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8 A.M. 9 A.M. 10 A.M. 11 A.M. 12 Noon

Fig. 1. Change in Free Fatty Acid, the Collins family

Families and Family Therapy

the children's "physiological lability" showed that there was no obvious difference in their individual responsivity to stress. Yet these two children, with the same metabolic defect, having much of the same genetic endowment, and living in the same household with the same parents, presented very different clinical problems. Dede was a "superlabile diabetic"; that is, her diabetes was affected by psychosomatic problems. She was subject to bouts of ketoacidosis that did not respond to insulin administered at home. In three years, she had been admitted to the hospital for emergency treatment twenty-three times. Violet had some behavioral problems that her parents complained of, but her diabetes was under good medical control.

During the interview designed to measure the children's response to stress, lasting from 9 to 10 A.M., the parents were subjected to two different stress conditions, while the children watched them through a one-way mirror. Although the children could not take part in the conflict situation, their FFA levels rose as they observed their stressed parents. The cumulative impact of current psychological stress was powerful enough to cause marked physiological changes even in children not directly involved. At 10 o'clock the children were brought into the room with their parents. It then became clear that they played very different roles in this family. Dede was trapped between her parents. Each parent tried to get her support in the fight with the other parent, so that Dede could not respond to one parent's demands without seeming to side against the other. Violet's allegiance was not sought. She could therefore react to her parents' conflict without being caught in the middle.

The effects of these two roles can be seen in the FFA results. Both children showed significant increments during the interview, between 9 and 10, and even higher increments between 10 and 10:30, when they were with their parents. After the end of the interview at 10:30, however, Violet's FFA returned to baseline promptly. Dede's remained elevated for the next hour and a half.

In both spouses, the FFA levels increased from 9:30 to 10, indicating stress in the interspouse transactions. But their FFA decreased after the children had come in to the room and the spouses had assumed parental functions. In this family, interspouse conflict was reduced or detoured when the spouses assumed parental functions. The children functioned as conflict-detouring mechanisms. The price they paid is shown by both the increase in their FFA levels

Structural Family Therapy

and Dede's inability to return to baseline. The interdependence between the individual and his family—the flow between "inside" and "outside"—is poignantly demonstrated in the experimental situation, in which behavioral events among family members can be measured in the bloodstream of other family members.

THE SITE OF PATHOLOGY

When the mind is viewed as extracerebral as well as intracerebral, to locate pathology within the mind of the individual does not indicate whether it is inside or outside the person. Pathology may be inside the patient, in his social context, or in the feedback between them. The artificial boundary becomes blurred, and therefore the approach to pathology must change. Therapy designed from this point of view rests on three axioms. Each has an emphasis quite different from the related axiom of individual theory. First, an individual's psychic life is not entirely an internal process. The individual influences his context and is influenced by it in constantly recurring sequences of interaction. The individual who lives within a family is a member of a social system to which he must adapt. His actions are governed by the characteristics of the system, and these characteristics include the effects of his own past actions. The individual responds to stresses in other parts of the system, to which he adapts; and he may contribute significantly to stressing other members of the system. The individual can be approached as a subsystem, or part, of the system, but the whole must be taken into account. The second axiom underlying this kind of therapy is that changes in a family structure contribute to changes in the behavior and the inner psychic processes of the mem­bers of that system. The third axiom is that when a therapist works with a patient or a patient family, his behavior becomes part of the context. Therapist and family join to form a new, therapeutic system, and that system then governs the behavior of its members.

These three assumptions—that context affects inner processes, that changes in context produce changes in the individual, and that the therapist's behavior is significant in change—have always been part of the common sense basis of therapy. They have occupied the background in the literature of psychotherapy, while internal processes have come to the fore. However, they have not become central to psychotherapeutic practice, where an artificial dichotomy between the individual and his social context still exists.

An example can be drawn from concepts of paranoid thinking,

Families and Family Therapy

because in this area an understanding of the patient's context is vital. Yet in intrapsychic terms, paranoia is approached as a formal thinking disorder, in which the perception of events is determined by internal processes. As Aaron Beck wrote: "among normals, the sequence perception-cognition-emotion is dictated largely by the demand character of the stimulus situation. . . [However] the paranoid patient may selectively abstract those aspects of his experience that are consistent with his preconceived idea of persecution, etc. He may make arbitrary judgments which have no factual basis. These are usually manifested by reading hidden significances and meanings into events. He also tends to overgeneralize isolated instances of intrusion, discrimination, etc."9 In these terms, paranoia is an internal phe­nomenon only tangentially related to reality.

Contrast this with a context-related view of paranoia. In a study of mental patients with paranoid symptoms, Erving Goffman pointed out that in early stages of the illness, the social context enters a complementarity with the patient which supports his illness.10 Significant social groups, such as job peers, try to contain the patient, because his symptoms have a disruptive effect. They avoid him when possible and exclude him from decisions. They employ a humoring, pacifying, noncommittal style of interaction, which dampens the patient's participation as much as possible. They may even spy on him or form a collusive net so as to inveigle him into receiving psychiatric attention. Their well-meant tact and secrecy deprive the patient of a corrective feedback, with the ultimate consequence of constructing around the paranoid a real paranoid community.

