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Family Therapy: An Exchange

In response to:

The New Wave in Psychiatry from the February 20, 1975 issue

To the Editors:

I congratulate The New York Review for commissioning an overview of the family therapy field—a notable First [NYR, February 20]. For one thing, New York intellectuals have had a long association with a class of personal advisers or wise men known affectionately as “shrinks.” Wise men, like psychotherapists of any type, are small businessmen. Questions of economic interests arise when the merits of rival therapies are presented, as in this essay, which claim to cut costs, take less time, and get better results.

For another thing, the few lay articles which have appeared on family therapy have described it as just another treatment method. Ms. First has made it clear that the family therapy movement is based on conceptual innovations which go beyond the concerns of mental health. There is a metaphysical frontier here which deserves to be more widely known. Ms. First has conscientiously taken on some of the abstruse ideas associated with this frontier (the “double bind” theory of the Bateson group; the cybernetic model for describing family “systems”) and wrestled them down to ground level where they can be understood.

As an overview of the therapy aspects of the family movement, the article is not so successful. This may only represent a failure to be a good anthropologist. Perhaps Ms. First has not sufficiently immersed herself in this big, messy family therapy tribe to get a real idea of what is going on. For instance, she limits her discussion to what she calls the “systems theory” therapists (Haley, Minuchin, Weakland, Watzlawick, et al.) as opposed to the more analytically oriented schools. Yet she excludes the work of Murray Bowen. Bowen is a therapist respected by the psychodynamic people because he works with and through the family of origin, but he also envisions families as systems of interlocking triangles and shares many concepts with Minuchin. This seems like an inexplicable oversight.

But perhaps the exclusion makes sense. After all, when a practicing analyst is asked to write a piece on a movement whose premises challenge those of the analytic establishment, and which is beginning to gain ground even in New York, what can one expect? In any case, Ms. First has taken on only those names in the family field which are most antithetical to psychoanalysis, including one (Haley) whom she seems positively to dislike.

Early in the essay, the point is made that systems-theory therapy has a reputation for being “unpleasantly manipulative.” This is the standard attack made by the psychodynamic schools of thought (including the analytically oriented family therapists) on the work of the writers and therapists reviewed in this piece. The reader, echoing Haley who originally made this point, might innocently wonder, “Aren’t all therapies manipulative by the nature of things, especially those which pretend not to be, like psychoanalysis and the so-called non-directive therapies?” But before this question can be asked, Ms. First has shifted to what systems-theory therapists do and why. Because she has a way of making it all sound like comic opera in a good cause, the reader forgets about his question and thinks, “Well, this new systems kind of therapy sounds very interesting indeed.”

Ms. First then starts to tell about some good results that have been achieved through the new therapy, like keeping schizophrenics out of hospitals, treating extremely disturbed adolescents, and offering hope for one very grave disorder, anorexia nervosa. These results, however, she dismisses as either trivial, or else explainable by age-old remedies which analysts also use, like “relabeling” of the “transference cure.” The reader thinks of another question: “Is a method and a rationale for treating a condition like anorexia, which up to now has been highly resistant to any form of therapy whatever, to be dismissed because it may turn out to consist of nothing more than a mixture of ‘half ritual drama, half behaviorism’?”

This new question is quickly buried under a splendid explanation of the difficult Batesonian concept of “second order change,” featured in a book by Watzlawick, Weakland, et al. The reader is once more beguiled. However, his contended state is broken into by the assertion that the therapists who make use of this concept work in a cynical, authoritarian way. The ideas of Gregory Bateson are only being used as window dressing, to give the place class.

Ms. First ends the article by stating that the systems-theory therapists feel that they have got hold of a “new paradigm,” in Kuhn’s sense of a new descriptive model. She also states her belief that this paradigm will stand or fall on the merits of the therapeutic techniques operating in its name. And the books she has reviewed, she tells us, do not assure her that “the solutions of family therapy are as yet so convincing.”

