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B O X 5 . 1 R E S E A R C H R E P O R T
HOW DISTURBED FAMILIES DEAL WITH EMOTIONS
One of the major contributions by Wynne and his colleagues was the observation that schizophrenic families deal with emotions, both positive and negative, in false and unreal ways. Wynne termed these patterns pseudomutuality and pseudohostility. He labeled as a rubber fence the shifting boundaries surrounding these families, allowing some outside information to be introduced but others to be deemed unacceptable and kept out.
Wynne offered the term pseudomutuality— giving the appearance of a mutual, open, and understanding relationship without really having one—to describe how such families cover up conflict and conceal an underlying distance and lack of intimacy between their members. Pseudomutuality is a shared family maneuver designed to defend all of the members against separation from one another as well as to avoid pervasive feelings of meaninglessness and emptiness in their lives. One family member typically is designated the “identified patient,” permitting the perpetuation of the myth by others that they themselves are normal. A person who grows up in a pseudomutual family setting fails to develop a strong sense of personal identity, since the predominant family theme is
fitting together, even at the expense of developing separate identities. Indeed, the effort to cultivate a separate sense of self is viewed as a threat to family unity. This lack of identity handicaps the person from engaging in successful interactions outside the family and makes involvement within his or her own family system all-important.
Families with pseudohostility maintain a relationship by engaging in continuous superficial bickering, masking their deeper need for tenderness and affection. Doing so serves to cover up their need for intimacy, which they have trouble dealing with directly, and impairs gaining a realistic sense of their relationship. Pseudohostility in families represents an effort to disguise underlying chronic conflict and destructive alignments within the family.
Wynne labeled the resistance to outside influences in a pseudomutual family as a rubber fence, a changeable situation in which the specific boundaries of the family may shift, as though made of rubber, allowing in certain acceptable information, but unpredictably or arbitrarily closing in order to keep unacceptable information out. Here the rules are in a state of continuous flux, as the family attempts to minimize threatening contact with the outside world.
Despite these deficits in research design, considerable enthusiasm was aroused by this new field of clinical inquiry into the baffling etiology of schizophrenia. A group of schizophrenia/family researchers met for the first time at the 1957 national convention of the interdisciplinary American Orthopsychiatric Association. Although no separate organization was formed by this still-small group of researchers, they did learn of each other’s work. The subsequent cross-fertilization of ideas culminated in Intensive Family Therapy (Boszormenyi-Nagy & Framo, 1965), a report by 15 authorities on their research with schizophrenics and their families. The clinical investigations that were initiated a decade earlier had laid the groundwork for the emerging field of family therapy.
MARRIAGE AND PRE-MARRIAGE COUNSELING
The fields of marriage and pre-marriage counseling, precursors of family therapy, are based on the concept that psychological disturbances arise as much from conflicts between persons as from conflict within a person. Focusing on some of the unique
B O X 5 . 2 C L I N I C A L N O T E
Social Workers and Family Therapy
Social workers are the unheralded pioneers of what later became the field of family therapy. From the founding of the first citywide charity organization in 1877 in Buffalo, N.Y., social workers have been at the forefront of delivering services to needy families. Family casework is an integral part of social work preparation; and the Family Service Associations of America, beginning in 1911, have been composed of
social work agencies specializing in the treatment of marital and family problems. Broderick and Schrader (1991) suggest that a case could be made that both marriage counseling and family therapy had their origins within the broader field of social casework. Beginning with Virginia Satir, many leading family therapists have come from a social work background (as mentioned throughout this text).
problems of this special form of coupling, early marital counselors (gynecologists and sometimes other physicians, lawyers, social workers, psychologists, and college professors who were family-life specialists), viewed as “experts,” attempted to provide answers for people with sexual and other marital difficulties (Broderick & Schrader, 1991). Clergy were especially prominent in offering formal premarital counseling, often as part of an optional or mandatory preparation program before a wedding (Stahmann & Hiebert, 1997).
If we assume that people have always been ready to advise or seek advice from others, informal marriage counseling has certainly existed for as long as the institution of marriage. On the other hand, formal counseling by a professional marriage counselor probably began somewhat over 70 years ago in the United States, when the physicians Abraham and Hannah Stone opened the Marriage Consultation Center in NewYork in 1929. A year later, Paul Popenoe (a biologist specializing in human heredity) founded the American Institute of Family Relations in Los Angeles, offering premarital guidance as well as aid in promoting marital adjustment. Family educator Emily Mudd started the Marriage Council of Philadelphia in 1932 and later wrote what is thought to be the first textbook in the field (Mudd, 1951). In 1941, largely through Mudd’s prodding, the American Association of Marriage Counselors (AAMC) was formed. The AAMC brought together various professionals, primarily physicians, but also others concerned with the new interdisciplinary field of marriage counseling. This organization has led the way in developing standards for training and practice, certifying marriage counseling centers, and establishing a professional code of ethics (Broderick & Schrader, 1991).
Similarly, the first documented premarital intervention program was offered by Ernest Groves (later to be first president of AAMC) in 1924 in a family life preparation course at Boston University. Through the mid-1950s the small quantity of pertinent literature available often focused on such individually oriented topics as physical examinations by physicians as part of premarital counseling efforts. Assistance offered by clergy was apt to be spiritual, educational, and informational, and to have an intrapsychic and religious orientation rather than attend to the couple’s interpersonal relationship. If relationship problems were addressed at all, they were likely to be seen as a by-product of a problem within one or both of the prospective newlyweds
ORIGINS AND GROWTH OF FAMILY THERAPY 109
(Stahmann & Hiebert, 1997). Rutledge’s survey of AAMC members in 1966 found very few professionals performing premarital counseling.
