Family therapy and family medicine

Family Process, 1971

American Journal of Psychotherapy, 1987

The first one-way mirror used to observe families should be preserved in the Smithsonian Institution. This simple invention has catalyzed revolutionary developments in family therapy, enabling supervisors and consultants to be actively involved in implementing change. Cloë Madanes is a recognized master in this method of training. Behind The One-way Mirror presents her thinking about problems and their solution in her role as a family therapy supervisor. She guides the reader, as she does the trainee, in formulating hypotheses and in testing strategies of intervention. This volume extends the work presented in Madanes's earlier book (1). She proposes a strategic, problem-solving model of therapy based on ideas about the use of metaphor, planning, and hierarchy in families. Through case studies, she presents a step-by-step process of assessment and intervention. Madanes attends to the metaphorical sequences of interaction involving symptoms, to the planning ahead by family members that is attempted through symptomatic behavior, and to the power imbalances that necessitate the symptoms. A specific strategy is designed to shift the family organization so that the presenting problem is resolved. In this volume, Madanes focuses on indirect intervention strategies, which she finds are often necessary in difficult cases. The book is organized into five chapters. The first presents Madanes's conceptual frame for understanding relationships and for planning strategies for change. Chapter 2 explores the possibility that relations between two individuals are dependent upon involvements with a third person, who functions as a metaphor for covert conflict. Issues of hierarchy and power are discussed in regard to relationship contracts. Chapter 3 presents the novel approach of influencing parents through their children, strategically reversing the generational hierarchy by putting the children in charge of their parents' well-being; this is done in order to provoke the parents to take responsibility for change. Chapter 4 discusses the use of humor in therapy, and the final chapter presents eight dimensions therapists may use to conceptualize problems. Madanes briefly describes paradoxical strategies that might be selected according to the therapist's conceptualization. Madanes's creativity shines most brightly in her many case studies, which reveal the novel ways she recasts problems and the highly inventive strategies she fits to particular situations. Her originality in the construction of playful metaphors, fantasies, and make-believe interventions is a highlight of the book. From my own work (2) with severely dysfunctional families, I share her conviction that families struggling unsuccessfully with difficult problems respond well to interventions that lighten and transform their hopelessness and sense of failure. Such playfulness, if employed without sensitivity, could run the risk of cleverness that is fun only for the therapist. Madanes, however, demonstrates both sensitivity and caring in the cases presented here. The case illustration "Pretending to Be Nurses" (p. 7) is a gem. Here Madanes addresses the problem of a mother's neglect in the care of her daughter's diabetes. She recognizes that the needs of the mother have also been neglected; mother suffers from diabetes herself, was abandoned by her husband, and lacks economic and social supports. Madanes calls attention to a common issue in cases of abuse and neglect: that the parents feel abused and neglected by authorities, in this case medical. An indirect strategy of intervention puts the mother benevolently in charge of her daughter without exercising authority over her. To accomplish this, the therapist asks mother and daughter, each in turn, to pretend to be a nurse to the other, even adding the theatrical touch of donning nurses' uniforms when they do so. The rationale for the strategy is well presented, and the planning of each stage of therapy is clearly described. The follow-up information confirms the effectiveness of Madanes's unique approach. Madanes writes in a straightforward, pragmatic way, and seems to assume that the reader has a basic knowledge of family systems theory and of strategic family therapy. There is, however, some conceptual unclarity and inconsistency. The most serious problems occur in the overuse of the term metaphor and in related assumptions about causality. Every presenting problem is viewed "as a metaphor for and a replacement of" some other (covert) relationship problem. In one case example, the therapeutic strategy is based on the hypothesis that the presenting conflict between a dysfunctional son and his father was a metaphor for, and replaced, an avoided conflict between the father and another son. The son is even referred to as "a metaphor for someone else: his brother" (p. 40). The second relationship is hypothesized to be the "true source" of the first conflict. The therapeutic goal, then, is to "take the problem back to where it originated" (p. 40) so that it can be discussed, thereby freeing the symptomatic son from replacing his brother. Even the chapter title, "Discovering the Source of the Conflict" suggests that there is always a covert source, or origin, of presenting problems that is the "real" problem and the "true" meaning and "cause" of symptoms. Such linear-causal terms and references scattered throughout the text are inconsistent with the systems paradigm of circular causality on which family therapy is based. Such assumptions need to be better thought through lest they slide into the sort of inferential, deterministic interpretations that systems theorists have rightly attacked.

