532
THE FIBLD OF FAMILY THERAPY
1. �h � a �e the practitioners of family therapy, by profes sional �1sc1pline and by demographic characteristics, and what mfluenced them to become family therapists? 2. Who are the patients, and h ow did they get into family therapy? 3. �ha� are the goal s pursued in family therapy, and what in d1cat !on� and contraindications are applied to the selection or re1 ection of patients for family therapy? 4. �hat con �e�tual approaches a re used by family therapists . m their thm�ng about treatment programs? 5. What techm ques are ut ilized in the conduct of family therapy programs? 6 . From what points of view do therapists conduct family treatment? 7. Wh �t ethical problems are encountered in the practice of famtly therapy? In the chapters that follow, each of these questions is treated in turn. The field �f family therapy i s expanding rapidly both in num _ bers of practicmg _Pr�fessional s and in varieties of practice. An snapshot of an entity m r apid change is likely to be blurred. Fu/ thermo �e, �other snapshot taken sh ortly after would likely re veal a s1gmficantly different picture. A report on techniques in a s tabI e w�ll- established practice would have a good chance of _ '. ret�m?g Its relevance for a decade ; a report on family thera . which is m a state of rapid transition, is likely to be quickly sup��� seded. Progre ss i � th � state of the art, then, will very quick! make . ��� report h1stoncally rather than operationally useful. !ts con n utors, however, have mad e every effort to assure that it i s a u � ll and accurate refl �ction of the field during the winter of 9�6 6:• !h_ese contnbutors represent all three major mental h hea t d1sc1plmes and all major ge ographic areas in the United
INTRODUCTION
533
States. Those who participated in this effort not only are them selves active in the field of family therapy, but have frequently visited major psychiatric teaching and training centers and seen at first hand the emergence of new developments. One con tributor, as editor of Family Process, has visited and observed ongoing work in virtually every center in the country where family therapy is taught. The preparation of this report has in volved a careful review of the literature and of the papers pre sented at the several sympo sia on family therapy within the last few years. Appendix 1 includes a bibliography of 200 articles and books specifically addres sed to family therapy, excluding the vast literature of anthropology, sociology, and social psych ology on family structure, o rganization, and process. A questionnaire, re produced as Appendix 2, w� distributed to 520 persons attend ing regional and national meetings of their professional organ izations,* and the respon ses of the 312 persons who filled in the questionnaire have been analyzed. To appreciate the purposes of this repo rt, one should keep the se questionnaire data in their appropriate perspect ive. It was not intended, nor would it be feasible now, to address th e entire population of family therapists or to designate a statistically representative sample of them. It is, therefore, not intended th at the numerical tabulations be interpreted as reflecting actual distribution of responses among all mental health profe ssionals engaged in the practice of family therapy during the period February 196 6 to February 196 7, when the questionnaires were completed. Rather, it was intended: ( 1) to gather information about a very b road range of therapists, families in therapy, prac tices, concepts, and problems so that practitioners who had not published and whose work was not generally known could con tribute information; and ( 2) to make a preliminary probe, very * All persons attending sessions or panels that included papers on topics involving the family at the annual meetings of the American Orthopsychiatric Association and the American Psychiatric Association in 1966 were invited to fill out questionnaires, as were individual subscribers to Family Process.
