs. The following group of clinicians and their therapeutic approaches represents a structural/functionalist orientation to family therapy practice. Bowens model of family therapy as discussed earlier and whose approach will be represented in more detail later saw the family as an emotional system that shares similar characteristics with other natural systems. Other earlier clinicians who were psychodynamically influenced were Nathan Ackerman and Ivan Boszormenyi-Nagy. John Elderkin Bell viewed families from the position of social groups while Salvador Minuchin, whose approach will be discussed in more detail in a later chapter, articulated a clearly structural model of treatment.
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family interactions (Ackerman, 1966). Ackerman could not fully move beyond his psychoanalytic orientation, which caused him to maintain his attention on the individual within the family. Yet his work demonstrated that he gave attention to the recursive interaction between a patients intrapsychic world and the familys interactional and relationship patterns. As such, Ackerman considered that interpersonal conflicts might be a manifestation of unconscious elements operating within the family system.
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and react to the actions of others and the interpersonal meanings attached to these actions. Interactive processes that are of particular importance to therapy include communication, conflict, role relations, and decision making. Because the communicative/interactive framework is concerned primarily with change rather than with stability, the concepts of family equilibrium and family transaction with the outside world are less important. The framework, when applied singularly, can easily shift from one that concentrates on interactive processes between system members to one that emphasizes intervention methods that focus primarily on individual actions or behaviors. With the exception of Carl Whitaker, other communicative/interactive clinicians such as Virginia Satir, Jay Haley, and the Milan Group represent the work done at the Mental Research Institute.
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the self-esteem of its members. As will be elaborated later, her therapeutic goal was the facilitation of clear, direct, and honest communication within the family system.
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Milan approach called for seeking positive connotation for problematic behaviors and how these behaviors may (or may not) be useful for the individual and others in the family. In addition therapists would use positive connotations on how or why family members may be cooperating with the problem (Boscolo, Cecchin, Hoffman, & Penn, 1987). As the Milan approach evolved they supported a more collaborative nonblaming approach to the family. This newer approach marked a shift in therapists expert role in their relationship to the family.
Photo 1.3 A childs emotional stability was viewed by the Child Guidance movement as reflective of parent-child relationship
Source: iStockphoto.com/hakinci
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was not considered as having an impact on the therapeutic process. Without this understanding of the possible power differential association with a clients or therapists social location, a salient aspect of a clients experience was felt to be ignored.
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2. Language concerns: Ethnicity is often experienced and persists through language. Although many ethnic minority clients are bilingual, problems of miscommunication may still occur. 3. Ethnicity and class status: The intersection of ethnicity and class may be a salient factor for families as they navigate the social terrain of ethnic group membership and social class location. Gordon (1965) uses the term ethclass to describe the point at which social class and ethnic group membership intersect. 4. Fluid ethnic identities: Ethnic identity generally refers to attributes of a group of people who view themselves as being bound together by a common history, traditions, language, and geographic origin. Yet for many individuals ethnic identities are experienced as fluid and socially and historically constructed. An example of fluid identities can be found within immigrant, biracial, and bicultural families. Within such families individual members may define their ethnic identities based on a variety of considerations, one being their level of acculturation or their wish to be accepted within a particular sociopolitical context (Cornell, 2000). For many ethnic minority families, how they are viewed by society may constrain their ability to construct more empowering and potentiating solutions to family problems. Thus as ethnic minority families present themselves for family therapy, family therapists are to acknowledge that they must be culturally attuned to how the familys experience is shaped by its unique ethnic, racial, and/or cultural experiences. Finally there is the increasing acceptance that a family therapist cannot understand the significance of a familys problem without recognition of the material, power-laden, and affectively charged elements of living within certain discriminatory and disempowering environments.
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broader than ones habitat. The environment includes not only the familys physical or geographical location or habitat but the sociopolitical, cultural, and economic context that surrounds ones living space. It is the broader context of culture, economics, and politics that determines if ones habitat is supportive of the mental, physical, and social functioning of the individual and family. The sustaining and nurturing resources within a familys environment are further determined by ones nichethat is, ones social position, class location, ethnic and racial identity, and economic status within the overall social structure. A good or enabling niche is one that avails the occupant the rights of equal opportunity to educational and economic resources (Kilpatrick & Holland, 2009; Taylor, 1997). There are, however, individuals and families with devalued personal or cultural characteristics, such as color, ethnicity, gender, sexual orientation, age, poverty, or other types of bias and oppression, who are entrapped in niches that are incongruent with fulfilling their human needs and well-being (Kilpatrick & Holland, 2009; Taylor, 1997). The ecological or ecosystem perspective provided a framework for addressing issues of diversity, marginalization, and oppression. From this perspective the therapists could ground their intervention strategies on the following practice principles (Ho et al., 2004). 1. Individual or family problems are not conceived as pathology; instead, problems or difficulties are understood as a lack or deficit in the environment (as in the case of migration of immigration) or a result of interrupted growth and development (role conflict and resource deficits in the environment). 2. Intervention efforts are directed at multivariable systems, and a single effect can be produced by a variety of means. The principle of equifinality, which means that a number of different interventions may, owing to the complexity of systems, produce similar effects or outcomes, encourages flexibility and creativity in seeking alternative routes to change. While a therapist may try to relate intervention strategies to existing theories that are Western middle-class American oriented, innovative strategies of change based on the clients cultural background are encouraged. 3. Intervention strategies should make use of natural systems and life experiences and take place within the life space of the client. The family itself is a natural helping system and an instrument of change. 4. Emphasis on the clients life space and family as a natural helping system places the therapist in a role of cultural broker instead of intruder, manipulator, or cultural expert.
