Techniques of Family Therapy
I Think It’s MeDifference Display as a Contextual Event, A Family With a Little Fire, The Open Door: A Structural Approach to a Family with an Anorectic Child
Some psychiatric patients (most notably, young adult schizophrenics) seem unable to get better because of the pressures their families exert on them. This common clinical observation gave rise, some fifteen years ago, to attempts to treat families as a whole. The number of clinicians treating families has since multiplied (there were several thousand at the last government count, with training programs at a dozen major city teaching hospitals), and they would describe themselves as the Family Therapy movement. There are two main schools within family therapy. One derives from psychoanalysis, and is interested in how the inner lives of family members interlock. The other school, more controversial though increasingly influential, is interested in families as “systems.”The instructions of a systems-minded supervisor to a beginning family therapist might run like this:
Assemble the family in one room. Ask them to pick out one of their problems and to try to negotiate a solution. Sit back and follow the structure of their conversation—the form, not the content—the sequences of “transactions” that take place. A transaction might take the form of people blaming each other, or of a child raising his demands each time the parents are about to agree, or of one person “invalidating” another’s perceptions. See what you can learn about the family by watching the patterns of their communication. Ask yourself: What alliances are formed in this family, and when? Why do their arguments never reach “closure” and what keeps happening to prevent a resolution? Where does the child’s “symptom” (for example, withdrawal or provocative courting of danger) appear in this sequence of transactions?
Making observations of this kind is clearly a persuasive experience, especially as it soon becomes apparent that every unhappy family does indeed have certain sequences of “transactions” which seem to recur automatically. It is doubtful whether a young psychiatrist or social worker who tries this experiment could ever think about the problems of therapy exactly as he did before. However, to carry it out, a different sort of attention from that of a psychoanalyst is required. The psychoanalyst, deliberately using his own empathy as a tool, pays close attention to the emotional “content” of what people say. While it is true that he observes the style of communication in order to detect “defenses,” he asks himself a rather different question: What form of relationship is this patient trying to re-create with me? Family therapy shifts the emphasis to the family as a whole and to the transactions within it as they take place in the present.
Many in the family therapy movement prefer to think of themselves as anthropologist-consultants to very small tribes in distress rather than as doctors who cure individual “cases” of psychological illness. Their new style of thinking was shaped by the work of the anthropologist Gregory Bateson1 and in fact all the books under review derive in part from the Palo Alto research group that, under Bateson’s leadership in the mid-Fifties, produced the “double-bind theory of schizophrenia.” This hypothesis has since become (to borrow Auden’s words on Freud’s death) a whole climate of opinion, not least through its influence on R.D. Laing.
Jay Haley, family movement spokesman, was a member of the Palo Alto group, as were John Weakland and the late Don Jackson, who appears in the book by Haley and Hoffman, and to whom Change is dedicated. Salvador Minuchin’s style of therapy was shaped by his work with Oriental immigrant families in Israel and with the families of black and Puerto Rican delinquent boys at the Wiltwyck School; but he has also been much influenced by Haley, whom he invited to join the Philadelphia Child Guidance Clinic.2 These books thus offer an opportunity to re-examine double-bind theory and some therapeutic techniques that have emerged from it during the last twenty years.
What the double-bind hypothesis did was to translate the relationship between the schizophrenia-producing mother and her child into communications theory. The hypothesis starts from the observation that the talk of schizophrenics leaves out—or leaves ambiguous—the signals or “metamessages” which tell us whether a message is serious or playful, real or imaginary, ironic or direct, literal or metaphoric. As Haley first suggested, schizophrenics cannot distinguish among different kinds of logical discourse; he and Bateson drew on Whitehead and Russell’s demonstration that confusion of “logical types” creates paradox. Why do schizophrenics apparently refuse all relationships by refusing to qualify their own messages? What could such schizophrenic communication be an adaptation to? It was, as Bateson put it, a response to a mother who continually puts her child in a paradoxical bind by a) giving him mutually contradictory messages, while b) implicitly forbidding him to recognize or point out what she is doing. If he could blame her he would be out of the bind; but such children sacrifice themselves in order to maintain the fiction that their parent’s “mystifications” (as Laing later called them) make sense.
Bateson specified what sort of mother this was: one who is made anxious and hostile by closeness to her child but finds it intolerable to acknowledge this. When the child approaches she withdraws, but when the child then moves away she becomes pseudo-affectionate and accuses him of being unloving. Such phenomena are readily observable, and Bateson’s description of them was simple and elegant.
Psychoanalysis doesn’t contradict the double-bind hypothesis. Bateson’s work meant that there were now two ways of describing the same phenomena. You could talk in psychoanalytic language about a highly ambivalent mother who projected her own hostility, an infant who lacked experiences of mutuality and so developed a weak ego, etc., or you could talk about the same behavior as a “dysfunctional relationship” which shows itself in disturbed communication. But if you do the latter, the emphasis shifts from past to present, from inner dynamics to communication, from pathology to a peculiar adaptation. Haley, in his Strategies of Psychotherapy, published in 1963, spelled out one version of the implications of double-bind theory. Unfortunately, Haley’s notoriously sardonic style has made it nearly impossible for anyone educated in psychoanalysis to give him attention.
