Case Vignette

The Bean family was referred to family therapy at the request of the individual therapist for Pam Bean (not her real name), a high school junior who had been losing weight over the past year and had become amenorrheic for the last 6 months. During the year of her weight loss, her older sister, Ellen, had left for college. When asked about other changes in the family, Mrs. Bean, a 45-year-old schoolteacher, stated that her brother’s teenage son had committed suicide the year before. Mr. Bean, a 47-year-old software engineer, added that he had recently taken a new job that necessitated a great deal of travel. Mrs. Bean noted that Pam had been a cheerful child who could be counted on to make others laugh; however, over the last year she had become both withdrawn and moody. Mr. Bean’s relationship with Pam had been close until she reached puberty, but now he felt clueless about how to communicate with her. To make matters more complicated, Mr. Bean’s sister had committed suicide when she was a teenager, and while they were alone together during their parents’ travels. Mr. Bean had always felt responsible for his sister’s suicide. Pam’s sister, Ellen, a 19-year-old college freshman, was about 30 pounds overweight and she worried that Pam might die.

The Theory

This therapy is derived from principles of object relations and Freudian theory. The goal for psychodynamic family therapy, as with individual psychodynamic therapy, is more self-awareness, which is created by bringing unconscious material into conscious thought. At the heart of this practice is the notion that current family problems are due to unresolved issues with the previous generation. Interpersonal function is distorted by attachments to past figures and by the handing down of secrets from one generation to the next. The psychodynamically oriented family therapist wants to free the family from excessive attachment to the previous generation and wants to help family members disclose secrets and express concomitant feelings (e.g., of anger or grief). Change is created through insight that is often revealed in one individual at a time, in a serial fashion, as others look on.

The Practice

In order to loosen the grip of the past on the present, the therapist uses several tools (including interpretation of transferential objects in the room, interpretation of projective identification, and the use of the genogram to make sense of generational transmission of issues). In family therapy, transferential interpretations are made among family members, rather than between the patient and the therapist, as occurs in individual therapy. For example, when Mr. Bean says “I guess I am not an expert when it comes to female problems,” the therapist may have asked, “Who made you feel that way in your family of origin?” When he reveals that he has felt this way since his sister’s suicide, he comes to understand how an old lens distorts his current vision (i.e., he still feels so guilty about his sister’s death that he does not feel entitled to weigh in with opinions about his daughter’s anorexia).

Another important tool for dredging up the past is the interpretation of projective identification, which Zinner and Shapiro² have defined as the process “by which members split off disavowed or cherished aspects of themselves and project them onto others within the family group.” This process generates intrapsychic peace at the expense of interpersonal conflict. For example, Mrs. Bean may disown her need to control her impulses by projecting her perfectionism onto Pam. Simultaneously, Pam can disown her anger by enraging her parents with her anorexia. As these unconscious projections occur reflexively, they are more difficult for the individual to recognize and to own. Put another way, each family member behaves in such a way as to elicit the very part of the self that has been disavowed and projected onto another family member. The purpose of these mutual projections is to keep old relationships alive by the reenactment of conflicts that parents had with their families of origin. Thus, when Mrs. Bean projects her perfectionism onto Pam, she re-creates the conflict she had with her own mother, who lacked tolerance of impulses that were not tightly controlled.

In part, the psychodynamic family therapist gathers and analyzes multigenerational transmission of issues through the use of a genogram (Figure 13-1), a visual representation of a family that maps at least three generations of that family’s history. The genogram reveals patterns (of similarity and difference) across generations—and between the two sides of the family involving many domains: parent-child and sibling roles, symptomatic behavior, triadic patterns, developmental milestones, repetitive stressors, and cutoffs of family members.²

Figure 13-1 The Bean family, October 2006.

In addition, the genogram allows the clinician to look for any resonance between a current developmental issue and a similar one in a previous generation. This intersection of past with present anxiety may heighten the meaning and valence of a current problem.³ With the Bean family (including two adolescents), the developmental imperative is to work on separation; this is complicated by the catastrophic separations of previous adolescents. Their therapist might discover a multigenerational pattern of role reversals, where children nurture parents, as suggested by the repetition of failed attempts of adolescents to separate from their parents.

The Proponents

James Framo⁴ invites parents and adult siblings to come to an adult child’s session; this tactic allows the past to be revisited in the present. This “family of origin” work is usually brief and intensive, and consists of two lengthy sessions on 2 consecutive days. The meetings may focus on unresolved issues or on disclosure of secrets; it allows the adult child to become less reactive to his or her parents.

Norman Paul⁵ believes that most current symptoms in a family can be connected to a previous loss that has been insufficiently mourned. In family therapy, each member mourns an important loss while other members bear witness and consequently develop new stores of empathy.