Journal of Adolescence

Family Process, 1969

This paper is a personal view of the literature of family therapy. It is written to inform those who, like ourselves, are second-generation family therapists, entering a field which began in the early 1950's, and has since developed rapidly. The field has its journals, its books, its GAP committee, its training programs, its internal wars, its multiplying hundreds of practitioners, and, most important for us, its pioneering teachers. In an attempt to bring coherence out of the various teachings and practices of these leaders of the field, we try here to evaluate them by imposing upon them our own order, in the light of our own experience with teaching and practice.

1985

This volume broadens the application of a family framework in more traditional psychological and psychiatric areas. In a field overly invested with ideological purity and factionalism, this presentation of clear models of integration deserves applause. Early in Ziffer's own superb chapter on "The Utilization of Psychological Testing in the Context of Family Therapy," he presents the book's raison d'être: To remain committed to the theoretical position of the dominance of contextual factors, and to thereby demonstrate viability to the traditional mental health establishment, family therapists have chosen to eschew many time-honored individual interventions, such as psychotropic medication, hospitalization, as well as psychological testing. The challenge for family therapy now is not to reject these interventions, but to find meaningful ways to employ them within a systems framework. [p. 38] The areas addressed by the book include: diagnosis; the incorporation of psychological testing in the evaluation and treatment of learning disorders; the use of psychiatric consultation; current psychiatric diagnostic categories (a sophisticated discussion); indications for and effects of psychotropic medication; a family model of hospitalization; successful physician-therapist collaboration in treating children with medical illnesses; the school as a subsystem in school-child-family interaction; family consultation; "live" versus videotaped supervision in the training of family therapists; integrating contextual treatment with hypnosis. Each chapter follows the basic outline: the "adjunctive" area's background and theory are explained, with presentation of an integrative clinical model. This is illustrated by extensive clinical material, and by discussion of the problems one might anticipate in applying this approach. Except for the chapter on psychiatric diagnosis, which is muddled by Szaszian philosophy, each author makes a major contribution to clinical practice and to the development of new treatment programs. This book will be of particular value to family therapists in a collaborative relationship with other health professionals and educators. The clarity of the models, the practical details, the extensive outlines and clinical illustrations all encourage experimentation and incorporation of bridging techniques between disciplines. The focus is on children, adolescents, and their families suffering from the enormous burdens of physical illness, psychiatric disorders, and learning and school problems. This text does not address couples issues nor those of the family life cycle. In his introduction, Braulio Montalvo suggests that "perhaps what is of most lasting value in the family approach will survive as a crystallization of flexible procedures for delivering adjunctive therapies" (pp. xiv-xv). Although this comment is exaggerated, clearly this text does address the need to expand the boundaries of family treatment. The application of a family framework, a contextual understanding of behavior, and the creative application of family therapy training can add much to the mental health field. The sensitivity and thoroughness with which complex and sophisticated problems are approached using the new integrative clinical paradigms make this an extraordinarily valuable contribution.

