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Marriage and Family Therapy, 3rd Edition

A Practice-Oriented Approach

There are other editions available.

This is the most recent edition.

Chapter 1: The Practice of Marriage and Family Therapy

The family is one of nature’s masterpieces.

—George Santayana

INTRODUCTION

The couple came to therapy in November, a few months after dropping their youngest child off at college. When asked what their best hopes were for coming to therapy, the parents immediately began talking about their children. They said they were pleased at how their children were doing. One child had graduated from college, one had opted to go to a culinary school, and the youngest was pursuing a music degree. While the couple seemed pleased with their children, they appeared stressed and unhappy. They shared with the therapist how different things had become between the two of them over the past few months. Arguments had started occurring over small things that, they said, they never argued about before. The king was home more, Cinderella said, and was “semiretired,” maintaining his kingdom remotely at times. Cinderella said she had been thinking about going back to school for a graduate degree, but when she mentioned it to the king, he got upset, saying it was time for them to travel. As the family therapist listened to the couple, she began to construct a genogram of the family, using their descriptions as they talked about their families and children.

The king had been busy too, and had created quite a legacy, helping the people under his reign to become more culturally sensitive to the many newcomers who wanted to join their kingdom. It seemed that the king had brought about a sense of inclusion, encouraged by Cinderella, who had lived part of her life as an outcast before she had met the king. The king listened to his wife, Cinderella, now the queen, and watched how she approached their children and the many friends of her children, many who were of different races, sexual orientations, and cultures. The castle had become known as friendly and welcoming to all who entered, and as a result, the community had become peaceful.

But now, the couple told the therapist, they wondered who they were, as a couple. The king wondered about his position and what might become of his kingdom if he left. Retirement plans were being considered, and the couple had mixed views of how to spend their fortune, inherited from the king’s father. The therapist listened closely and watched the couple as each person talked about their situation. The therapist knew that the couple had stepped into a life span stage of launching, or, “empty nest,” yet the therapist was careful to not share that information. Instead, the therapist was listening for other features of the relationship. When there was a pause in the conversation, the therapist sat up a bit and asked them again, “What are your best hopes for our time?”

The couple told the family therapist that they wanted to be close again, like they were before. The therapist asked them what it might begin to look like someday when they were close again. Cinderella responded first by saying they would go for walks and talk about things other than the children, which they had been doing for over twenty years. The therapist said, “So instead of talking about the children, what would you talk about?” And Cinderella said, “Dreams, plans for the future, for just he and I.” The therapist asked, “And, what difference would that make to you to talk about those things?” Cinderella replied, smiling, “I would feel important to him again.”

The therapist turned to the king, who had sat back as his wife talked and bowed his head, and asked him what it would look like someday when they were close again. The king responded, “She would be happy to see me when I come home. She would take time to ask me about my day, and then I would do the same. We used to do that when we first married.”

More questions were asked around the values they shared early in their marriage that helped to create closeness, and even later as they began having children. Cinderella said her values of care and kindness were always important to her, but she also said she realized that her care and kindness might have turned more to the children than her husband. The king said his values of providing well for his family were what he thought he was supposed to do. Then, as he talked, he said he realized that he had forgotten about who the beautiful girl he found in the forest was and what she had stood for. To him, she was a breath of fresh air, full of life and not interested in material things like he was used to being given. The couple took time to reflect on each question, and the therapist started noticing that the couple began smiling at each other toward the end of the session.

The therapist then added a systemic question to the session as the conversation came to a close. She said, “I wonder, what might your children see you doing in the near future when you are close again?” The couple looked at each other and quickly described things that they would be doing together that had not happened in a long time. The therapist was so enamored with their answers, she questioned further, “And king, what might your subjects notice about you as you return to the castle over the next few weeks, after being closer to Cinderella?” And, to Cinderella, “What might others notice about you, as the weeks go by and you become closer to the king?” As the couple responded to these questions, which attempted to further specify their preferred future, the therapist continued to compose a list of the couple’s answers throughout the session.

As they left, the therapist asked the couple what they might have found helpful, if anything, during the session. The king said that he was relieved about the session, as he was afraid it was his fault that they had grown apart. He responded, “I liked remembering who we were.” Cinderella said she liked the session because it meant they both had to work on things, rather than just she, which she had become accustomed to doing over the years. She said she loved hearing him talk about her when they first met. The therapist gave a copy of the list she had composed during the session to the couple and asked them to think about the list they had created. As they walked out the door, the therapist told them to let her know when they wanted to return. They looked at each other and said, “In two weeks.”

A VIEW OF THE FAMILY

Families go through life cycles. The king and Cinderella were in the launching children phase of their family life and, like some couples, suddenly found themselves distanced from each other. The session described in the introduction was an example of a beginning session, using a solution-focused narrative therapy approach. The model, as described in Chapter 14, acknowledges the life span stage but does not focus on that stage for therapy. Instead, the therapist, as described here, was solely interested in what Cinderella and the king wanted to talk about.

The therapist continued to work with the couple over several months, and eventually the couple said they would call back if they needed to continue therapy. By then, the king and Cinderella had “talked more than in years” about the people they wanted to be in the next chapter of their marriage. When the holidays rolled around, and the children came home, they seemed pleased to see their father and mother embracing at times and laughing together. Possibly as a result of sensing the newfound openness in the family and happy parents, the oldest brought up future plans that involved him moving away from the kingdom and doing an internship in another country. The youngest felt so comfortable around her family, that she came out to them during the holidays. She shared that she had met someone at school that she was quite fond of. The middle child seemed to enjoy hearing both of his siblings’ comments and eventually shared loudly with everyone about his sister, “I knew she was gay. You go for it, Sis.” And, to his brother, he said, “So, when you get to your internship site, I would like to come visit and check out job openings. I love the food there.” The family system was evolving, and with the parents closer, the children seemed to be … launching.