Ivan Boszormenyi-Nagy⁶ introduced the idea of the “family ledger,” a multigenerational accounting system of obligations incurred and debts repaid over time. Symptoms are understood in terms of an individual’s making sacrifices in his or her own life in order to repay an injustice from a previous generation.

Murray Bowen⁷ stressed the dual importance of the individual’s differentiation of self, while maintaining a connection to the family. In order to promote increased independence, Bowen coached patients to return to their family of origin and to resist the pull of triangulated relationships, by insisting that interactions remain dyadic.

The Metaphor

This therapist is like a lead-testing scientist who tests for levels of lead in one’s garden to assess the legacy of toxins from previous homeowners. Only when the true condition of the soil has been revealed is the current homeowner free to make decisions about whether the soil is clean enough to plant root vegetables; somewhat contaminated, so that only fruit-bearing bushes will be safe; or so toxic that only flowers can be grown without hauling in truckloads of clean, fresh soil. Examination of the past enables the current gardener, and, by analogy, parents, to make informed choices about how the current environment needs to be adjusted and what kind of growth is allowable.

The Theory

In contrast to the psychodynamic family therapist’s focus on the past, the experiential therapist is primarily concerned with the here and now. In this model, change occurs through growth experiences that arise in the therapy session; experiences are aimed at the disruption of familiar interactions among family members. The experiential family therapist tries to make something surprising and unexpected happen, thereby amplifying affect. In general, the expression of feeling is valued over the discovery of insight. In its embrace of experience, this model is atheoretical and it can best be understood in light of its practice.

The Practice

The experiential family therapist is interested in small interactions that take place during the session. For example, the therapist might ask Pam, “Who told you about the meeting today, and what was said?” This therapist might also ask each family member, “What would you wish for right now, here today, that would make your life better?” The therapist would hope to amplify any communication that conveyed warmth and closeness and would interrupt any antagonistic communication. He or she might ask Mrs. Bean to look her husband in the eye, to hold his hand, and to ask for his help in dealing with Pam’s anorexia.

This therapist uses psychodramatic, or action-oriented, techniques to create a new experience in the therapy session. She or he might “sculpt” the family, literally posing them to demonstrate the way that the family is currently organized—for example, with mother and Pam sitting very close together, with Mr. Bean with his back to them, and with Ellen outside of the circle. This therapist would hope to heighten feelings of frustration and alienation, and then to relieve those feelings with a new sculpture that places the parents together. These sculptures would serve to increase affect, to create some focus away from the identified patient, and to demonstrate the merits of the parents who are standing together to combat their daughter’s anorexia.

The Proponents

Virginia Satir,⁸ an early luminary in family therapy (a field that was largely founded by men), believed that good communication depends on each family member feeling self-confident and valued. She focused on what was positive in a family, and used nonverbal communication to improve connections within a family. If families learned to see, to hear, and to touch more, they would have more resources available to solve problems. She is credited with the use of family sculpting as a means to demonstrate the constraining rules and roles in a family.

Carl Whitaker⁹ posited that most experience occurs outside of awareness; he practiced “therapy of the absurd,” a method that accesses the unconscious by using humor, boredom, free association, metaphors, and even wrestling on the floor. Symbolic, nonverbal growth experiences followed, with an aim toward the disruption of rigid patterns of thought and behavior. As Whitaker puts it, “psychotherapy of the absurd can be a deliberate effort to break the old patterns of thought and behavior. At one point, we called this tactic the creation of process koans” (p. 11)⁹; it is a process that stirs up anxiety in family members.

The Metaphor

This type of therapist is like a folk artist who takes commonplace objects and transforms them into works of art. The viewer is surprised to find that a box of mismatched buttons could become the wings of a butterfly. Making the unfamiliar out of the familiar, and using playful techniques to do so, are key features of experiential family therapy.

The Theory

The structural family therapist focuses on the structural properties of the family, rather than on affect or insight. Structure is defined by several features: by the rules of the family (e.g., what subjects can be discussed at the dinner table? What kind of affect is acceptable to express?); by boundaries within the family (e.g., do the children stay clear of marital conflict? Do siblings have their own relationship?); by boundaries between the family and the outside world (e.g., do parents easily request help from outsiders, or are they insulated?); and by the generational hierarchy (e.g., who [the parents, the adolescent, or the grandparents] is in charge of decision-making?). In this model, change occurs when the structure shifts and when symptoms are no longer needed.