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An ecological systems framework was viewed as providing a lens in which the family and family members could be understood within the context of transactions with a variety of biological, psychological, cultural, and historical environments. By adopting an ecosystem perspective, a family therapist could focus on adaptive (and maladaptive) transactions between persons and between the person and various environmentsthat is, the interface between them.
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construct about their lives that provides them with a sense of personal identity. Narratives further reveal the significance of an individuals lived experience within the context of his or her social world (Gergen, 1999; Polkinghorne, 1988; Semmler & Williams, 2000). Thus family problems are located within narrative descriptions. And as with narrative descriptions, the focus is not on what is described but on the interpretation of what is described. Reality is thus a matter of interpretation rather than a description of an objective or external given. Thus a family problem may gain its saliency and potency not on its factual presence and existence but on its effects, interpretive description, and meanings for family members. The therapists task is to create a therapeutic space for the emergence of alternative and more empowering interpretations of the problem. Facilitating, in a collaborative manner, a change in the familys language from a problem-oriented discourse to a solution-focused discourse creates a space for increased individual or family competency. In this collaborative relationship the therapist moves from the hierarchical expert position to a collaborative relationship with the family. One of the important contributions of this perspective is that it can contextualize the meaning of both the family therapists and the family members lived experience in therapy by locating that experience within a specific ecological, historical, economic, and political context. To say that the personal is political underscores one of the basic assumptions of a postmodern orientation. Any understanding of an individual or family system or family narrative must include an inquiry into the familys social, political, economic, and cultural position within the social order. The therapist must view her or his narrative (and the familys narrative) with a critical eye to uncover the extent to which the unique reality of both the therapists and the family members lived experience is shaped by the dominant social and political ideology. The postmodern-oriented practitioner can view liberation from oppressive ideologies and structure as an indispensable condition of the quest for human potential and authenticity (Stevens, 1989). Liberation is attained by first developing a state of critical consciousness, which is achieving an awareness of how the social, political, and economic ideology constrain a family members sense of agency and identity (Freire, 1973). Informed by this new awareness, the therapist and family members can take action against those oppressive structures and articulate in their own voice a narrative of self that represents their unique lived experience. One of the interesting implications of the postmodern perspective is that the self is no longer viewed as a stable, enduring, embodied, and autonomous object in which the task of the clinical observer is to discover what is within the self. This is the position taken by the psychodynamic and other individual nonsystems approaches to therapy. The postmodern perspective also raises questions about the
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relational self or the self that is defined within the context of systems or interactional patterns. While postmodern thought acknowledges that the self is embedded, the embedment is found more in the narrative text of ones own or others narrative renditions rather than relationships. Two approaches that speak to this perspective are the solution focus and the narrative approach. As these two approaches will be elaborated later, a brief summary of these perspectives is presented here.
Solution-Focused Approach
The solution approach is marked by a more collaborative stance between the therapist and the family. Family problems are not seen as a sign of failure. In fact problem-saturated narrations of the problem are deliberately ignored (de Shazer, 1985). The focus of the therapist-family collaboration is on discussing patterns for previously attempted solutions. Focusing on the times when the problem or symptom is less or not present allows the therapist with the client to design interventions around the exceptions. It is these exceptions that form the basis for a solution. As the solution patterns are amplified the problem patterns can recede into the background.
Narrative Approach
In accordance with the above description of the role of narrative in constructing reality the narrative approach as developed by White and Epston (1990) gives attention to how language shapes problem perceptions and definitions. As the family stories its experiences around the problem, a narrative orientation focuses on themes of oppression and liberation and how the family members may be oppressed by the problem(s). By externalizing the problem, the problem not the persons involvedbecomes the problem. A narrative therapist helps families notice their own expert knowledge and, through the use of literary metaphors, acknowledge their ability to reauthor their own lives with more empowering narratives.