1984

The first one-way mirror used to observe families should be preserved in the Smithsonian Institution. This simple invention has catalyzed revolutionary developments in family therapy, enabling supervisors and consultants to be actively involved in implementing change. Cloë Madanes is a recognized master in this method of training. Behind The One-way Mirror presents her thinking about problems and their solution in her role as a family therapy supervisor. She guides the reader, as she does the trainee, in formulating hypotheses and in testing strategies of intervention. This volume extends the work presented in Madanes's earlier book (1). She proposes a strategic, problem-solving model of therapy based on ideas about the use of metaphor, planning, and hierarchy in families. Through case studies, she presents a step-by-step process of assessment and intervention. Madanes attends to the metaphorical sequences of interaction involving symptoms, to the planning ahead by family members that is attempted through symptomatic behavior, and to the power imbalances that necessitate the symptoms. A specific strategy is designed to shift the family organization so that the presenting problem is resolved. In this volume, Madanes focuses on indirect intervention strategies, which she finds are often necessary in difficult cases. The book is organized into five chapters. The first presents Madanes's conceptual frame for understanding relationships and for planning strategies for change. Chapter 2 explores the possibility that relations between two individuals are dependent upon involvements with a third person, who functions as a metaphor for covert conflict. Issues of hierarchy and power are discussed in regard to relationship contracts. Chapter 3 presents the novel approach of influencing parents through their children, strategically reversing the generational hierarchy by putting the children in charge of their parents' well-being; this is done in order to provoke the parents to take responsibility for change. Chapter 4 discusses the use of humor in therapy, and the final chapter presents eight dimensions therapists may use to conceptualize problems. Madanes briefly describes paradoxical strategies that might be selected according to the therapist's conceptualization. Madanes's creativity shines most brightly in her many case studies, which reveal the novel ways she recasts problems and the highly inventive strategies she fits to particular situations. Her originality in the construction of playful metaphors, fantasies, and make-believe interventions is a highlight of the book. From my own work (2) with severely dysfunctional families, I share her conviction that families struggling unsuccessfully with difficult problems respond well to interventions that lighten and transform their hopelessness and sense of failure. Such playfulness, if employed without sensitivity, could run the risk of cleverness that is fun only for the therapist. Madanes, however, demonstrates both sensitivity and caring in the cases presented here. The case illustration "Pretending to Be Nurses" (p. 7) is a gem. Here Madanes addresses the problem of a mother's neglect in the care of her daughter's diabetes. She recognizes that the needs of the mother have also been neglected; mother suffers from diabetes herself, was abandoned by her husband, and lacks economic and social supports. Madanes calls attention to a common issue in cases of abuse and neglect: that the parents feel abused and neglected by authorities, in this case medical. An indirect strategy of intervention puts the mother benevolently in charge of her daughter without exercising authority over her. To accomplish this, the therapist asks mother and daughter, each in turn, to pretend to be a nurse to the other, even adding the theatrical touch of donning nurses' uniforms when they do so. The rationale for the strategy is well presented, and the planning of each stage of therapy is clearly described. The follow-up information confirms the effectiveness of Madanes's unique approach. Madanes writes in a straightforward, pragmatic way, and seems to assume that the reader has a basic knowledge of family systems theory and of strategic family therapy. There is, however, some conceptual unclarity and inconsistency. The most serious problems occur in the overuse of the term metaphor and in related assumptions about causality. Every presenting problem is viewed "as a metaphor for and a replacement of" some other (covert) relationship problem. In one case example, the therapeutic strategy is based on the hypothesis that the presenting conflict between a dysfunctional son and his father was a metaphor for, and replaced, an avoided conflict between the father and another son. The son is even referred to as "a metaphor for someone else: his brother" (p. 40). The second relationship is hypothesized to be the "true source" of the first conflict. The therapeutic goal, then, is to "take the problem back to where it originated" (p. 40) so that it can be discussed, thereby freeing the symptomatic son from replacing his brother. Even the chapter title, "Discovering the Source of the Conflict" suggests that there is always a covert source, or origin, of presenting problems that is the "real" problem and the "true" meaning and "cause" of symptoms. Such linear-causal terms and references scattered throughout the text are inconsistent with the systems paradigm of circular causality on which family therapy is based. Such assumptions need to be better thought through lest they slide into the sort of inferential, deterministic interpretations that systems theorists have rightly attacked.

The popular view of structural family therapy sees the structural diagnosis of families as lying at the heart of this therapeutic approach. This article challenges that view. I t argues that the practice of structural family therapy is driven not by structural diagnosis but by two fundamental assumptions about human and family functioning: the assumption of competence and the assumption of uniqueness. Consequences of this revisionist view are explored in two areas: ( a ) the area of the dialogue within the family therapyfield regarding the emerging tradition of secondorder therapy and ( 6 ) the area of training in structural family therapy.

Family Process, 1983

From Psyche To System: The Evolving Therapy of Carl Whitaker, by John R. Neill and David P. Kniskern, New York:, Guilford Press, 1982, 409 pp. $24.50 cloth. This collection of Carl Whitaker's writings makes an important contribution to the literature of psychotherapy, and family therapy in particular. From Psyche To System offers the reader a unique opportunity to examine the evolution of a creative and controversial therapist and to understand both his approach and how it relates to his personal philosopy.

1997

Journal of Family Therapy, 1979

A psychoanalytic framework for a systemic approach to family therapy Alan Cooklin* Family Therapy has no 'Standard Edition' or 'Collected Works'. Many would see this as a major strength of the 'Family Therapy Movement'; which is not based on a unitary theory, but is united in looking at human phenomena through a family (or natural systems) 'pair af eyes' (Bloch, 1973). Inevitably such a picture contains conflicts-they are in some ways the stuff of Family Therapy. A central conflict often rises between the interventions based on psychoanalytic theory and those based on communications theory.