2
THE FAMILY'S ROUTE TO FAMILY THERAPY
THE FAMILY'S ROUTE TO FAMILY THERAPY
There is no doubt that during the past few years there has been a growing interest in family therapy. Although only 26 per cent of the respondents answered the question about numbers of referrals, 48 percent of those who did reported an increase in the referrals they received over the preceding year; only 2 per cent reported a decrease; the remainder indicated no change. It would appear t�at mor� �nd mo�e people, laymen and professionals, are learnmg of _ this mnovative method and are turning to it as a psychological problems. Another in �e a�s of wo�kmg through _ dication of this growmg interest is the increase in programs and works�ops focused on family therapy at professional conferences. Sect1on _ II.3 of the questionnaire (Appendix 2) sought to ascert�m the so�rc�s of referrals among our respondents . The followmg table indicates the percentages of family therapists who reported receiving referrals from each of several medical sources . Percentage of Respondents Receiving Referrals
Medical Sources Psychiatrist General practitioner Pediatrician Internist Psychoanalyst
58
51 33 31
25 540
541
These percentages include any level of referral from a few to many cases. These figures suggest that, despite their tradition of the individual-patient model, psychiatrists and p sychoanalysts are frequent endorsers of a family therapy approach. It sometimes happens that these professionals will use family therapists as consultants to individual therapy when they encounte r impasses in treatment because of family conflicts or resistances. Occasion ally, when there is a family involved with several therapists for its individual members, a family therapist becomes necessary to integrate this network of therapies and to consult with those family members not under treatment. The interest of general practitioners in familx therapy is sig nificant. When the general practitioner treat s illnesses for the entire family, he often becomes aware of conflicts and tensions in family interrelationships and is likely to look toward family therapy as a possible remedy. Because of this, a number of post-,, graduate courses in family mental health and pathology have been evolved to broaden the skill of the general practitioner. To educate the nonpsychiatric physician in matters of family psycho therapy, innovative approaches have been developed to teach family medicine to the medical student to enhance his clinical s kills. "Psychiatric Family Consultations," by Treusch and Grotjahn, * outlines a technique by which a family physician can utilize family therapy to understand better the interde pendence between some physical disorders and relationships among family members. Of the community sources for referrals to family therapists, the school was most frequently reported ( by 54 per cent). Thirty nine per cent reported referrals from the police or court, and 34 per cent reported referrals from a church. These figures suggest which community organizations are turning toward family therapy and why. The school, for example, deals not only with
* See Bibliography, Appendix 1.
542
THE FIELD OF FAMILY THERAPY
st udents but a lso with their parents in reporting on student progress and soliciting conferences for the review of problems. Thus the school often becomes aware of family problems and, in making recommendations for psychiatric therapy, would be likely to prefer a treatment mode that could encompass both the st udent and his f amily. Both the police and the cour t deal with alter cations b etween spouses and delinquents and, to some extent with families that nurture these problems. They are thus inclined to view family therapy as a means for ameliorating such prob lems. Church referra ls may reflect an increased awareness in pastoral counselors of the relationship between individual distress and family difficulties. Surprisingly, only 19 per cent of our respondents reported ref �rral � from the children's agen cies, and only 1 O per cent from re�1dent1al centers for children. This may suggest that child onented treatment centers tend to cling to the traditional focus on the child's pathology. The fact that many of the child ren und�: their care come from fragmente d and severely disturbed _ fam1!1es w�th a low l�vel of child-caring capability may preclude cons1de�a ti�n �f faml ly therapy by social wor kers and therapists at such 1 �stlt utions. Ther e is a growing awareness, however, that _ chlld�en m pl acement tend to replicate thei r parents' behavio r _ _ later m the1r hves and eventually place their own children. Some p lacement agencies, therefore, have endeavored to prevent place ment by providing multiple therapeutic services to the entire family and, wh ere placement is unavoidable, to work with the family toward the eventual reintegration of the extruded child into the family. Responses to the que stionnaire indicated a number of self e � ��rr �s, that is, �ati ents seeking family therapy on their own 1mt1at1ve after heanng of it from other patients or from the mass media. Thirty-eight per cent of the families were reported to have re quested family therapy for th emselves, including 21 per cent
