Foundations of Family Therapy: A Conceptual Framework for Systems Change
Foundations of Family Therapy is a fascinating encyclopedia of the history, schools, techniques, and masters of family therapy. During the past thirty years, family therapy has expanded into an organized and rigorous discipline within the larger field of mental health. Its theoretical scheme and its practical techniques and training contrast with those of other mental health disciplines, such as psychiatry, social work, psychoanalysis, and supportive forms of family counseling. Family therapy may be described as a movement: family therapists believe that their picture of mental disturbance is more “true” to reality, superseding both traditional forms of therapy and contemporary therapies which center upon the individual client.
In her enthusiastic survey of the field, Hoffman both advances the movement of family therapy and establishes it as a serious intellectual discipline. According to Hoffman, family therapy is not just “a novel therapeutic technique” or even another theory of mental disturbance; it represents “a new epistemology,” which touches on all the sciences and replaces traditional theories of personal motivation. Unfortunately, these larger claims are sometimes grandiose and often inappropriate when addressed to a stereo-type of contemporary psychoanalysis (which here is labeled “the psychodynamic approach”).
“Epistemology”—the theory of knowledge—and “conceptual revolution” have become popular terms in psychotherapeutic writing. A theory of human behavior which purports to reveal the true nature of reality by way of the metaphor of knowing carries weight among therapists today. Another frequently used term, “scientific revolution,” which is borrowed from Thomas Kuhn, attempts to give a theory a progressive quality and, thus, protect it from charges of dogmatism.
But these concepts are part of two separate, and conflicting, belief systems. One holds that there is an absolute true reality which may be accurately represented by the correct method, the other that theoretical schemes are relative to a specific culture and time. In Hoffman’s book, the Kuhnian approach, which might help to restore a healthy relativism to the discipline of psychotherapy, is used to isolate, and thereby elevate, the author’s point of view. She offers us the true epistemology—a “circular,” “systemic” method—through which the real world which exists behind the mirror is, at last, made manifest. Indeed, in the first sentence, we are told that “this book is a journey to a newly discovered kingdom, the world behind the looking glass.” To Hoffman, the advent of the one-way screen through which the family therapist observes the therapy sessions is “analogous to the discovery of the telescope”; through this clear glass, we are now able to “view the fauna of a realm that had always been before us yet never truly seen.”
The new “bicameral” vision, created by the one-way screen, has indeed revolutionized the study of therapeutic interactions, since a therapist is able to observe from two places. For the first time, the therapist is able not only to observe his own contributions to the therapeutic relationship but also to have these monitored by a third person. However, Hoffman’s larger epistemological claim, based on the analogy of the screen, is naïve. Unlike the observer behind the screen, we are not in a position to step out of our conceptual schemes, shut the door, and enter a Kantian world of “things-in-themselves.”
Family therapy is particularly suited to people, such as children and psychotics, who are trapped in ongoing, intense, emotional relationships with their families. Family therapy is a group experience, its therapists usually working in pairs or teams. The family network, which is gathered into one room by the therapists, may comprise three or four or sixty people. Meetings may take place at regular times or they may be arranged when a crisis arises. Some therapists refuse to meet a family unless the whole network can be assembled; others will meet with individuals or subgroups. While family members express their grievances to one another, the therapists try first to uncover the structure of their relationships and then to formulate the most expedient plan for change so that the family system can function more beneficially. A large number of psychotherapy’s customers, however, are adults who feel trapped although they have physically separated from their families. These people do not need a therapist to step in to disrupt an ongoing system, but wish to free themselves from a past pattern of relationships.
Family therapy offers much that is new to the theory and treatment of mental dysfunction, and Hoffman has a good deal to say about the evolution and breakdown of the social system of the family. First, as her book so lucidly describes, the systemic viewpoint, borrowed from cybernetics, presents a radically different approach from both the medical model of mental illness and from Freud’s theory of psychic reality and motivation. Put simply, the family therapist looks at the patterns and rules of the relations governing a system. Any one person is no more than a passing element in a never-ending sequence. For instance, patients often switch places; as one gets well, another gets sick, all in the service of preserving a family’s internal balance.