By this time, the innocent reader will be in a state of bemused confusion. Ms. First, with her flip-top phrases and a smattering of deepness, has shown herself to be a master illusionist. The illusion she gives the reader, in true non-directive style, is that he or she is being asked to make up his or her own mind. But simplified, the underlying argument of this piece could be translated into the following dialogue:

Q: What is bad about systems-theory therapy?

A: It is unpleasantly manipulative.

Q: What is good about it?

A: Apart from some trivial achievements as a treatment modality, it claims to offer a new paradigm.

Q: Then we don’t have to judge it as therapy?

A: Not so. If it is ineffective therapy, that will prove the paradigm to be wrong too.

Q: Is there any proof yet that it is effective therapy?

A: No.

Q: Then we can throw it all out?

A: Right.

For myself, I believe in illusions, am convinced that clever writers, like clever therapists, are always weaving them about their clients’ heads, and applaud Ms. First for an enchantingly ingenious performance.

Lynn Hoffman

Brooklyn, New York

To the Editors:

We were initially pleased that our book Change—Principles of Problem Formation and Problem Resolution was included in Elsa First’s review of several works on family psychotherapy in the February 20th issue of The New York Review (V. XXII, No. 2), but then rather disappointed.

This is not because Dr. First’s remarks about our work were critical. Criticism is legitimate, and indeed it is expectable that a psychoanalyst’s comments on our work should be quite critical. But because often writers are read only by like-minded readers, which gets nowhere, we welcome an opportunity to have our book appraised by someone using different ideas and values in approaching human problems, and very different criteria in assessing change.

What we do regret is that Dr. First has referred to what in our judgment and in the book’s emphasis are peripheral aspects. In fact, she quoted us so cursorily that it is difficult to call it a review. We would have hoped that she take her orientation and her task seriously enough to be critical especially of the central points of Change—our application of group theory and Russell’s theory of logical types to human problems, our focus on analyzing “solutions” rather than problems, our choice of deliberate rather than inadvertent manipulation of people, and our unsophisticated concern with observable, concrete and rapid results even in the highly personal business of psychotherapy.

Paul Watzlawick
John H. Weakland
Richard Fisch

Mental Research Institute

Palo Alto, California

Elsa First replies:

Lynn Hoffman’s letter is at least a helpful example of how context can affect our reading of content. I was “labeled” in The New York Review as a psychoanalyst; this evidently has led her to suppose that my intention would be to discredit family therapy, albeit in the wily manner of non-directive therapists. It seems to be hard for her to imagine that my approach could be genuinely exploratory (would it have helped if she knew that I had done some work with families?); or that I limited myself to one particular strand of the family therapy tradition not to make it look bad but because I find its ideas enormously suggestive, and because it is a historically significant element in the broader critique of “medical-model” psychiatry.

I do not believe that keeping schizophrenics out of hospitals is in any sense trivial. Nor do I anywhere “state” my “belief” that the new paradigm will stand or fall on the merits of what Lynn Hoffman chooses to call “the therapeutic techniques operating in its name.” It would, I think, be somewhat difficult for me to believe that after having read Thomas Kuhn. Moreover, General Systems Theory is scarcely in danger from its having been taken up by family therapists (any more than it is in jeopardy because some psychoanalytic theorists are also trying to make use of it). Even the specific notion that families can be seen as homeostatic systems seems to be thriving nicely.

To raise questions about the efficacy or sensitivity of particular clinical techniques is not necessarily an attack on anyone’s paradigm. Every responsible therapist must ask of his techniques: whom does this seem to help best? whom does it not help? how much does it help? for how long? any adverse side effects? etc. Lynn Hoffman, who deserves credit for the major part of the work on the films from the Philadelphia Child Guidance Clinic, must surely realize that a freeze frame of smiling faces is not a complete follow-up study. Dr. Minuchin and his colleagues do, I understand, view their work with anorectics as experimental, and I gather they are already considering modifying some of their more dramatic and sudden techniques as they carefully observe the longer-term outcomes.