As before, in previous editions, it is tempting, as the writer, to end this fairytale by writing that the couple and children lived happily ever after. After all, there are always many other variables that intrude into the lives of family members that steer them off track. Yet, family therapy was created to see family members as resilient beings, who can learn to interact with each other so their dreams come true. What family therapists see is the family system, an entity with many moving parts that involve people trying to learn, love, and find ways to connect and interact in a healthy manner.

As in this introductory case, the job of the family therapist is to assist the family in foreseeing a chapter where they get back to the family they once were or move forward into becoming the family they wish to be. While we can’t say that clients like the king and Cinderella will all live happily ever after as a result of family therapy, many family therapists would say that they, themselves did.

A NEW VERSION OF AN OLD STORY

This story provides a traditional example of the family therapy field’s systemic underpinnings. Notice the “ripple effect” that happened as new versions of beliefs, thoughts, and interactions emerged. Notice how the king and Cinderella, after rearing children for twenty years, had become different and distant, as the couple moved into a new life span stage, realizing that they had somehow lost their couplehood. Notice how their children relaxed and began to share personal realizations and make statements about who they were becoming when they saw their parents getting along and perceived an openness in the air. By honoring values that he must rule the kingdom, and not sharing his thoughts about losing the relationship he had with Cinderella, the king got off track, thinking it was his fault they were not close. Once focused on a direction by answering the question regarding best hopes, the preferred future building with his wife came easier. And in the end, as his preferred future suggested a return to the values that were important to him, she likewise did the same in recognizing that their next life chapter could be similar to the first one in several ways, even though they had each matured and developed into older adults.

The family therapy model used in this introductory case was solution-focused narrative therapy with families. In Chapter 14, the reader has more opportunities to learn how the model works systemically with families and couples. A couple such as the king and Cinderella might attend therapy five or six times and see opportunities to construct the preferred future they wanted all along. Staying systemic, the therapist included what the children might see someday soon that would tell them their parents were close again. By looking outside of the couple dyad, the couple was able to continue constructing a preferred future in such detail that when they walked out of the therapy office, trying out their own ideas was more probable.

This chapter uses this tale to explain some basic tenets of family therapy that may be helpful to the new family therapy student who desires to understand the process of thinking and acting systemically. Throughout the chapter, more excerpts from the king’s family therapy session will be provided to explain the tenets of family therapy in the most understandable manner.

A HISTORY OF FAMILY THERAPY: ORIGINS AND CONCEPTS

Before 1950, seeing the family as part of psychotherapy was not common. When Murray Bowen began noticing that treating individuals often did not lead to long-lasting change, he began studying relationships of his patients in the hospital instead. He found that unless family dynamics changed, rarely did the individual. He also noticed that, generationally, certain traits left unchanged in a family often surfaced as traits of the next generation. Thus, family therapy evolved out of psychoanalysis and the medical psychiatric model when treatment with an individual meant involving the family in treatment.

As family therapy continued to evolve, so did discoveries about why and how individuals developed as they did. New answers were discovered about how emotional distress occurred, and those answers led to strategies designed to mend interpersonal relationships.

Concepts from the field of psychology, such as small group dynamics, where individuals collaborated, confronted, or negotiated issues, became tools of the family therapist. When the child guidance movement found that treating only the child did not lead to long-lasting change, the invitation to the family to join therapy led to more success. In social work practices, where the practitioner often visited the family in their home context, problems were better understood. New family therapists were often former social workers, so using such conversational techniques resulted in richer dialogue surrounding an individual’s problem.

When Bateson et al. (1972/1956) began studying the causes of schizophrenia, they found that the families they studied had a strong impact on the course of therapy and on the schizophrenia. The group found that schizophrenia could be recognized as a method by an individual to maintain a homeostatic balance in their family. Therefore, the symptom was the result of interactions of family members around the individual. This discovery led to a belief that by changing the individual reactions, the symptoms lessened.

The discovery by family therapists who began noticing that to change a system meant that patterns had to be disrupted was the prompt that led to various ways of working with families, developing into the many models presented in this book. How such disruptions occurred took on many forms. Some models focused on interpersonal communications, challenging family members with paradox, circular questions, and directives. Other models focused on generational trends, offering insight and discovery to family members. Still others took the approach of understanding systemically how the organization operated and tried changing thought patterns, which led to new actions. The field began to burst with ideas, claims of success, and strategies for intervention with families dealing with various individual issues, which, when brought to the surface in a family therapy session, finally saw relief.

FAMILY THERAPISTS ARE INFLUENCED BY THE MODELS THEY USE

“Family therapists … believe that the dominant forces in our lives are located externally in the family. Therapy based on this framework is directed at changing the organization of the family” (Minuchin et al., 2006). If the king had just continued on as he was, focusing on being a king rather than on his wife, the chances of his wife feeling even more distant would have been more probable. When the family therapist gave the king and his wife a safe place to talk to each other, they responded with their best hopes, which, not surprisingly, were quite similar. In this retelling of the Cinderella story, the family therapist, using a solution-focused narrative approach, helped the king and his wife to imagine a preferred future where he and his wife were close again. When the wife and king grew close again after constructing a preferred future, the ripple effect, described later, impacted their children and helped them to be free to launch.