THE FAMILY'S ROUTE TO FAMILY THERAPY
543
who had heard of it from other families, 9 per cent who had learned of it from newsp ap ers or magazines, and 8 per cent whose information had come from TV or radio. The potential use of mass media for bringing to p ublic attention the concepts and possibilities of all modes of therapy has scarcely been explored and merits careful consideration. Furthermore, none of the respondents, all car etakers, were q uestioned about the influence of mass media on themselves. It might also be useful to assess the potentialities of these media for increasing awareness of therapeutic modalities and innovative app roaches among caretaking professionals. . A cautious note in this conn ection is necessary. The eVIdence of family disorder and breakdown, the extent of youthful unrest, rebellion, and alienation from the p arental generation is so great that people in need will clutch at any straw. It is, therefore, essential in utilizing the mass media not to make unrealistic claims for the family app roach or to "oversell" it. If the public's e xpectations for services p romising some degree of success are stimulated unrealistically and then disappointed, psychiatry c.lm e xpect a backlash. Whether through the mass media or any other educational approach, the newness of the method has to be acknowledged and its goals made as clear as possible. Precisely because the treatment of the family unit offers a link that has been missing between the individual and the community, it seems to "make sense" for many p eople, yet it need not be presented as a panacea, a substitute for all other approaches, or even appro priate in all cases as a total self-contained service. This is particularly important at this time when community-based psy chiatric services are being set up and expande d everywhere and the use of the family therapy app roach p romises to be among the major services of community psychiatry. In respect to the decision to employ family therapy as a mode of treatment, almost 7 5 per cent of the respondents indicated that,
544
THE FIELD OF FAMILY THERAPY
in over two-thirds of their cases, thei r e valuation of the presenting pro�lem was a major consideration. Most of the respondents mdica ted that, for half of their cases, individual treatment devel oped into family therapy. There were fewer reports of moving from the treatment of a marital pair to the treatment of the whole family, possibly because of spontaneous improvements in children accompanying a stabilization of the marital situation, or possibly because therapists working with marital pairs tend to overlook the family context of which the marital relationship is one sub system. Since th e number of respondents who answered this ques tion ( II.4) was con siderably sma ller than the total popu lation of respondents, any a ssessm ent of the data s hould await a follow-up, perhaps in two or three years. These data indicate that family therapy is beginning to have an impact on both professionals and laymen. Community institutions and med�cal men are recommending it more f requ ently; patients are leammg about it from other families and from m ass media. Yet other responses indicate that the acceptance of this mode of _ treatment is, at best, gradual. Respondents were asked about the settings for their family treatment : private practi ce, research or training project, pastoral or school setting, or mental health facility. Of the 1187 families report ed on in this pa rt of the questionnaire, only 2 per cent were seen under the auspices of a training project. This suggests that our sample consists primarily of service-oriented practitioners who ra rely teach family therapy. Most training institutions do not provide this kind of teaching in their curriculum. Only 3 p er cent of the sample indicated that they were involved in research-another indication that family therapy is, at this point, almost exclu sively the province of service programs with f ew efforts toward cont rolled studies. The sample included no students i n psychiatric socia l work, though both psychology and psychiatry were represented at the student level.
THE FAMILY'S ROUTE TO FAMILY THERAPY
The Slow Growth of Family Therapy
545
est to the sl_ow The questionnaire yielded other data that att of the therapists growth of family therapy. Forty-eight per c�nt only _16_ per cent in private practice who responded were treatmg ractitlo�ers saw of the families reported on; nearly half o� the p , car�takmg pro only one or two families each week. Obviousl� th this approach. fessional s are slowly acquainting themselves wi ted by these re rea t s The total number of families and couple the tota l number of rerson s spondents i s slightly in excess of Although these the�a_rists �re seen in individual psychotherapy. traditional m using family therapy, they lean strongly on the ch of the re oa r app dividual treatment mode. This pluralistic and fam�ly therapy, !ndicat�s a spondents, using both individ�al _ ap utlc practice. period of transition and expenmen�ation m the� : antly low. Figures on diagnostic evaluations we:e. sigmfi: y therapy, l i fam mg Thirty-five per cent of the therapists