Second, the overriding goal of family therapy is change. No one seems to care too much about “follow-up”—about who, or what, changes and into what—just so long as the malfunctioning system self-destructs. Many fascinating and highly effective techniques have been devised in pursuit of this goal. Hoffman portrays the family therapist as a trickster and bully, stage actor and director, a master of strategy and gamesmanship. Insofar as symptoms interest him, they are viewed as “harbingers of change,” the weakest links in the chain that binds the family. The symptom is always exploited as a source of disruption of the faulty system and never sedated. Needless to say, since the therapist works as an “agent provocateur” he or she is not usually seen as a kindly, sympathetic family doctor.
For example, a family seeks therapy because of the difficult behavior of the thirteen-year-old son at mealtimes. The mother may have tried to please her son by cooking his favorite dishes, yet all her efforts are met with scorn and disgust and her son continues to eat snacks out of the refrigerator. The problem, of course, does not lie in the nature of the food but in the changing relationship between mother and son—in particular, the shift from a complementary relationship to one of equality. The wily therapist might interfere by issuing the absurd prescription that the mother make her son two of his favorite meals during the next week and then sit beside him while he eats, perhaps offering to cut up his food for him. In addition, she might get out his baby cup. This ritual symbolizes the closeness both mother and son have to give up. Father is also told to eat the same meal. Hoffman points out that, although the aftermath is unpredictable, the ridiculous assignment often hits home and all the family members are forced to recognize their difficulty in saying goodbye to their old positions, even though on the surface they wish to be rid of them.
Family therapy began in the Fifties and flourished in the Sixties, inspiring a revolt against the medical establishment and, in particular, its treatment of schizophrenia. In the US and in Britain, its principal theoretical mentor has been the British anthropologist, the late Gregory Bateson. In psychiatry, Bateson is best known for his work on the “double bind,” an important pattern of communication in the syndrome called schizophrenia. A double bind is a communication on several levels in which an overt statement at one level is covertly nullified or contradicted at another. Drawing on Bertrand Russell’s work on logic, Bateson teased out the different levels of communication, which are mixed up in the schizophrenic’s “word salad” or “thought disorder,” and ordered them hierarchically.
At the first level, one person, usually in a subordinate or dependent position, is issued a command—say, “Eat your food”; at the next level, he is told not to obey by a message such as “Grow up and stand on your own two feet”; at a third level, he is forbidden either to comment on the contradiction or to ignore it—“You are too young and weak.” This last comment is particularly incapacitating for a child, who is dependent upon his parents for survival, but it is also constricting for people in institutions.
Although the early researchers in this field saw children and mental patients as the principal victims of double binds, most therapists now regard all participants as equally enmeshed in this paradoxical type of communication. Indeed, in his crazy-sounding statements, the identified patient may be the most skilled master of the double bind. In one of Hoffman’s examples, a young man sends a card from a mental hospital to his mother on Mother’s Day. On it are written the words “To One Who has been Just Like a Mother to Me.” In another example, a catatonic girl parries her father’s inappropriate advances to her by saying “Petting between teenagers sometimes gets out of hand.”
Many of the theoretical and technical developments in family therapy can be seen as expansions of Bateson’s original double-bind hypothesis. The pathogenic type of mother-child interaction, vividly portrayed in Laing’s original study of schizophrenia, The Divided Self, is now seen to extend across generations and to be a notable feature of three-person relationships. Hoffman describes family life as a “multi-generational changing of the guard.” Crises usually occur when members change places—during adolescence, at birth, marriage, retirement, or when a child goes to kindergarten. The double bind comes into play at these times to confuse and prevent disengagement. Suddenly, a teenage girl becomes anorectic, an eighteen-year-old college freshman develops a phobia, a child becomes asthmatic, or a mother falls prey to migraines.
The founders of family therapy were struck by the rigidity of disturbed families and by their resistance to the normal evolutionary processes of family life. Hence family therapy’s technical emphasis on strategies of change. In its early stages, the circularity of social systems was defined by the cybernetic concept of homeostasis. A homeostatic system is like a house thermostat in that it is self-regulating and conservative. Family interaction was viewed as a closed information system which sought stability and equilibrium. In malfunctioning families, so the family therapists thought, antihomeostatic, i.e., destabilizing, runaways had got out of control, thus leading the system to break down.
This view of the organization of living systems was consistent with Freud’s law of conservation, which he elaborated in his principle of the universal compulsion to repeat. But for some reason, presumably connected to their immersion in pathology, therapists have concentrated on the resistance of people to anything new rather than on the concomitant, though conflicting, desire for variation. Ethologists have been the first to point out the importance of the attraction of both the familiar and the strange throughout human development. We cherish home yet long for foreign places.