In contrast, a Bowen family systems therapist might have explored how the king’s childhood affected his life and caused him to be so driven to be successful as king. The Bowen family systems therapist would have seen the family for a long period of time, possibly years. The cognitive behavioral family therapist might have asked the king about his thoughts that led him to feel the distance was his fault. Such thoughts resulted in certain actions, and in this case, he worked more and talked less. The structural family therapist might have confronted the king and Cinderella and accused her of divorcing her husband and marrying her children. The strategic family therapist might have told the couple to quarrel in front of the children so they would know their parents still spoke.

There are many ways that different family therapy models might have approached this scenario. But how do novice family therapists know where to begin? How do they know which family therapy model best fits their personality and their client’s needs? And how, after learning the theories behind a model, does the beginning family therapist formulate how a session will be conducted? That is the purpose of this book: to provide beginning family therapists with information, practical applications, and steps that will help them understand the impact that family therapy can have on couples and families. In fact, each chapter provides a list of certain attributes at the beginning of each chapter for future therapists to consider when choosing their model. But above all, to skillfully develop that understanding, the new family therapist must first begin to understand how a family therapist thinks.

FAMILY THERAPISTS THINK IN CIRCLES, NOT LINES

“Reality is made up of circles, but we see straight lines” (Senge, 2006, p. 73). In linear models of psychotherapy, A causes B. This is helpful in many situations where there is a simple explanation. If a mother yells at her 13-year-old daughter for her untidy bedroom (A) and the daughter starts to cry (B) because she is hurt that her mother did not notice that she had cleaned the living room, it is not hard to understand how A causes B. If, however, the daughter never tells her mother that her feelings are hurt, and the mother continues to yell, and the daughter eventually becomes lazy, resentful, and rebellious, the mother may become frustrated and may decide to think that her daughter hates her, when in fact, her daughter desires her acknowledgment. This type of thinking takes on a more “circular” flavor because A, the yelling, causes B, the resentment; then, C, rebellion develops; then A, the yelling increases, again leading to B, more resentment, and so on. This dynamic is referred to as circular causality in that it consists of reciprocal actions that occur within interacting loops. A family therapist intervening in such a situation can disrupt the sequence of events. In fact, interrupting such sequences made the model, strategic family therapy, famous!

If you remember, the king blamed his parents for being distant, which led him to work hard and be away from Cinderella. In Chapter 3 on Bowen family systems theory, you will read more about differentiation, a process in which family therapists encourage their clients to partake, so that the choices they make are more rational and thought driven, rather than emotion driven. Imagine how different the fairy tale might have been if the king had been more differentiated. Perhaps he would have delegated more and come home early to be with his wife and children when they were growing up, relieving her of too much responsibility. Imagine how she might have reacted during those years, feeling as if she had a true partner!

What the king did not realize, too, was that his distancing at the castle was pushing Cinderella away from him. On occasion, she had tried to get him to do things with her, but he said he was too busy. It was always Cinderella who tended to the children. Cinderella’s resentment for having to do it all further fueled her distance. She began thinking of graduate school to have a purpose again when the children grew up. She rarely brought up her husband’s absence so as not to get him upset. She just went about her way to keep the peace and grow on her own. This tendency to preserve homeostasis, that is, the seeking of members of the family system to maintain their customary organization and functioning of the family over time, perpetuated the issue. For example, the mother of the teenage daughter, who may be worried that her rebellious daughter will be further punished by her strict father, may cover up for her daughter when the daughter comes home drunk. By doing this, she, too, maintains homeostasis. Unfortunately, she also maintains the problem drinking of her daughter.

FAMILY THERAPISTS WATCH FOR COMMUNICATION PATTERNS AND MATCHING BEHAVIORS

As family therapists, we make sense of what we do through systems theory. Systems theory focuses on the relationship between parts. For example, our body is more than separate organs. It functions because the organs work together as a system. The way the body is organized and works together determines our level of health. Ludwig von Bertalanffy, a biologist, coined the term “systems theory” in 1936.

He felt the need for a theory to guide research in several disciplines because he saw striking parallels among them. His hunch was that if multiple disciplines focused their research and theory development efforts, they would be able to identify laws and principles which would apply to many systems. This would allow scholars and scientists to make sense of system characteristics such as wholeness, differentiation, order, equifinality, progression and others. (Gillies, 1982, p. 56)

Today, there are many systems, such as healthcare systems, banking systems, family systems, and even social networking systems. Forming individual entities into systems is one way of making sense of the information we receive each day. Families are the same in that they need to organize their family members to stay on track and focused. They do this through generating roles, communication patterns, and behaving in ways that materialize as a result of how the family system organizes itself.

In all families, each family member is part of the family system, sending out and receiving communication. Family therapists have long known that roles in such a family system are taken on by individuals when allowed, often leading either to successful systemic interactions or unsuccessful ones. For example, an only child who “rules” the house with his or her every whim can often cause dysfunction on how the family interacts on a daily basis. The parents of the child ruler put aside their own needs, personally and intimately, to do as the child wishes, to keep the peace. The child, too young to take on such responsibility for two adults’ choices, often becomes symptomatic with depression, tantrums, anger, and so forth. A family therapist viewing the dynamics would conclude that, to regain a functional home, the parents would need to hierarchically take on the roles of parents in an authoritative manner.

The need for such boundaries, often created in a family therapy session, would provide the structure needed to disrupt the family system and help it rejoin in a healthier manner. Structural family therapy does this well, often rearranging family members’ seating while in therapy. The assumption is that the manner in which the family comes to therapy, sits, and interacts holds clues on how the family interacts at home. By rearranging the system in the therapy room, roles change, which leads to changed interactions at home.