practic n r ce t of_ those 19 per cent of those treating couples, and 22 r: nostic evaluations du�g th e seeing individuals performed diag of rof essi nals preceding 12 months . It appears that this min?rity p s um�ts to anou v do diagnostic evaluations only when referrmg s many who t:eat other professionals for treatment. Or, perh_ap _ m erms of diag families, couples, and individu als do not th�nk � ediate tre atmen t nostic evalu ation but r ather in ter ms of imm reatment implies t f rom thei r first contact with patients. If, indeed, tion of t reatm ent intervention at the very first session, a redefini related not only to versus diagnosis is needed. This p roblem is family therapy but to all forms of treatment. . n pose� an addi The whole question of diagnostic evaluati? t concerned with family or con tional p roblem for the therapis termi nology used for joint marital treatment. The traditional s not apply to a group individuals in individual psychotherapy doe cal maladaptations of patients. One cannot label the psychologi
546
THE FIELD OF FAMILY THERAPY
of a whole family with one tenn; the malfunctioning and prob lems may vary sharply from one member to another. What is needed, then, is a new nomenclature, a new method whereby the problems of an entire family can be diagnosed systematically and validly. Question II.2 of the questionnaire (Appendix 2) asked those respondents working in mental health facilities to specify the �ype of t?e faci �ty. Twenty-one per cent reported that they work m a famtly service agency; 88 per cent of these are social work �rs and 4 p�r cent consulting psychiatrists. Twenty per cent work m co�m?ruty mental health centers; of these, 37 per cent are psychi�tnsts, 33 per cent social workers, and 18 per cent psy _ ranked third among respondents, chologists. The state hospital followed by the child guidance clinic and the private mental hos pital. It is clear that the family service agency, which formerly treated each family member separately, has begun to see family groups. One reason for this shift in emphasis is the feeling in such agencies that there is a need for more effective and efficient pro grams to deal with the growing pressures and tensions in the mod em family. In November 1967, Clark Blackbum, General Direc tor of the Family Service Association of America, noted in a statemen� �o the press that "service programs need to change to help families successfully cope with their changing environment and personal tensions." He stated that "While individual counsel ing is still us��ul for many people, some of the traditional ways of _ servmg families are outmoded." This shift of focus from the individual to the whole family is also reflected in the community mental health center. Respondents were also asked to specify the number of hours per week they spent at these various mental health facilities. Forty per cent reported 20 hours or less at these settings; 60 per cent reported more than 20 hours; only 3 per cent of the latter group reported more than 40 hours per week. These data suggest that,
THE FAMILY'S ROUTE TO FAMILY THERAPY
547
for many practitioners, work in the public-oriented sector is part time. Among all respondents, 46 per cent wor� in a� outRatient service setting, while only 24 per cent work m an mpatlent �ent�l health facility. Since in an inpatient service setting the patient ts separated from his family and from his community environment, the tendency to use family therapy in the treatment of such a patient is reduced. Family therapy S��ms mor� relev�t to t?e outpatient service since it implements t�e resolution of difficulties _ with community-related persons, particularly the family. The percentage of respondents working in inpatient servic_es suggests, however that such institutions are beginning to consider the pa tient's life in the community and to include the whole family in working toward a resolution of the prob!e�. . . Thus, the questionnaire appears to mdicate that while family therapy is attracting a good deal of n?tice and interest, by and . large it is still viewed as an innovative approach, mamly the province of caretakers interested in trying new methods and theories. It has not yet become sufficiently established to be in cluded in the curriculum of most teaching institutions or in the treatment orientations of many inpatient services. Thus, most families arrive at family therapy through advice of various care taking professionals, community organizations, or a�quaintances who have been attracted to this innovative therapeutic approach. One interesting possibility, not at all adequately answered by the questionnaire, is the idea that some turn t?. family therapy because of failure in other therapeutic modahtles, such as m dividual treatment. It seems possible that some mental health workers, as well as families, who have experienced failure in the use of other more traditional forms would try family therapy sim ply because it is a different and somewhat new approach. Un fortunately, however, there have been ho comprehensive s�udies made of the incidence of failures and the reasons for them m the different modes of therapy. If such data could be garnered, it