Jay Haley has warned us that every therapy tends to define cure in terms of the changes that it is likely to produce. It would be a pity if the promising field of family therapy succumbed prematurely to that sort of doctrinaire attitude. Elsewhere, Lynn Hoffman has written an account of some theories of “deviance amplifying” processes; wherein she valuably traced the notion of deviance as a function of social transactions back to Gregory Bateson’s early anthropological study, Naven. Surely she can see that it does not constitute an attack on Bateson’s work if one asks whether a good way to intervene in deviance-amplifying processes in a family is for the therapist to keep changing where he sits in the consulting room.

I happen rather to enjoy the fact that we can juggle alternate descriptions of our clinical material. I confess that I am not at all convinced that the psychoanalytic and the family-systems paradigms need at this point to be considered mutually exclusive in our practice. I don’t see why I should not try to be equally aware of the impact of present messages, and of each patient’s characteristic modes of seeking relationships or avoiding anxiety. Most clinicians have had the experience of freeing an adolescent from a double-binding family, only to see him replay the same script elsewhere. Similarly, most of us have had the experience of offering tactfully supportive “directives,” or even the most deftly casual (or metaphoric) “suggestions,” or some implicit model of behavior, only to have them backfire in our faces because we were insufficiently aware of what a positive suggestion would mean to that particular patient at that particular time (e.g.—that we did not take his suffering seriously enough, that we were trying to take him over, etc.).

The therapeutic situation is more complex than Lynn Hoffman’s partisanship seems to allow, and I would suggest we try to bring to it every form of understanding we have. We do not make ourselves more skillful by ruling out our intuitive empathy, or by decreeing that the inner life is merely epiphenomenal, or by the sophistical argument that since all therapy is in some sense directive (as I would agree) then the most explicitly manipulative therapies will work better and faster.

To untangle a further muddle, let me add that I have too much respect for the healing rituals of other cultures to “dismiss” any remedy simply because it is “age old.” I cannot imagine why my looking for “age old” or universally therapeutic elements in family therapy should be considered an attempt at disparagement. Lynn Hoffman and Jay Haley, among others, have taught us that when we examine any form of therapy we ought to see if we can account for what it does in terms other than the mythology of its practitioners. This is what I was trying to do.

I chose to point out probable transference elements to counter the dogma of some family therapists that transference to an “active” therapist is negligible, as in Jackson and Weakland’s classic and otherwise edifying paper “Conjoint Family Therapy” (1961), which declared that transference is an artifact of the psychoanalytic situation, and does not occur in family therapy, largely because the room is already so crowded with current events. This is a serious misunderstanding of the notion of transference. My impression is that the skill of trainee family therapists would be much enhanced if they were allowed and taught to recognize transference phenomena when they occur, which is quite often. They are particularly caught off guard by hostile transference because they don’t recognize it early, as they take for granted that they will be viewed as benign.

And when I said that psychoanalytic interpretations could also be seen as a form of relabeling, this was surely not a disparagement of relabeling. It was actually a somewhat daring suggestion that we use ideas which family therapy has brought forward (namely, the notions of context and of context change) in looking at what psychoanalysts do, also.

There was little in Watzlawick, Weakland, and Fisch’s theoretical exposition that seemed new, and therefore I chose to introduce readers instead to Bateson’s original version.

To assess Watzlawick, Weakland, and Fisch’s work in the manner they ask would require a different book from the one they have written, and their request therefore places me in a double bind. For reasons of their own they have chosen not to include the sort of detailed clinical material which would allow one to judge independently what sort of changes they have brought about, nor to ask whether alternate accounts of their results might not be equally cogent.

The bind is tricky: If in their world explanations of why things happen are irrelevant, then they are perhaps excused from not telling us any more than they do. Nevertheless, I hope that in their next book they will indeed give us the opportunity to consider their work more closely.

The jocular book they have written is full of amazing incident. But its characters—despite their delightful capacity for passing through second order change at a moment’s notice according to how their situations are defined by the authors—remain inscrutable.

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