The king’s family system consisted of his wife, Cinderella, their three children, relatives, the nannies, the palace staff, subjects, and his kingdom. In family therapy, triangles develop when tension between two people is too much for them to handle, so they “triangle in” a third person to relieve the pressure. This often happens in couples with children. Perhaps a mother travels a lot, and the father becomes lonely. He may complain to his wife that he is lonely, and she may reply that her paycheck keeps the family going so she can’t currently decrease her work hours. The hurt feelings lead to the father triangulating in a child, such as his 10-year-old son, who then becomes like a good friend. The father and son do everything together, and the mother is soon frustrated that there is little intimacy between her and her husband when she is at home. Detriangulation during therapy would entail the therapist removing the son from between the mother and father (if he indeed sat between them, which often happens) and asking him to play in the reception area while his parents talked to each other. Salvador Minuchin became famous for his confrontation with, in this case, the father, by saying, “When did you divorce your wife and marry your son?” Such strategies often lead to insight on the part of the parents, who are then guided by the family therapist to reclaim their couplehood.

In the king’s story, his wife began looking at graduate school instead of talking to her husband when she wanted him near. When the distance grew, she stopped trying to bridge it and focused on finding a purpose, thinking that he did not care about her as he once did. When the couple’s children did launch, the couple was at a loss. Who were they? The triangle with the children was gone when the children left home. Instead of talking to each other, the king and Cinderella looked at other ways to distract themselves from the loneliness. Hence, a new triangle.

CYBERNETICS: THE AESTHETICS OF CHANGE

Cybernetics was defined by Norbert Wiener, a child prodigy and mathematician, as the study of control and communication in the animal and the machine (Wiener, 1948). The ideas of cybernetics, as defined by Wiener, have been adopted by clinicians who see it as a homeostatic mechanism whereby communication patterns develop, mostly because of feedback loops, which is defined later. Many of the family therapy models in this book are based on the theory of cybernetics. How the family therapist observes the family and its interactions has much to do with the therapist’s hand at helping the family to achieve change.

W. Ross Ashby was an English psychiatrist and a pioneer in cybernetics. He viewed systems as living, able to respond to variations within the system as simply as one’s body responds to a range of temperatures in its environment. The home thermostat works similarly, in that it adjusts itself to keep the temperature the same (Ashby, 1956). This first-order change is often seen in families where alcohol or other destructive habits resonate and family members scamper around trying to pretend that the problem is not as serious as it seems, often hiding bottles of alcohol or promising to supervise the alcoholic person. First-order change is achieved only through the work of the family members, who must maintain their new roles. It is not a long-lasting change, or second-order change, which occurs when the alcoholic makes the decision to stop drinking and asks his or her family to help through support. Without second-order change, this homeostatic process will continue, sacrificing not only the identified client’s need to change but also that of other family members, who put their own lives on hold to preserve homeostasis. In the king and Cinderella’s case, they wanted to be closer but their attempts ended in arguments. There might have been a few days of peaceful conversations afterwards, or, first-order change, but within a week, the couple was back to their distanced relationship, avoiding topics to keep the peace. It would take a family therapist to help the couple identify what they wanted, what it would look like when they got there, and past successes to give the couple a glance at who they wanted to be. That led to second-order change as the couple decided upon new actions and recovered values to keep them focused on their preferred future. When the children saw the change, the system evolved again and the couple was impacted once again by how the children got along and interacted with each other and the parents.

In family therapy, the therapist often sees a family’s attempt at change when the first session happens. It is often that very attempt to change their interactions that leads to chaos. By simply asking the family, “What have you tried so far?” a multitude of first-order change strategies are explained, most of which have led to short-term change. In most families, when there is a symmetrical escalation, whereby two people escalate simultaneously, there is also a complementary escalation, whereby one person escalates to overcompensate for the other, such as that in the previously mentioned alcoholic family. Again, this keeps change at the first-order level. That level of change does not always last because the system does not change.

Second-order change (Watzlawick et al., 1974) is a longer lasting change because it requires a purposeful, systemic change. The lowly household thermostat, if broken, requires a physical manipulation or mechanical replacement to set a new temperature. Because it is a new thermostat, a new system, it will react differently, maybe more efficiently. By resetting the temperature, things are altered in a different manner, intentionally. When Cinderella told her husband that she wanted to be close to him like they were before, and the king began to recall what he did before that kept her close, the couple had a chance to rekindle closeness, leading to a chance for second-order change. That is quite different than a therapist telling a couple to go on a date on Friday nights. That would be the therapist’s idea, not the couple’s, and that would be an attempt at first-order change.

Morphostasis and Morphogenesis

The survival of families depends on two important processes. One is morphogenesis and the other is morphostasis. When an adolescent, such as the king, grows up and plans to move out and begin his own life, his family has two options:

Support and encourage him, because he is growing up, becoming independent, and needing to launch his career as a prince. His family knows it is time to let go.
Discourage him from having lofty ideas to rule the kingdom someday, as he is not ready to venture out on his own because he may not have the tools necessary to survive … he may fail. He must stay close to the nest until he is ready, if ever, to leave. Even though his father was distant, the mother might want the prince to stay around so she has company.

The first reaction is an example of morphogenesis (also referred to as positive feedback). In this case, the family is able to be flexible enough, despite their fond feelings for the prince, to let go and wish him well. Although not always happy that their offspring is launching, the family puts its own needs aside and sees the individual leaving the nest as an independent person who needs to continue growing. Even though it is a strain on the system, it is still considered “positive feedback” because in the end, positive occurrences result for the family in the form of flexibility and growth. At home, the family will then reorganize the chores, roles, and activities to accommodate this natural evolution of their family. As the prince leaves home, goes to college, and marries his princess, Cinderella, the chances are that he will feel confidence that he needs to rule the kingdom and be a good husband. The fact that the parents encouraged his launch would translate into confidence. He could think for himself and be open to what his bride wants from him.