Paranoid thinking and behavior can also be created experimentally in normal, highly educated professionals by group experiences, such as those devised at the Leadership Institutes of the Tavistock Clinic. In the "large-group exercise," thirty to fifty participants are seated in three to five concentric circles. The faculty are scattered through the circles, wearing business clothes, poker-faced, and silent. The group is given an ambiguous task: to study its own behavior.

Within the structure of this leaderless exercise, participants make statements that are not directed to anyone in particular, and because of the seating arrangements, half the participants have their backs turned and cannot see who is speaking. Dialog does not develop; a statement may be followed by a different statement in a different area. Thus, communications are not validated by consenting or dissenting feedback. Again and again, one sees the rapid appearance of

Structural Family Therapy

suspicion, confusion about the nature of reality that is being experienced, the search for a target, and finally, the appearance of scapegoats in the group or the labeling of the faculty as omnipotent persecutors. In this context, "paranoid thinking" invariably develops in and is expressed by participants whose life circumstances and developmental histories have otherwise been very diverse.1 1 It is thus clear that individual experience depends on the individual's idiosyncratic characteristics in his current life context.

A CASE STUDY

In Wonderland, Alice suddenly grew to a gigantic size. Her experience was that she got bigger while the room got smaller. If Alice had grown in a room that was also growing at the same rate, she might have experienced everything as staying the same. Only if Alice or the room changes separately does her experience change. It is simplistic, but not inaccurate, to say that intrapsychic therapy concentrates on changing Alice. A structural family therapist concentrates on changing Alice within her room.

The treatment of a patient with paranoid thought disorders is instructive of these different views. An Italian widow in her late sixties, who had lived in the same apartment for twenty-five years, came home one day to find the apartment robbed. She decided to move and called a moving company. It was the beginning of a nightmare. As she described it, the people who came to move her things tried to control where she went. When they moved her belongings, they purposely misplaced and lost precious possessions. They left sinister markings—cryptograms—on her furniture. When she went outside, people followed her, secretly signaling to each other. She went to a psychiatrist, who gave her tranquillizers, but her experiences did not change. She was then referred to an inpatient unit, where another psychiatrist interviewed her. He purposely left bottles on the table. Although she did not know what they were, they appeared clearly dangerous to her. He recommended hospitalization, but she refused.

She went to see another therapist, whose interventions were based on an ecological understanding of the old and lonely. He explained to the woman that she had lost her shell—the previous home where she had known each object, the neighborhood, and the people in the neighborhood. At this point, like any crustacean that has lost its shell, she was vulnerable. Reality had a different experiential effect. These

Families and Family Therapy

problems would disappear, he assured her, when she grew a new shell. They discussed how to shorten the time this would take. She was to unpack all her belongings, hang up the pictures that had decorated her previous apartment, put the books on the shelves, and organize the apartment so that it became familiar. All her movements were to be routinized. She was to get up at a certain time, shop at a certain time, go to the same stores, the same checkout counters, and so on. She was not to try to make new friends in the new neighborhood for two weeks. She was to go back to visit her old friends, but in order to spare her friends and family, she was not to describe any of her experiences. If anyone inquired about her problems, she was to explain that they were merely the problems of illogical, fearful old people.

This intervention established a routine to help the patient increase her sense of familiarity with a new territory, in much the way that animals explore and examine a strange area. The frightening experience of unfamiliarity with new circumstances had been interpreted by this lonely person as a conspiracy against her. In the very measure by which she had tried to communicate her experiences, her environmental feedback had amplified her experience of being abnormal and psychotic. Her relatives and friends had become frightened for her and had in turn frightened her by their conspiracy of secrecy. A paranoid community had developed around her. Two psychiatrists diagnosed her condition as a psychosis with a paranoid delusion and, in accordance with that interpretation, proposed seclusion.

A context-related therapist, however, interpreted the movement to a new apartment as an ecological crisis. Following the metaphor of Alice in her room, he perceived the woman as changing more slowly than her world. His intervention involved changing the position of the woman in her world by giving her control over her world until it had become familiar. He moved in to protect the woman by taking over the situation, guiding her while she "grew a new shell." At the same time he blocked the feedback processes that were amplifying the patient's pathology. As his intervention changed the patient's experience of her circumstances, her symptoms disappeared rapidly. She continued living in her new apartment, with the independence she desired. In this example, as in the parable of Commander Peary, the change occurred not so much inside or outside the patient as in the way that the patient related to her circumstances.