This therapist approaches a family with a blueprint of what a normal family should look like, with some allowance made for cultural, ethnic, and economic variations. Most broadly stated, a high-functioning family should have well-defined parental, marital, and sibling subsystems; clear generational boundaries (with the parents firmly in charge); and flexible relationships with outsiders. The family with an eating-disordered member would be expected to have four structural fault lines: first, to be enmeshed (with little privacy and blurred boundaries between the generations so that children may be parenting parents); second, to be excessively overprotective (so that attempts by the children at autonomy are thwarted); third, to be rigid in the face of change (so that any stressor may overwhelm the family’s resources); and fourth, to be relatively intolerant of individual differences (so that the family’s threshold is low for individuals who voice an unpopular or maverick position).

The Practice

This therapist joins the Bean family by supporting the existing rules of the family and by making a relationship with each member. These individual relationships may later be used to restructure the system, for example, by empowering the parents. The therapist, assessing the formal properties of the family, would earmark the shaky alliance between the parents and the lack of well-defined marital, parental, and sibling subsystems. The boundaries within the family are judged as enmeshed, with members talking about each other’s feelings rather than about their own. Between the family and the outside world, the boundaries are rigid, since the Beans have not asked for any help from extended family or school personnel. This family therapist describes the family as involved in a pattern of conflict avoidance called triangulation, with each parent wanting Pam to take his or her side, putting her into an impossible loyalty-bind.

As assessment becomes treatment, this therapist might challenge enmeshment by imposing a rule about communication, whereby each member should speak only for herself or himself. The therapist would try to challenge the lack of a generational hierarchy by manipulating space. For example, the therapist might ask Mr. and Mrs. Bean to sit side-by-side while also instructing Pam and Ellen to leave the room for part of the interview. To challenge the rule that conflict should be avoided, particularly regarding disagreements about how to get Pam to eat, this therapist would have the couple sit together and create a plan for the next meal while the therapist blocks any attempt to involve Pam. The family might then role-play a family meal (in a session) to illustrate Pam’s role in their power struggle. Additionally, Pam and Ellen could be invited to have their own meeting to explore and to shore up their relationship.

The Proponents

Salvador Minuchin,^10,11 regarded as the founding father of structural family therapy, worked extensively while head of the Philadelphia Child Guidance Clinic with inner-city families and with families who faced delinquency and multiple somatic symptoms. Both populations had not previously been treated with family therapy. He delineated how to assess and to understand the existing structure of a family, and pioneered techniques such as the imposition of rules of communication, manipulation of space, and use of enactments to modify structure.

The Metaphor

This therapist is like a building inspector who renders an opinion about the stability of a structure and guides the owner to decisions regarding a large-scale renovation or merely a cosmetic touch-up. The inspector does not care about either the furnishings or the paint colors, but is concerned with whether the walls are solid, the locks are in working order, and the wiring is functional and safe. Everything else follows smoothly if the house is solidly built.

The Theory

The strategic family therapist believes that change occurs when maladaptive behavioral sequences are interrupted. This therapist differentiates between two kinds of change: “first order,” in which commonsense solutions to initial difficulties actually become unsolvable problems; and “second order,” where random events or therapeutic interventions disrupt first-order solutions. These therapists view families as fundamentally homeostatic, or invested in maintaining the status quo even at the expense of a symptomatic family member. Consequently, this therapist anticipates a power struggle between him or her and the family and develops strategies to destabilize the power structure in the family. One such strategy involves the use of paradox, which is used to meet the family isomorphically at the time when they present for therapy. In essence, the position taken by the family is, “Help us get rid of the symptom, but don’t make us change.”

The Practice

The therapist inquires about the behavioral sequences that occur around the family’s problem to understand the first-order solutions that the family has devised, solutions that themselves have become problems. The therapist is interested in the behaviors that occur when Mr. and Mrs. Bean attempt to get Pam to eat. For example, if Mr. Bean says to Pam, “Do you want to eat your sandwich?” and she says “No,” he tries to reason with her. At this point, Mrs. Bean might interrupt and say, “Just eat,” which annoys Mr. Bean, who says, “Let her finish eating on her own timetable.” He adds, “Perhaps there is something you’d prefer to a sandwich.” When Pam doesn’t seem to respond, Mrs. Bean says, “Your not eating is just killing me.” Pam responds by stating, “I won’t eat even if you force the food down my throat.” The strategic therapist notes that the more Mrs. Bean threatens, the more Pam protests; the more she protests, the more Mr. Bean tries to appease. But when he appeases, Pam still doesn’t eat, and Mrs. Bean escalates her argument. Each parent feels that he or she is offering a logical solution: Mrs. Bean is insisting that Pam eat, and Mr. Bean is trying to leave the eating up to Pam. Both are first-order changes that leave Pam in an intolerable bind—to choose one parent over another.