The second reaction is that of a family where morphostasis (also referred to as negative feedback) occurs. Such families often have relational difficulties that keep them from launching their adolescent. Perhaps the marriage has been in shambles for years, with the father and the mother barely speaking except at dinnertime. If the adolescent leaves, the triangle that was created between him and his parents will be disconnected, meaning that the parents may have to face their marital dilemma. Thus, the family overprotects the prince, which causes him to feel less confident in his own vision of the future, and he remains at home to keep his parents’ relationship somewhat alive. The prince may become depressed, because he is foregoing a normal life stage of launching into an adult. He may go to therapy as an individual and may be treated with antidepressants and complain about his life. His parents “support” him in going to therapy but are unable to let go. With the help of a family therapist, the prince might be able to voice his need to leave to his parents in a session, with the therapist later suggesting that the couple come to therapy.

Morphogenesis and morphostasis occur throughout the family life cycle, such as when a family loses a loved one or must move to a new city. Both concepts happen, too, when a senior adult retires from a job where he worked for 50 years. The desire to finally retire may soon be met with resentment by a wife or partner who has enjoyed her solitude at home as a homemaker for 50 years. Suddenly, she is not alone, and arguments abound about boundaries, chores, money, and so forth. Her desire to keep things the same and his desire to finally retire are met with conflict. What is helpful in cases such as this one is for a family therapist to see the couple and offer them an opportunity to negotiate “Chapter 2,” a narrative therapy strategy, in their lives, providing time for them to talk about what each of them wants individually and together. This renewed sense of purpose and vision does much for the elderly couple, who could easily get stuck in a rut and risk health problems later.

The Mechanics of How Families Process Their Lives

Although many families in distress may call a family meeting, some will go to therapy. These are routes that aim to accomplish the same thing, although not always, … to get the relationships back on track so that the family becomes a place of serenity, peacefulness, and comfort. This phenomenon is called equifinality, and the premise behind it is that there are many ways to achieve the same result. When the Mental Research Institute began in Palo Alto, its founders believed that problems were simply the results of the family trying to fix itself. Members tried many different avenues to make things better but were unsuccessful. Thus, this change caused conflict. Equifinality is helpful, however, as it gives the family therapist a reason to believe that families can try different ways to solve their own problem and reach their goal. Some families, for example, may enforce rigid routines and curfews for their teenage children, hoping to teach them self-discipline and to follow rules for being responsible. Other families may be more lenient, asking the teenagers to negotiate a curfew that might work for everyone in the family. Both seek to teach responsibility, yet both try different avenues to do so. Both may be successful.

Additionally, the concept of equifinality helps the family therapist by enabling him or her to be flexible in the strategies used during sessions. The communications therapists found that however they approached the family, in whatever manner, change occurred. In the king’s case, the therapist began therapy by asking him what he wanted in his marriage to Cinderella. The therapist then asked Cinderella what she wanted in the marriage. When the couple said they wanted to be close again, the therapist inquired from them what that might look like. This put the onus on Cinderella and the king to build their own preferred future. When therapy was over, the king remarked that he felt relieved by the session. There are many ways to approach the family, but the end product, when successful, would have led to change in the system, and when that occurs, roles change and behaviors follow suit.

Metacommunication: What Did You Say?

Gregory Bateson was a British anthropologist, social scientist, linguist, visual anthropologist, semiotician, and cybernetician who studied communications on all levels. He wrote about two different levels or functions: report and command (Bateson, 2000). A mother desiring that her 10-year-old son become more spontaneous, in the hope that he will initiate friendships at school, may scold him by saying, “Good grief, go be spontaneous.” She means well, but her command negates what she is trying to instill in him. This is a metacommunication. It is a covert message and often is not noticed because it is attached to the first message. How the message is presented through the tone of voice, body language, or action has everything to do with how well it is received and then put into action.

In the king’s case, the messages he sent were those that the kingdom was more important than time with his wife. However, a closer observation into the family dynamics showed us that the king just thought that his wife did not want to be close and that was probably his fault. Cinderella was also sending messages that she wanted to get away more, by going to graduate school. Rather than talk directly, each sent a metamessage that made both of them feel worse about themselves and their marriage.

In families, metacommunication can be handed down through generations, creating havoc unless stopped. A young daughter’s mother may tell her to grow up and ignore her violent alcoholic father’s behaviors. This suggestion of not talking about what was happening keeps the daughter unsure of her real feelings and makes her question what she thinks. Later in life, the mother may continue their relationship with similar messages of “I love you, you are wonderful,” but “You are wrong about this situation, do it this way.” The grown daughter may later come to therapy describing how she was reared, with little clue that her mother kept her stuck with metacommunication. A family therapist can then ask the daughter to describe how she would like to live her life as an adult, by opening doors for the daughter to see the metacommunication patterns and learn how to respond so that the mother stops sending the messages.

It is a wise family therapist who can observe metacommunication during sessions, as it teaches the therapist how the system operates. In fact, if a therapist examines how he or she feels after a chaotic or challenging session, the therapist may discover the metacommunication patterns felt by the family. When the metacommunication patterns materialize again, the therapist can intervene, asking the person spoken to what the message meant to him or her. This examination of interactions will allow family members to identify how they are communicating and what to try that would be more successful.