By the mid-1960s, it was still possible to characterize marriage counseling (and pre-marriage counseling) as a set of practices in search of a theory (Manus, 1966). No breakthrough research was being carried out, no dominant theories had emerged, no major figure had gained recognition. The AAMC published no journal of its own. If practitioners published at all, they apparently preferred to submit articles to journals of their own professions. By the 1970s, however, the situation began to change. Among others, Olson (1970) urged an integration of marriage counseling and the emerging field of family therapy, since both focus on the marital relationship and not simply on individuals in the relationship. In 1970 the AAMC, bowing to increased interest by its members in family therapy, changed its name to the American Association of Marriage and Family Counselors (in 1978, it became the present American Association for Marriage and Family Therapy). In 1975, the organization launched the Journal of Marriage and Family Counseling (renamed the Journal of Marital and Family Therapy in 1979). By then, as Broderick and Schrader (1991) observe, marriage counseling (and by implication pre-marriage counseling) had “become so merged with the more dynamic family therapy movement that it had all but lost its separate sense of identity”(p. 15).
The history of sex counseling parallels that of marriage counseling, and the two disciplines had many of the same practitioners. Moving to become a separate specialty, the American Association of Sex Educators and Counselors was formed in 1967 and set up standards and granted certificates for qualified sex therapists. Since 1970, two journals, the Journal of Sex and Marital Therapy and the Journal of Sex Education and Therapy have disseminated information in this fast-growing therapeutic movement.
What exactly is marriage counseling—or, as it is more frequently called, marital therapy? Not considered to be as deeply probing, intensive, or as prolonged as psychotherapy, marriage counseling, as initially practiced, tended to be short-term, attempted to repair a damaged relationship, and by and large dealt with here-and-now issues. Unlike psychotherapy, which presumably probed inner meanings, marriage counseling addressed reality issues and offered guidance to troubled couples in order to facilitate their conscious decision-making processes. Early premarital counseling, which tended to be even less attentive to relationship issues or why this couple chose one another, was content to help the pair prepare for marriage by becoming aware of any neurotic individual problems that might cause later hardships.
Couples entering premarital therapy may be doing so as a kind of checkup on the viability of their relationship before marrying—or, more significantly, one or both may fear that some underlying conflict remains unresolved and may lead to a further deterioration of their relationship once married. In some cases, such counseling may be mandated by religious groups to which they belong. When one or the other (or both) has been divorced, particularly if there are children from a previous marriage, such caution is especially pertinent (Goldenberg & Goldenberg, 2002).
Most people who seek help for their marriage are attempting to cope with a crisis (such as infidelity, threat of divorce, disagreements regarding child rearing, money problems, sexual incompatibilities, ineffective communication patterns, conflicts over power and control) that has caused an imbalance in the family equilibrium. Each partner enters marital therapy with different experiences, expectations, and goals and with different degrees of commitment to the marriage. At least one of the partners is
110 CHAPTER FIVE
C L I N I C A L N O T E |
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Two persons seeking couples therapy rarely arrive |
decision to separate. He or she may continue for a |
with the same degree of motivation or identical |
brief time to go through the motions to give the |
agendas. When therapeutic progress is at a stand- |
appearance of making the effort to reconcile, but in |
still for no discernible reason, the therapist might |
reality is preparing to leave his or her spouse for the |
consider that one partner already has made the |
therapist to treat individually. |
usually invested in staying married or they would not seek professional help, but the strength of the determination to stay together may vary greatly between them.
As marital counseling began to focus on the couple’s troubled relationship, conjoint therapy, in which a couple works with the same therapist together in the same room and at the same time, has replaced earlier efforts to counsel each partner separately.
THE CHILD GUIDANCE MOVEMENT
Two additional streams of thought and clinical development, sometimes overlooked, deserve mention for their influences in the evolution of family therapy. The child guidance movement, emerging early in the twentieth century, was based on the assumption that if emotional problems did indeed begin in childhood—as Freud and others were arguing—then early identification and treatment of children could prevent later psychopathology.
Alfred Adler, an early associate of Freud’s, was especially cognizant of the key role early family experiences played in determining later adult behavior. Adler helped found the child guidance movement in Vienna in the early 1900s, and while he did not work therapeutically with entire families, he did influence one of his disciples, Rudolph Dreikurs, who later emigrated to the United States, to expand child guidance centers into family counseling centers (Lowe, 1982). In 1924 the American Orthopsychiatric Association, largely devoted to the prevention of emotional disorders in children, was organized. Although child guidance clinics remained few in number until after World War II, they now exist in almost every city in the United States. They provide major settings for identifying and treating childhood psychological disorders, and are especially valuable in involving parents and attending to the larger social systems from which the presenting problem evolved.
Early treatment programs were team efforts, organized around a psychiatrist (psychotherapy), a psychologist (educational and remedial programs), and a social worker (casework with parents and outside agencies). It was standard procedure (and still is in traditional clinics) for the parent (in most cases the more available mother) to visit the clinic regularly for treatment, usually seeing a different therapist from the one working with her child. This collaborative approach has now evolved into conjoint therapy sessions in most clinics, more than likely involving both parents as well as siblings of the identified patient. Rather than viewing the child as the identified patient with intrapsychic problems, or the parents as the source of the child’s difficulties, today’s outlook focuses on pathology between all the family participants. Child