A Family Therapy Narrative

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A Family Therapy Narrative 51

overtly or covertly. Thus, they reasoned, it would be better if these impor-tant others were also involved in the process. (3) There were huge waitinglists at agencies post World War II, so seeing couples or families togetherseemed a viable way to decrease the patient backlog and the waiting time

for therapy.Family casework, an approach developed in social work interventionswith distressed, multi-problem families (Richmond, 1917) was one early fore-runner of family therapy. This often entailed home visits by the caseworker,rather than having families come into the agency. In the 1950s office-basedtreatment evolved in family therapy as the preferred and more time efficientpractice model and this has continued to be true. (For history of the fieldsee Guerin, 1976; Kaslow, 1982, 2004; Kaslow, Kaslow, & Farber, 1999.)Nonetheless, since the early 1990s there has been a resurgence of interest inhome-based treatment, both in the United States (Lindblad-Goldberg, Dore,

& Stern, 1998) and abroad (Sharlin & Shamai, 1999) with poor and multi-problem families who are unable to go to therapists offices. This approachrecognizes that not all families can mobilize their members to travel to anoffice for therapy and that this inability is not necessarily an expression ofresistance.

The Child Guidance Movement was another tributary, begun in Chicagoin 1909. It was nurtured further in Boston, beginning in 1917, when psychi-atrist William Healy established the Judge Baker Guidance Clinic. The usualprocedure followed in child guidance clinics was for a psychiatrist to seethe child alone and a social worker to interview the parent, perhaps con-

currently, but not conjointly. Frequently parent meant mother. Few clinicshad evening or weekend hours to accommodate working parents, especiallythose with fixed work schedules.

Some concepts that evolved from the psychoanalytic movement com-prised a third historic force; especially the pressure exerted early on forfamily diagnosis. Flugel, for example, wrote in 1921 it is probable that thechief practical gain that may result from the study of the psychology of thefamily will ensue from the mere increase in understanding (of) the natureof, and interactions between, the mental processes that are involved in fam-

ily relationships, (Flugel, 1921, p. 217). Not all of the early analysts wereexclusively individually oriented. The intrapsychic concepts that are imbed-ded in attachment theory (Bowlby, 1988) and object relations formulations(Fairbairn, 1952) are interactive ones and have been subsumed into the psy-chodynamic school of family therapy/psychology, which includes objectiverelations (See typology later in this chapter).

The discontents already alluded to had begun rumbling and jelling inthe minds of various clinicians by the early 1950s. By then they had startedto be expressed by some courageous, outspoken theoreticians/therapists in

various parts of the United States. Research into the patterns of interaction

between those diagnosed with schizophrenia and their significant others led


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52 F. W. Kaslow

to speculation about and recognition of the key role family members mayplay in the psychogenesis and maintenance of the illness. One flagship groupformed in Palo Alto, California, in 1952 with Gregory Bateson at the helm.

John Weakland and Jay Haley joined him in 1953. Their initial interest in

metacommunication, i.e., the message about the message, the intent behindthe content, steered them toward developing a theory of communication thatcould perhaps enable them to unravel the origin and nature of schizophrenicbehavior, particularly as it evolves in the milieu of the family (Bateson,

Jackson, Haley, & Weakland, 1956).Shortly thereafter these pioneers formed the Mental Research Institute

(MRI). Other theoreticians and clinicians who became part of the earlyMRI group included Paul Watzliwick, Virginia Satir, and Don Jackson. Con-ceptualizing the phenomenon of the double bind was one of their corecontributions (Jackson & Weakland, 1959). Two of their other basic contri-

butions were that destructive patterns of relationships are maintained throughrepetitive, self-regulating interactive patterns within the family constellation,and that there are multiple and often contradictory levels of communicationsoccurring simultaneously.