The Double Bind

A mother brings her 7-year-old daughter to a therapist because the girl is refusing to stay at school when the mother takes her each day. During therapy, the girl sits on her mother’s lap and sucks her thumb, clinging to her mother with her other arm. The mother laments how hard a recent move has been for her family, particularly for her, the mother, who left her job and good friends. Although the mother talks about her concern for her daughter, the mother consistently comes back to her own hardship. When the therapist asks the mother what she desires for her daughter, the mother replies that she wants her daughter to be more independent again, like how she was in the town they lived in before. But the more the mother tries to remove her daughter from her lap, the more she clings. The therapist talks to the child later and learns that she is worried about her mother. The child says that her mother is lonely without her at home. When the mother comes into the therapy room, the therapist asks the child to tell her mother that she is worried about her. The mother is surprised and tells the daughter that she needn’t worry. The therapist encourages more dialogue from the mother about her plans for making new friends, finding a job, and so forth. The therapist also encourages the mother to talk about her plans for the day each morning when she drives her daughter to school. The daughter soon attends school without complaint and makes new friends.

The previous scenario is a classic example of a double bind, a situation in which a person gets two conflicting demands and cannot seem to win by pursuing either demand. In this case, the girl was caught in a double bind because the mother wanted the girl to go to school but also told her at times how she loved spending time with her since she did not have friends in the new city. The double bind is often seen in families, where one family member is told to do one thing but the interactions and behaviors of other family members tell him or her otherwise. Identifying times when a double bind is occurring helps the family therapist to dissect the communication and behavior behind the double bind, so that the family can begin sending out clearer communications. This is done by a family therapist asking a member who is trapped by the double bind to explain how he or she reacts to and feels about such messages. Once out in the open, the therapist can then help the member discuss how trapped he or she feels and then discuss what needs to happen so that he or she can respond and behave.

In the king’s situation, if he had told his wife how he felt they were growing distant and that he felt it was his fault, she might have chosen to take time with him, talk about her thoughts now that the children were gone, rekindling the relationship. But the metacommunications of the king being married to the kingdom, rather than to her, put her in a bind of trying harder, in a loop that had no end.

Emotional Strategies of Families

One of Lyman Wynne’s contributions to the field of family therapy was that of his observation of schizophrenic families and their attempts to deal with emotions. As an American psychiatrist and psychologist, he found that they often dealt with emotions in positive and negative, hostile, and unreal ways. Wynne was famous for his coined phrase “rubber fence,” which described how families would encourage their members to move forward but keep the rubber fence as a guardian so that the members did not move too far out of the family’s control. He created the term pseudomutuality, describing how a couple may keep up a front of being a loving couple, yet at home are distant. Another term used by Wynne to describe how families keep symptoms developing was pseudohostility, a technique whereby bickering keeps a couple from being close, often resulting in their going outside the relationship for intimacy.

If the king had told Cinderella about things he wanted to do with her now that the children were gone, Cinderella might have felt that she needed to do more too, to rekindle their relationship, feeling that she was important to him. She would have seen him as the man she met years ago in the forest and fell in love with. A glimpse into the future with her prince by her side might have led to her to do things differently as well. Together, in a family therapy session, if both members hear that what they both want is similar, as it was with the king and Cinderella, second-order change has a chance.

GENOGRAMS: MAPPING FAMILY LIFE

Monica McGoldrick, a groundbreaking family therapist, and her colleagues (McGoldrick et al., 2008) at the Multicultural Family Institute of New Jersey, created genograms as a diagnostic tool to help families see patterns within their past and present. Genograms display not only family relationships (mother, father, brother, sister, son, daughter, etc.) but also the emotional ties between family members. Genograms assist the family therapist in understanding the relationships, symptoms, and presenting problem’s function. Families are often intrigued by genograms, and it is suggested that the family therapist show the family how their genogram is constructed. This transparent approach continues to build the therapeutic relationship (see Chapter 2) and assists the family in identifying patterns on their own.

Over the past few decades use of the genogram as a practical tool for mapping family patterns has become more and more widespread among health care professionals. As genograms have become widely used in the fields of medicine, psychology, social work, and the other health care, human service, and even legal fields, I wrote, originally with Randy Gerson, Genograms: Assessment and Intervention, a practical guide to genograms, now in its second edition and published by W. W. Norton, to illustrate more fully the growing diversity of family forms and patterns in our society and the applications of genograms in clinical practice. The genogram is still a tool in progress. (McGoldrick et al., 2010)

The following are some basic ideas of how to construct a genogram, from GenoPro, a genogram software package (https://genopro.com/genogram). Note that other software packages may use slightly different symbols, but the underlying principles are the same.

Figure 1.1 shows the symbols used to identify gender. Male individuals are noted with a square shape, females with a circle.

Figures 1.2 and 1.3 show various symbols for children, pregnancy, and miscarriage, including multiple births. The children are placed below the parental line from the oldest to the youngest, left to right. Although this may sound obvious, it will be very important to remember these rules when the situation becomes a bit more complex.

FIGURE 1.1

Gender symbols used in genograms.

Source: GenoPro, https://genopro.com

FIGURE 1.2

Various genogram symbols for children and pregnancy.

Source: GenoPro, https://genopro.com

FIGURE 1.3

Genogram symbols for multiple births.

Source: GenoPro, https://genopro.com

FIGURE 1.4

Genogram of a husband with multiple wives.

Source: GenoPro, https://genopro.com

Figure 1.4 shows a husband with three partners. The husband had three children with the first wife, and then divorced. The husband married the second wife, had one child, and separated. The husband currently lives with another woman. As you can see, the oldest child is at the left, and the youngest child, the half sister, is at the right of her family, as she is the only child of the husband and the second wife.

Reversing this scenario to depict the wife having had multiple husbands, we get the genogram shown in Figure 1.5, which depicts a female with three husbands. She had three children with her first husband and divorced. She remarried, had one child with her second husband, and now lives with someone else. Please notice that the oldest child is always at the leftmost position of the family of his parents. In this scenario, the “oldest brother” is older than the twins and the half sister; however, the half sister must be placed under the family of her biological parents. Because the second marriage is after the first marriage, it follows that the half sister is younger than the children from the first marriage. The half sister, therefore, appears to the left, although she is not the oldest child.