Structural Family Therapy

Structural family therapy deals with the process of feedback between circumstances and the person involved—the changes imposed by a person on his circumstances and the way in which feedback to these changes affects his next move. A shift in the position of a person vis-a-vis his circumstances constitutes a shift of his experience. Family therapy uses techniques that alter the immediate context of people in such a way that their positions change. By changing the relationship between a person and the familiar context in which he functions, one changes his subjective experience.

For example, a twelve-year-old girl had asthma, which was psychosomatically triggered. She was on heavy medication, missed school often, and in the previous year had to be taken to the emergency room three times. She was referred to a child psychiatrist, who insisted on seeing the entire family—two parents and the identified patient's two older siblings. During the first interview, the therapist directed the family's attention to the oldest girl's obesity. The family's concern then shifted to include worry about the newly identified patient. The asthmatic child's symptoms then diminished to the point that her asthma was controllable on considerably less medication, and she stopped losing school time.

Change had taken place in the structure of the family. It moved from two parents protectively concerned with one child's asthma to two parents concerned with one child's asthma and another child's obesity. The previously identified patient's position in the family had changed and, concomitantly, her experience changed. She began to see her older sister as a person also having difficulties. Her parents' concerned and overprotective way of interacting with her diminished with the addition of another target of concern. The therapist had changed part of the family's organization in such a way as to make movement possible. He joined them in a modality familiar to them—concern—but amplified the target of concern. The new perspective changed the experience of the family members.

This is the foundation of family therapy. The therapist joins the family with the goal of changing family organization in such a way that the family members' experiences change. By facilitating the use of alternative modalities of transaction among family members, the therapist makes use of the family matrix in the process of healing. The changed family offers its members new circumstances and new perspectives of themselves vis-a-vis their circumstances. The changed organization makes possible a continuous reinforcement of the

Families and Family Therapy

changed experience, which provides a validation of the changed sense of self.

The individual is not ignored in this theoretical structure. The individual's present is his past plus his current circumstances. Part of his past will always survive, contained and modified by current interactions. Both his past and his unique qualities are part of his social context, which they influence as the context influences him. What comes out of studies like Delgado's is a respect for the individual in his context, a concern not only with the individual's inherent and acquired characteristics but also with his interaction in the present. Man has memory; he is the product of his past. At the same time, his interactions in his present circumstances support, qualify, or modify his experience.

Structural family therapy utilizes this framework of conceptualizing man in his circumstances. The target of intervention could as well be any other segment of the individual's ecosystem that seems amenable to change-producing strategies.

THE SCOPE OF THE THERAPIST

The scope of the family therapist and the techniques he uses to pursue his goals are determined by his theoretical framework. Structural family therapy is a therapy of action. The tool of this therapy is to modify the present, not to explore and interpret the past. Since the past was instrumental in the creation of the family's present organization and functioning, it is manifest in the present and will be available to change by interventions that change the present.

The target of intervention in the present is the family system. The therapist joins that system and then uses himself to transform it. By changing the position of the system's members, he changes their subjective experiences.

To this end the therapist relies on certain properties of the family system. First, a transformation in its structure will produce at least one possibility for further change. Second, the family system is organized around the support, regulation, nurturance, and socializa­tion of its members. Hence, the therapist joins the family not to educate or socialize it, but rather to repair or modify the family's own functioning so that it can better perform these tasks. Third, the family system has self-perpetuating properties. Therefore, the processes that the therapist initiates within the family will be maintained in his absence by the family's self-regulating mechanisms. In other words,

Structural Family Therapy

once a change has been effected, the family will preserve that change, providing a different matrix and altering the feedback which continuously qualifies or validates family members' experiences.

These concepts of structure are the foundation of family therapy. However, structural family therapy must start with a model of normality against which to measure deviance. Interviews with effectively functioning families from different cultures will illustrate the normal difficulties of family life, which transcend cultural differences.

£ A Family in Formation: The Wagners and Salvador Minuchin

The family is a social unit that faces a series of developmental tasks. These differ along the parameters of cultural differences, but they have universal roots. This common aspect of family situations was ably expressed by Giovanni Guareschi:

Why do I keep talking about myself, about Margherita, and Albertino, and the Pasionaria? There is, truly, nothing "exceptional" about us . . . Margherita is not an "unusual" woman. Neither are Albertino and the Pasionaria "extraordinary" children.

There are a hundred different varieties of grape—from white to black, from sweet to sour, from small to large. But if you press a hundred bunches of grapes of different varieties, the juice is always wine. If you squeeze grapes, you never get gasoline, milk, or lemonade.

And it's the juice that counts—in everything.

And the juice of my family is the same as the juice of millions of "ordinary" families, because the basic problems of my family are the same as those of millions of families: they spring from a family situation based on the necessity of adhering to the principles that are the foundation of all "ordinary" homes.1

The Wagners, in the interview that follows, are an ordinary family; that is, the couple has many problems of relating to one another, bringing up children, dealing with in-laws, and coping with the outside world. Like all normal families, they are constantly struggling with these problems and negotiating the compromises that make a life in common possible.
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