Murray Bowen, a psychiatrist who initially specialized in the treatmentof schizophrenia in the l940s during his years at Menninger Clinic, becameintrigued by the dynamic of mother-child symbiosis. His working with thispattern of attachment led to his generation of the theory of differentiation ofself (Bowen, 1978). During the 1950s he worked at NIMH concentrating onanalyzing family of origin dynamics before moving to Georgetown Medical

School, where he continued to do his pioneering work from 19591990.Among Bowens lasting contributions are his elaborations of the cycle of

emotional reactivity of family members to one another evidenced when theyare seen conjointly, and that feelings bubble up and overshadow thoughtscreating a chaotic milieu. Bowen described his awareness of how the dis-traught families he saw tended to try to draw him into their undifferentiatedfamily ego mass He stressed that it is imperative for the therapist (con-ductor) to resist this pull and remain neutral, objective and external to thefamilys enmeshed interactions. He also formulated the parallel concepts of

triangulation and detriangulation, which continue to undergird or influencethe work of many family therapists (Bowen, 1988).By 1952, Lyman Wynne, who was a psychiatrist and a psychologist,

also had begun working with families with a loved one with schizophreniaat NIMH. He became aware of the unreal, as if perfect nature of thesedisturbed families and developed the still current concepts of pseudo mutu-ality, pseudo hostility and the rubber fence and connected the constructs ofcommunication deviance, thought disorders and a continuum of severity ofpathology (Wynne, 1984).

At Yale University, psychiatrists Theodore Lidz and Steven Fleck inves-

tigated the dynamics of families with a member with schizophrenia focusing


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on the destructive impact of pathological fathering styles. Their underlyingassumption challenged the then-prevalent assumption that maternal rejection

was the major causative factor. These clinician-investigators invariably foundthat the parents of the schizophrenic person had a disturbed relationship.

They elaborated upon two primary types of disturbance: (1) marital schism,the repetitive inability to build mutual accommodation and no achievementof role reciprocity, and (2) marital skew, a pattern which evolves when onespouse has serious pathology and controls the other more dependent part-ner/parent. They noted that the child with a serious mental disorder waspulled into trying to stabilize the parents rocky marriage (Lidz, Cornelison,Fleck, & Terry, 1957).

These early theories of the families etiological role in the develop-ment of schizophrenia spectrum disorders have been seriously challenged inrecent years. While there is evidence to support the notion that family pat-

terns, such as high levels of expressed emotion (EE) (Leff & Vaughn, 1983)may contribute to the maintenance or exacerbation of symptoms, it has nowbecome apparent that neurobiological and genetic variables are also maincontributors in the development of these disorders.

In New York, child psychiatrist Nathan Ackerman, who had, like Bowenand Wynne, trained at Menninger Clinic, started seeing the family togetheras the basic patient unit for diagnosis and treatment (Ackerman, Beatman,& Sherman, 1961). For the 1955 meeting of the American Orthopsychiatric

Association he organized one of the first sessions on family diagnosis. At thisconference Ackerman, Bowen, Jackson, and Wynne learned of each others

separate but similar efforts to treat entire family units and realized theyshared a sense of common purpose. Ackerman founded a Family Institutein Manhattan in 1960. It was renamed the Ackerman Family Institute in 1971as a tribute to his legacy after his death. Ackermans work emphasized theintrapsychic and the interpersonal, the unconscious and the conscious, andconfronting and challenging the defense mechanisms. He was well aware ofthe complex interplay and dances of selves within systems.

Carl Whitaker was one of the most imposing, intriguing, playful, irrev-erent, and daringly innovative of the founders. From his work with children

and with psychotic inpatients he had come to comprehend a great dealabout craziness and this seemed to give him entre into the inner world ofhis patientsallowing his unconscious to connect to theirs, doing what henamed psychotherapy of the absurd (Whitaker, 1975). His unique blend of

warmth and emotional chiding enabled him to get patients who had frozentheir emotions to slowly defrost. As early as 1943, he and colleague John