FIGURE 1.5

Genogram of a wife with multiple husbands.

Source: GenoPro, https://genopro.com

In summary, here are the three rules to build a genogram:

The male parent is always at the left of the family and the female parent is always at the right of the family.
Always assume male–female relationships when drawing the genogram until the client specifies a same-sex relationship. This is done as a protection, because early generations did not always acknowledge same-sex relationships. It is also helpful to ask a client who seems ambiguous whether the relationship is with a male or female, for clarity.
A spouse must always be closer to his or her first partner, then the second partner (if any), the third partner, and so on. The oldest child is always at the left of his or her family; the youngest child is always at the right.

As family therapists begin drawing genograms with their family clients, it is important to ask about the relationships between family members, particularly if the family therapist uses a Bowen family systems theory, structural, strategic, contextual, or cognitive behavioral model of family therapy. By soliciting from the family client how the relationships developed and evolved to the present day, the family therapist will learn about patterns of interactions.

Many family therapists use the genogram when working with a client dealing with a dangerous situation such as substance abuse. By drawing the genogram with the family’s assistance, other addictive habits are identified. Additionally, if a couple comes for marriage counseling and, after assisting the family therapist in drawing the genogram, notices the pattern of divorce and infidelity in both of their family genograms, or even one of their genograms, the family therapist will learn how previous generations dealt with marital issues. Also, identifying trends in a family surrounding religion, cultural beliefs, and activities that influenced interactions and choices is valuable for the family therapist to identify with the families. This rich history explains not only to the family therapist how the family arrived at the current dilemma, but also provides an opportunity for the family to explain to the therapist who they are. This dialogue is essential, especially with families of different ethnicities and cultures. A family therapist should always be ready to ask these families, “Would you teach me who you are and how I may work with you best?”

Emotional cutoffs and dyads are discussed in later chapters in this book and are also identifiable through drawing genograms. For example, the king’s father and he were emotionally cut off when the king was a prince. By examining the genogram with the king’s family, the family therapist may find that the king’s father had an unhealthy relationship with his father after his mother died when he was a young prince. Nurturing by nannies furthered the distance. The wise family therapist who notices such patterns and asks the family to discuss them may find that the family begins healing on its own, recognizing that past cutoffs and strategies did not work.

Family therapists using a solution-focused or narrative family therapy approach may also find the use of genograms helpful in identifying “exceptions” or “unique outcomes” in a family’s history. For example, a family coming to therapy with a family member who abuses substances may work with a solution-focused family therapist to identify family members who did not use drugs or alcohol but did deal with problems in a healthy manner. This identification of healthy family members becomes a resource for the client and an opportunity for the family therapist to explore with the family what the healthy person might say to the substance abuser.

Narrative family therapists may look at the genogram as the family’s story and encourage the family to keep looking closer for “unique outcomes” of times when the family went through challenging times. As a solution-focused and narrative family therapist, I often use exceptions and unique outcomes to encourage the client family and the identified client, and invite them to create the next generation genogram. For example, using a current genogram, I may ask a young adult client dealing with substance abuse:

Suppose we were to fantasize and draw in the next generation, a product of your future relationship with someone. How do you want your children to develop as young adults? What behaviors do you think you need to begin taking on so that such development is possible in the future? And who in your family can you draw on now for support to help guide you there?

These questions might have been helpful in generating a preferred future for the king when he first came to therapy.

These are just a few of the applications of the genogram in family therapy. Families enjoy the process of developing a genogram with their family therapist and often ask for a copy to take home. In addition to the genogram used by family therapists, the culturagram may be a great addition to the family therapy toolbox. The culturagram was created by Dr. Elaine Congress, a professor and associate dean at Fordham University Graduate School of Social Service. She writes:

The culturagram is a family assessment tool I developed to help social workers and others understand better families from different cultural backgrounds. It basically consists of a diagram with 10 different aspects. I think of culture as not being a singular concept, a singular term. Under culture I feel is subsumed race, ethnicity, national origin, and religion, as well as values and beliefs. So I feel as social workers it’s very important for us to understand completely the cultural background of families we work with. I’ve decided that one way to really do this would be to develop a tool to help social workers really better assess the families they work with. (Congress & Kim, 2007)

Figure 1.6 is an example of a culturagram, which is included to provide an additional tool for family therapists who work with diverse families.

FIGURE 1.6

Culturagram.

Source: From Singer, J. B. (2008, December 1). Visual assessment tools: The Culturagram—Interview with Dr. Elaine Congress [episode 46]. Social Work Podcast. http://socialworkpodcast.com/2008/12/visual-assessment-tools-culturagram.html

USING DOCUMENTATION TO RECORD YOUR UNDERSTANDING OF FAMILIES

One just has to go to the local shopping mall, sit for a while, and watch families interact to understand the various roles, rules, interactions, and cultures that govern who they are and who they will become. Imagine sitting in an office with five other people, some adults, some adolescents. One can only listen to so many messages, metamessages, actions, perceptions, observations, and comments at once. It means that you, the new family therapist, may, at times, find yourself in the role of more than a therapist. You may find yourself to be a mediator, a coach, a confidant, and a professional friend. You may be the only one in the family system (because you will become part of the system) who can clearly see the dynamics that keep the problem alive. The way that you share your observations, which then turn into interventions, is what the rest of this book is all about.