Every communication, Haley wrote, functions both as a report and a command; and as a command each communication can be seen as redefining the nature of the relationship one is having with the partner. If I discuss the weather I may be defining our relationship as one in which we will only talk about conventional matters. If you then ask me why I am talking about the weather, you have redefined our relationship as more intimate. (Try observing this. It can be unnerving.) Every relationship (marriage, therapy) can be seen, Haley says, as an implicit power struggle over who defines the nature of the relationship. In the above example, if it is a psychoanalyst who asks why I talk about the weather, he has thereby taken control of the context: my pleasantries are now something to be examined. All symptoms of “disturbance,” according to Haley, should be looked at as strategies that control relationships that cannot be controlled by other means. (Part of the strategy is the claim that the symptom is involuntary.)
Haley also suggested that we look at all situations in which one person sets out to change another, whether by hypnosis, religious conversion, psychoanalysis, behavior therapy, family therapy, or whatever, and ask what formal characteristics they have in common. He found that they all contained “benign” double-binds, i.e., they make it impossible for the patient to re-create the kinds of relationships he has formed in the past.
Minuchin, Haley, and their colleagues command our attention, moreover, because they represent one of the first concerted attempts to apply systems-theory concepts to the practice of psychotherapy. Their defenders say they are trying to give us a grammar of situations rather than a grammar of individual motives. As such, their work appeals to the loyalty of those who sympathize with Bateson’s plea that we need to think “ecologically,” in terms of patterns and relationships, rather than in linear fashion, in terms of cause and effect, individual vs. environment, etc. (Minuchin, for example, calls himself a “context-oriented” therapist, in contrast to those who are “individually oriented.”) Their clinical methods, however, can strike outsiders as unpleasantly manipulative and authoritarian. And their style suggests that something of Bateson’s vision has been lost in translation.
“Family therapy is best defined as what a number of family therapists are doing,” write Haley and Hoffman in the introduction to their book, which combines interviews with noted family therapists and transcripts of representative sessions. “To learn what it is they do, one must watch them at work and inquire about their actions…. From such queries we learn what a therapist’s beliefs are about his work. If these be rationalizations, that is what all clinical writing is.” This calculated ingenuousness and mistrust of explanatory concepts are characteristic of Haley, but they also reflect the state of the art. When C. Christian Beels and Andrew Ferber, who are more ecumenical teachers of family therapy, set out to survey their field, they too watched therapists at work through one-way screens, studied video tapes, and interviewed colleagues. Their report3 sounded a similar note:
It was pointless to try to abstract “the technique” from these many approaches, since the personal stamp of the therapist was so clearly the first thing we had to understand…. We avoided the evaluation of theory because we believed that in many cases the theory advanced was a rationalization for the practice….
Indeed, at first view all that the various forms of family therapy may seem to have in common is that the whole family is usually in the clinic or the consulting room at once, and that the setting is somehow public; the tape recorders, video cameras, and one-way screens suggest an audience. Therapists may have co-therapists, and the one-way screen may harbor behind it a supervisor, armed with a microphone that he may use to intervene. The therapist himself may disappear behind the screen, emerging like a deus ex machina when the plot gets too thick.
Family therapy, like some family quarrels, needs witnesses, to keep track. The watchers often prefer to be watched too, to guard against their being drawn in to take sides in a way that would perpetuate the family’s patterns. Family members, also, may be taken behind the screen, to show them how the family gets on without them (for example, to show an intrusive grandmother that her daughter can cope with the children). The invisible drama of the transference has been replaced by what has been described as a kind of Brechtian theater. The therapist functions as stage director, and some (Minuchin is one) double as actors too.
Despite their shyness of concepts, the systems-theory therapists, as I’ll call them, do have some. Following Don Jackson, they try to look at families as systems that are kept together, or kept within certain limits of behavior, by homeostatic mechanisms which continually re-establish the status quo. (Examples might be: whenever this wife shows a certain degree of resentment, her husband deprecates himself; whenever these parents quarrel, their child diverts them by becoming troublesome; whenever another child shows a certain degree of independence, his mother labels it as dangerous or disturbed.) They are not interested in the history or causes of a symptom, but in how it serves to regulate present behavior.
See Gregory Bateson, Steps to an Ecology of Mind (Chandler, 1972; Ballantine, paper).↩
Another major influence on the Palo Alto group was the imaginative work of Milton H. Erickson, the doyen of medical hypnotism, who wrote the foreword to Change. Erickson advised Bateson and Mead on their work on trance in Bali. From his work comes the understanding that trance can be seen not just as an inner state but as a form of relationship, and that inducing trances typically proceeds by double-bind communications. See also Jay Haley, Uncommon Therapy (Norton, 1973; Ballantine, 1974, paper), which is about Erickson's work.↩
"What Family Therapists Do," in The Book of Family Therapy, edited by Andrew Ferber, Marilyn Mendelsohn, and Augustus Napier (Aronson, 1972; Houghton Mifflin, 1973, paper).↩
See Gregory Bateson, Steps to an Ecology of Mind (Chandler, 1972; Ballantine, paper).↩
Another major influence on the Palo Alto group was the imaginative work of Milton H. Erickson, the doyen of medical hypnotism, who wrote the foreword to Change. Erickson advised Bateson and Mead on their work on trance in Bali. From his work comes the understanding that trance can be seen not just as an inner state but as a form of relationship, and that inducing trances typically proceeds by double-bind communications. See also Jay Haley, Uncommon Therapy (Norton, 1973; Ballantine, 1974, paper), which is about Erickson’s work.↩
“What Family Therapists Do,” in The Book of Family Therapy, edited by Andrew Ferber, Marilyn Mendelsohn, and Augustus Napier (Aronson, 1972; Houghton Mifflin, 1973, paper).↩