Warkentin invited spouses and children to join in patients therapy sessionsin their work in Oak Ridge, Tennessee. Whitaker introduced the use ofcotherapy, based on the premise that having a colleague engaged in thetreatment enabled either therapist to interact spontaneously without fear of

getting over involved, as the co-therapist was available to pull him/her out if


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need be, and that they could each assume or switch supportive, exploratoryor confrontational roles as needed. The experimental brand of provocativepsychotherapy that he and his colleagues at Emory University Medical SchoolDepartment of Psychiatry forged there and in their private practice in Atlanta

between 1946 and 1965 and later at the University of Wisconsin in Madisonwas quite controversial. Whitaker believed the therapist had to win the battlefor structure in the first session of therapy yet pushed patients to take chargeof and be responsible for their own decisions and lives. Consequently, hebelieved that the family needed to win the battle for initiative. The FamilyCrucible (Napier & Whitaker, 1978) provides an excellent portrait of his styleknown as experiential family therapy and of the co-therapy he and AugustusNapier conducted together.

In Philadelphia two active groups of therapists emerged. One grouporiginally joined together at the Eastern Pennsylvania Psychiatric Institute

(EPPI). This group included Ivan Boszormenyi-Nagy and Geraldine Sparks,who were co-therapists and co-authored the now classic Invisible Loyalties(Boszormenyi-Nagy & Sparks, 1973) which articulated an ethical/existentialledger of balances within the intergenerational family system. Others in thisgroup, most of whom also were initially trained in the psychoanalytic tra-dition, included James Framo and Ross Speck. Speck, along with Carolyn

Attneave, fashioned the original version of network therapy which tookinto account and utilized sociocultural and racial diversity and the natu-ral networks within families with schizophrenic or drug addict members.Their work did not resemble psychoanalytic treatment, but it did reflect their

knowledge of intrapsychic processes (Speck & Attneave, 1973). In the mid-1970s Boszormenyi-Nagy moved to Hahnemann Medical College in Philadel-phia to direct a graduate Marriage and Family Therapy Program and his careerintersected with several others, including Israel Zwerlingthen Chair of theDepartment of Mental Health Sciences. Zwerling was an energetic, dedicatedcommunity and family psychiatrist. Boszormenyi-Nagys work also has beeninfluential in Eastern Europe, particularly in his native Hungary.

Many from the EPPI and Hahnemann groups formed the PhiladelphiaFamily Institute as a loosely affiliated forum for interchange of ideas and to

provide stimulating workshops and later, to do training for fledgling familytherapists. The Institute evolved into a strong professional support networkwhich lasted for many years.

The Philadelphia Child Guidance Clinic was located on the other side ofthe Schuykill River. When Salvador Minuchin, a brilliant charismatic pioneerlike most of the others already described, left Wiltwyck School for Boys inNew York to assume the directorship in 1965, he brought Braulio Montalvoand Bernice Rosman with him. They were joined in Philadelphia by Jay Haleyin 1967 and subsequently by many others. Minuchin, a psychiatrist, dividedtroubled families into those that were enmeshedtoo tightly intertwined and

chaotic, and those that were disengagedisolated, indifferent, seemingly


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uninvolved with one another. His early work was with Families of the Slums(Minuchin et al., 1967) and he has long continued to focus on inner city, poor,underserved populations. He believes the hierarchy in these families often isin need of restructuring with the parents being helped (or pushed) to assume

their rightful position as the architects and executives of the family and thatthe therapist must join the family before being able to restructure and changeit. Out of the heady golden years at Philadelphia Child Guidance came Min-uchins Structural Family Therapy and the groundwork was probably laid forHaley and Cloe Madanes to evolve Strategic Family Therapy (Haley, 1973).

The two major groups in Philadelphia held very different views ontreating families and supervising trainees and they rarely came togetherapattern that unfortunately has been repeated in other cities and countries,

when those espousing the efficacy of their approach over all others havebeen unable to even meet together for conferences. Fortunately, some of

the less doctrinaire and ethnocentric members of the profession have beenable to intermingle and exchange ideas in a mutual learning process.