To begin, however, you will need to keep notes, both during and after the session is over. Notes serve many purposes. For you, the family therapist, they will keep you grounded as you record interactions that you hear about other family members onto the genogram. Notes also serve to remind you of the family’s story when they return to the next session.

Besides the genogram, you should keep notes of every session. Figure 1.7 displays a sample format that I share with practicum students for them to use during their sessions. The last question on the Therapy Notes sheet is helpful because it reassures the family therapist that he or she is on track and relays a sense of respect to the family for their opinion about the session. The question also helps keep everyone involved in the process and helps you, the therapist, to know what works best during therapy sessions.

FIGURE 1.7

Sample therapy note.

Source: Copyright by Linda Metcalf, 2009.

The Therapy Notes sheet can be altered to your family therapy model’s specifications. For example, if you use a solution-focused approach (see Chapter 12), you may add a line for the miracle question, which is a marvelous goal-setting question. If you use an experiential approach (see Chapter 7), you may add a line for your impressions of the family for later review. If you use a narrative approach (see Chapter 13), leave some blanks for language used by the client that you can use in your conversation with the client.

CONCLUSION

Becoming a family therapist involves more than reading and understanding theory. It involves practice. It requires drawing a genogram, listening intently for client language and goals, and stepping into a system that will teach you how it operates. It takes choosing a family therapy model that feels right to you and embraces your view of how families work. When you choose it, stay with it. On days when a session might not go as you wished, returning to the premises of your chosen model can help revitalize yourself and help you gather ideas for the next session.

It is important too, to tread softly into family territories and to do so with curiosity and understanding. Families will welcome the family therapist who empathizes and shares their concern, and then gently guides them toward change. The rest of this book provides insight into those strategies that will give both you, the family therapist, and your families, direction. It is my hope that you too will remember that when you deal with a system, you become part of it.

https://bcove.video/485EXTt

Podcast: The Practice of Marriage and Family Therapy: A Systemic Fairy Tale

Speaker: Linda Metcalf

REFERENCES

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Congress, E., & Kim, W. (2007). A comparative study on social work ethical codes in Korea and the United States: Focused on confidentiality, dual relationships, cultural diversity and impaired colleagues. Korean Journal of Clinical Social Work, 4(2), 179–192.Google Scholar
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McGoldrick, M., Gerson, R., & Petry, S. (2008). Genograms: Assessment and intervention (3rd ed.). W. W. Norton. http://multiculturalfamily.org/genograms Google Scholar
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KEY TERMS

Circular causality

The multiple transactions between family members and how each interaction affects other interactions.

Complementary escalation

One spouse or a family member’s attempt to give in to another family member to stop a behavior, which results in an escalation of the behavior.

Culturagram

A family assessment tool that provides a graphical representation of various aspects of individuals and their family’s culture.

Cybernetics

The interdisciplinary study that describes the vast interplay of networks involved with communication within a system.

Differentiation

The capacity of a person to manage his or her emotions while thinking rationally regarding his or her individuality and his or her connections to others.

Double bind

A dilemma in communication in which an individual or group of individuals receives two or more conflicting messages, where one message negates the other, prohibiting either response from being favorable.

Equifinality

The principle stating that an attempt to achieve a certain end can be approached and reached by many potential means.

First-order change

The idea that doing more or less of something we are already doing, such as raising the temperature on a thermostat, can be reversed and thus is not significantly different enough to create long-lasting change.

Genogram

A pictorial display of a person’s family relationships and medical history that goes beyond a traditional family tree by including hereditary traits, patterns, and relationships.

Homeostasis

A tendency for systems to maintain stability, balance, or equilibrium at all times.

Metacommunication

Communication that supports or contradicts verbal communication, often sending a message that is in direct conflict with the words used because of the physical traits exhibited when the communication occurs.

Morphogenesis

The evolutionary development of the structure of an organism or part that creates new organizational forms. The change can occur when environments change, thereby being adaptive, or change can occur as a result of positive feedback, which may be destructive.

Morphostasis

The process of retaining a structure, organization, or form in a system.

Negative feedback

Interactions that allow the family to respond superficially by adopting first-order changes that serve only to temporarily alleviate any threat to homeostasis yet do not result in long-lasting change.

Positive feedback

Interactions that allow the family system to acquire a new level of homeostasis by adopting more long-term and permanent solutions, such as adapting to an adolescent’s need for independence and growth.

Pseudohostility

Constant but superficial bickering that is used as a way of avoiding intimacy.

Pseudomutuality

A facade of togetherness, but little affection or real intimacy occurs.

Second-order change

A major transition that occurs within a system (or within an individual person) that leads to long-lasting change.

Symmetrical escalation

When a standoff occurs, leading to escalation between persons.

Systems theory

An interdisciplinary theory that studies the complex nature of systems and the interactions within the systems.

Triangle

A dynamic created when tension arises between two people, and a third person is engaged to relieve the tension between the original two people, who then focus on the third person, rather than dealing with the tension.

WEBSITES

GenoPro

http://genopro.com/genogram

Multicultural Family Institute

http://multiculturalfamily.org

Site Title

Family Dynamics and Therapy

Marriage and Family Therapy, 3rd Edition

Chapter 1: The Practice of Marriage and Family Therapy

INTRODUCTION

A VIEW OF THE FAMILY

A NEW VERSION OF AN OLD STORY

A HISTORY OF FAMILY THERAPY: ORIGINS AND CONCEPTS

FAMILY THERAPISTS ARE INFLUENCED BY THE MODELS THEY USE

FAMILY THERAPISTS THINK IN CIRCLES, NOT LINES

FAMILY THERAPISTS WATCH FOR COMMUNICATION PATTERNS AND MATCHING BEHAVIORS