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behavior. There is another major shift occurring as family therapy moves into the 21st century. This shift is predicted as reflecting an increased focus on the effectiveness of family therapy approaches (Hanna & Brown, 2004). Influenced by such societal changes as the emergence of managed care, the major concern in medicine, psychology, and social work is the integration of clinical judgments with research evidence. Thus the third generation of family therapy may not be grounded in theoretical models or concerned with issues of epistemology but rather may be grounded in empirically supported interventions. This emphasis on evidence-based practice is also generating more integrative models and approaches in family therapy. As there is the movement toward integrative models there may be fewer adherences to specific models. The focus is beginning to shift to examining the efficacy of specific interventions as they demonstrate effectiveness with specific client populations. Giving attention to matching interventions to specific client populations is creating a therapeutic climate that calls for deliberate and careful decision making regarding intervention. It is interesting to note that as postmodernism challenged the epistemological basis for theory and model construction, the evidence-based orientation by being anti-model is moving family therapy into another, perhaps more viable, era. One model representing this new generation of family therapy is cognitivebehavioral family therapy. This approach expands traditional cognitive and behavioral family therapy to an approach that is research based and problem focused and addresses multiple levels of the change process. As an integrative model it gives attention to internal processes (thoughts, expectations, images, and affect) and how they influence behavior. The intervention techniques share commonalities with the Milan, structural, and strategic approaches (Hanna & Brown, 2004). This approach has also provided the theoretical foundation for psycho-educational and parent training protocols.
SUMMARY As we end this chapter on the history of family therapy we can summarize some of the distinguishing features of family therapy as a treatment modality (Collins, Jordan, & Coleman, 2007). As we describe family therapy we can say that the framework for family therapy is directed by thinking of family as context informed by the belief systems wherein the family is a special social environment conceptualized as consisting of multiple systems. A family is more than the sum of its individual parts; it is a unique system with particular
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responsibilities and functions, and changes within the family system affect all family members. By approaching a complicated family situation from a systems theory perspective, the practitioner is able to be somewhat more objective about family issues. Utilizing a multiple systemic perspective for family assessment and intervention addresses many important aspects in helping families and the systems interacting and supporting the individuals in families. Practitioners who see the family context as interactions of multiple systems, the family, and its social environment will be better able to build on strengths and resilience in families and promote family selfa notion critical to practice. The ecosystem perspective, because of its person-in-environment focus, provides a lens through which the family and family members can be understood within the context of transactions with a variety of biological, psychological, life cycle, cultural, and historical environments. Families from different cultural, racial, ethnic, and religious groups and representing alternative lifestyles may experience the impact of legal, social, and economic biases and discrimination that may impact family functioning. Finally, families have their own unique narrative or story that defines their identity, their place in the world, and how they interpret significant events and intrafamilial relationships (White, 2007; White & Epston, 1990). While we have reviewed some of the clinical and conceptual influences on the history of family therapy, we have not included all the major theorists who have made and continue to make a significant contribution to the field of family therapy. But we have given an overview of some of the significant theorists, researchers, and clinicians who have made family therapy what it is. We have further presented some of the conceptual and theoretical influences on family therapy as a psychotherapeutic modality. We have presented some of the issues and critiques that continue to inform the theoretical development of family therapy models. Let us say in summary that as a corrective measure to systems theories, the postmodern critiques do address some of the major limitations of family systems theories. Yet these critiques do not necessitate a rejection of systems-based theories. The focus of the structural-functional and communicative-interactive practice models, within the context of ecological theories, can provide a framework for understanding the actual structure of the family along with the narrative meaning and interpretation of that structure by family members as they are impacted by ethnic, cultural, historical, economic, and sociopolitical factors. This orientation informed by research can provide the clinician with sound judgments in providing the most effective help to families in need.
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RECOMMENDED READINGS
Becvar, D. S., & Becvar, R. J. (2000). Family therapy: A systemic integration. Needham Heights, MA: Pearson Education. Broderick, C. B., & Schrader, S. S. (1981). The history of professional marriage and family counseling. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy (Vol. II, pp. 538). New York, NY: Brunner/Mazel. Hull, G. H., & Mather, J. (2006). Understanding generalist practice with families. Belmont, CA: Thomson Brooks/Cole. Sayger, T. A., Homrich, A. M., & Horne, A. M. (2000). Working from a family focus: The historical context of family development and family systems. In A. Horne (Ed.), Family counseling and therapy (pp. 1238). Itasca, IL: F. E. Peacock.
DISCUSSION QUESTIONS 1. The Progressive Era, which began in the late 1890s and ended at the start of the Great Depression, was marked by a wide range of social and political reform movements. How might these reform movements be seen as historical precursors to family therapy? 2. What impact did systems, cybernetics, communications, and ecological theories have on the development of models of family therapy? 3. It is suggested that during the social and political climate of social activism of the 1960s a group of iconoclastic and innovative therapists who were staging their own social revolution within the fields of psychiatry, psychology, and social work emerged. Who were these therapists, and what were their contributions to the development of family therapy? 4. As the field of family therapy has moved into the 21st century, what have been the key paradigm and generational shifts in theoretical perspectives? REFERENCES
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