At Georgia State University, Luciano LAbate developed a graduate pro-gram in Family Psychology, a term he coined to connect this field to de-

velopmental and clinical psychology and to have it rooted in basic research(LAbate, 2008). A prolific teacher and writer since the 1960s, he has beeninfluential in the United States and his country of origin, Italy. He has beenone of the pioneers in manualized treatment of patients (LAbate, 1983, 1985,1997).

There are many more notable individuals who have made significant

contributions but space limits restrict discussing everyone. Therefore, theforegoing has been an attempt to highlight some of the most illustrious(great) grandparents in the family therapy field.

CONCEPTUAL FOUNDATIONS AND BASIC PRINCIPLES

The word and concept family as used herein broadly encompasses nuclearand extended/kinship families, stepfamilies, adoptive and foster families,and gay and lesbian couples and families. It includes those who make a

mutual commitment to regard one another as family, and to assume certainresponsibilities to and for each other on a sustained basis.

In addition to some of the basic principles of family therapy already al-luded to in the discussion of the pioneers, there are additional core assump-tions that have evolved over time and which remain salient. The evolution offamily therapy contained overlapping periods of development; which havebeen elucidated as follows (Kaslow, 1990).

Generation Ipre 1969 The Pioneers and Renegades formulated and re-

fined the premises


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56 F. W. Kaslow

Generation II19691976 The Innovators and Expanders Generation III19771982 The Challengers, Refiners and Researchers Generation IV19831995 The Integrators and Seekers of New Horizons Generation V1995Present: Researchers for an evidence based real-

ity. Post modernism, social construction of reality and personal narrativeapproaches.

CORE ASSUMPTIONS UNDERGIRDING FAMILY THERAPY INCLUDE

Members of a family constitute a system, with all parts interdependent andinterrelated

Change in any part (member) of the system usually induces correspondingchanges in some/all other members of the system; pain in one mem-

ber of the system causes pain in all members of the system. (Satir, 1964,1967)

All families have rules and expectations, implicit or explicit; and storiesabout their histories and their family heroes; myths and secrets (Imber-Black, 1998). Each member of the family may perceive and tell the familystory or narrative differently (White & Epston, 1990).

Families range on a continuum from dysfunctional, through mid-range, tofunctional and healthy (Lewis, Beavers, Gossett, & Phillips, 1976; Walsh,2003). Certain characteristics typify the various categories of families, andknowing these characteristics can help clinicians in their assessment andtreatment.

Healthy families exhibit good problem-solving and decision-making skills,integrity, and open communications styles (Lewis et al., 1976).

Many dysfunctional families are characterized by rigid alliances, schisms,and high conflict.

Boundaries between generations and among members of the same gener-ation should be clear and should not be crossed inappropriately (Minuchin& Fishman, 1981).

Many patterns of behavior and interaction are transmitted intergenera-

tionally; these can be detrimental or healthy, depending on the pattern.(Kaslow, 2004). Many techniques in addition to verbal ones can be useful in assessment and

treatment, such as genograms (Bowen, 1988; McGoldrick & Gerson, 1985;Kaslow, 1995; Shellenberger, 2007), and family sculpting (Duhl, Kantor, &Duhl, 1973; Papp, 1983; Satir et al., 1991).

Use of paradoxical techniques may be beneficial in some situations. (Haley,1976; Selvini-Palazolli, Boscolo, Cecchin, & Prata, 1978).

The core tenets presented here comprise a representative sample of

some of the foundational beliefs; however, this list is far from exhaustive.


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A significant event connoting recognition of the maturation of familytherapy was the birth of the journal, Family Process, in 1961. It is still apremier publication 49 years later. Daniel Araoz started the Journal of FamilyCounseling in 1973. It has continued into the present, having been renamed

The American Journal of Family Therapy many years ago. The Journal of Marital & Family Therapy was launched in 1974 as the official Journal ofAAMFT. Since then at least a half dozen other major family journals have beenfounded in the U.S., including the prestigious empirically based Journal ofFamily Psychology, which debuted in 1987. The number of books publishedin many countries on this ever expanding and multifaceted field also hasproliferated rapidly, heralding the prominence of the field.

Since the 1960s, the movement has expanded rapidly, with therapistscoming from everywhere to observe the masters at work in their own settingsover one-way mirrors or to hear them present at workshops and conferences.

Trainings sprung up at newly formed Family Institutes in such places asBoston and Chicago, in addition to those already mentioned, and in graduateand professional schools.

In the United States several organizations have been formed that arededicated to the field of family treatment and research: (1) The American

Association for Marriage and Family Therapy (AAMFT), begun in 1942 as theAmerican Association of Marriage Counselors, a name which representedits primary focus at that time. It began as an interdisciplinary organizationof marriage counselors, physicians, clergy, social workers, etc., changed itsname to AAMFT in the late 1970s, reflecting its newer focus which included

treating families, and that there were then more psychologists and psychia-trists in its membership. (2) The American Family Therapy Academy (AFTA)

was founded in the mid-1970s by many of the family therapy pioneers andwas originally known as the American Family Therapy Association. (3) TheDivision (now Society) of Family Psychology (#43) of the American Psycho-logical Association (APA), formed in the mid-1980s. (4) The American Psy-chiatric Association (ApA) has a separate small section focused on the family.

Family therapy began to spread to other countries by the 1970s. Ini-tially clinicians from many lands traveled to the United States and England

to get training. Universities and organizations in far-flung countries invitedacknowledged leaders to come to present workshops to interested practition-ers. Subsequently, many countries and regions have established their ownfamily focused organizations and training programs. Today credentialing isa key concern in many regions of the globe.

There are two major contemporary international organizations which en-compass diverse members practicing in various arenas of this disciplinetheInternational Family Therapy Association (IFTA), created in 1987, and thesmaller International Academy of Family Psychology (IAFP), founded in 1990,plus many extant regional associations, like the European Family Therapy As-

sociation (EFTA). Utilizing organization memberships, journal subscriptions,


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58 F. W. Kaslow

and the number of books published annually as a quantitative measure ofthe fields significance, family therapy/psychology is thriving throughout the

world.

Theoretical Models

Over the past six decades numerous schools of family therapy have evolvedand been elaborated; (Becvar & Becvar, 1996; Nichols & Schwartz, 2006);each model has had its major progenitor(s), generation leaders and staunchfollowers here and abroad (Kaslow, Kaslow, & Farber, 1999). Each theory hasposited and promulgated its idiosyncratic perspective as to the definition oftherapy and how treatment should be conductedthat is, the processes andtechniques that it advocates. Each school is predicated upon ideas about whatcontributes to pathology or dysfunction and what promotes and maximizes

change, and each should delineate the interventions to be used to achieve thedesired outcome. These should be consonant with the theorys underlyingassumptions and beliefs.

Previously I have divided and organized the theories into categoriesand subsumed the most prominent of the current approaches under themajor headings that appear most appropriate. (Kaslow, 2004). The varioustheories have fluctuated in their popularity; once having waned, a revivalof interest has been generated in several and they have again come tooccupy a central place within the spectrum of available explanatory theoriesof family dynamics, structure, functioning, and treatment. Different theorieshave attracted followers and proponents in different countries, depending on

where they were propagated initially, which leaders have come to that regionto present workshops on their approaches, and which therapeutic stylesand treatment methodologies are most compatible with a specific cultural,psychosocial, religious, political, and economic context. The typology, nowupdated follows (Kaslow et al., 2001):

I. Transgenerational ModelsPsychodynamically informed (including Object Relations and Attachment

approaches)BowenianContextual/relationalSymbolic/experientialEmotionally focused

II. Systems ModelsCommunicationsStrategicStructuralSystemic

Brief and solution focused


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III. Cognitive and Behavioral ModelsBehavioralFunctionalCognitive behavioral

IV. Post Modern ModelsNarrativeSocial constructionist (including linguistic approaches)

V. MiscellaneousPsychoeducationalIntegrative (including Comprehensive and Multi-Modal Models)

CONTEMPORARY ISSUES AND TRENDS

The field has witnessed the ascendance of various charismatic leaders, someof whom achieved guru status, garnered disciples, and been featured in mas-ters presentations and on videotapes. They have convincingly taught anddemonstrated their models and intervention strategies at family institutes,in graduate school classrooms, at conferences and in workshops, some-times before there was any research conducted to validate the efficacy oftheir assumptions and intervention approaches. However, in the last twoand a half decades at least part of the field, primarily the more research-oriented professionals, has pushed for evaluation of what works throughboth qualitative and quantitative research on process and outcome variables,reaching beyond clinical experiences and personal testimonials. In these25 years pressure for having empirically validated and/or evidenced basedtreatments, such as functional family therapy, has mounted (Alexander &Sexton, 2002) in the ranks of researchers, practitioners, third party insurers,and in academic and other training institutions and from certifying boards.

A frequent controversy arises as to whether graduate students of familytherapy should be trained broadly initially, learning many of the theories,and then proceeding to gain competence in one or several theories and aset of techniques they believe have greatest value, or whether they should

become immersed in one theory and its accompanying techniques, and oncethat is mastered, then be exposed to multiple approaches. Some see thislatter training model as akin to indoctrination with a rule book of absolutedicta, yet others deliberately select such a specific unidimensional curriculumand model. This tends to lead to doctrinaire thinking and practice, akin toethnocentric politics that hold our way is the only right way and is theantithesis of the strong trend toward integrative family therapy (Kaslow &Lebow, 2002; Lebow, 2005; Pinsof, 1995).

Family theoreticians and practitioners, supervisors, consultants, and re-searchers continue to be drawn from the fields of psychology, psychia-

try, social work, marriage and family therapy, sociology, counseling and


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60 F. W. Kaslow

guidance, pastoral counseling, and nursing. Such diversity of discipline oforigin enriches the field, yet also contributes to interdisciplinary tensions andrivalries around competency issues, such as how much education and train-ing is needed, what should be included in the curriculum and in internships,

and at what degree level; and around licensure, i.e., who can use the titleand who can legitimately practice marriage and family therapy; as well aswho can receive third party payments for these services. These turf battlesare apt to continue.

Since the new millennium began, family therapists have been practicingand teaching in an expanding variety of venues, including primary healthcare settings, with family physicians, and with other kinds of specialists. Theirexpertise is also valued beyond the health /mental health arenas in suchsettings as school systems, and in fields like family business consultation(Kaslow, 2006). Some family practitioners specialize in the forensic arena,

focusing on intimate partner violence, child custody, divorce and myriadother issues (Kaslow, 2000). Others are engaged in the domains of healingfamily trauma, assisting military families, and family public policy (Heldring,2008). Competence regarding gender and multiculturism has become crucialin this expanding field.

Given that we are each born into a family, grow up in a family of ori-gin, and grow up in our own family of origin, adoptive or foster family andthat most people later move on to create their own families, the fascination

with the family as a system which warrants and commands professional andsocietal attention, will continue unabated for decades to come. Clinicians

from various professional backgrounds and theoretical dispositions sharethis fascination and many find being engaged in family therapy/psychologychallenging, stimulating, growth enhancing, frustrating, rewarding, and usu-ally gratifying.

REFERENCES

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Alexander, J. F., & Sexton, T. L. (2002). Functional family therapy: A model fortreating high-risk, acting out youth. In F. W. Kaslow & J. Lebow (Eds.), Compre-hensive handbook of psychotherapy. Vol. 4: Integrative/Eclectic (pp. 111132)New York: Wiley.

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Becvar, D. S., & Becvar, R. J. (1996). Family therapy: A systemic integration (3rded.). Needham Heights, MA: Allyn & Bacon.

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A Family Therapy Narrative