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1996 November/December (1)

Friday, 02 January 2009 10:39

It's more Complicated Than That

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It's More Complicated Than That

Don't Smooth Out Life's Wrinkles Says Salvador Minuchin

by Richard Simon

IT'S BEEN ALMOST 20 YEARS SINCE I FIRST SAW SALVADOR MINUCHIN in action. Back then, I was a young Ph.D., just a few months into my first clinical job. In graduate school I had of course read Minuchin's books Families of the Slums and Families and Family Therapy, which were, as far as I was concerned, practically sacred texts, but I had never actually seen him do therapy in person. The family field was at the peak of its messianic, we-shall-change-the-world phase and Minuchin, in his staunch opposition to psychiatric orthodoxy, was both its leading visionary and presiding clinical wizard, part Moses, part Merlin with a little dash of Rush Limbaugh thrown in on the side.

So my trip to the Philadelphia Child Guidance Clinic for an introductory workshop Minuchin was giving on structural family therapy was more than a quest for a few C.E.Us. It was a pilgrimage to the place that Minuchin had turned into the Mecca of family therapy itself, an initiation into the mysteries of how to put the airy abstractions of systems theory to work transforming lives. Standing in front of the audience of 200 therapists, Minuchin, a compact, dapper man with a Latin accent as thick as his black mustache, exuded an air of brusque command at odds with the traditionally pacifist culture of psychotherapy. Heaven protect anyone who stumbled through a lame question or tried to say a kind word about psychoanalysis. He seemed to me the most confident person I had ever met, as if he had been to the mountaintop, seen the Truth and discovered he was It. Of course, he was exactly the kind of hero I was looking for. And when he began to explain a clinical strategy by quoting from a 16th-century book called The Way of the Samurai, any last reservations I may have had completely disappeared.

The centerpiece of the workshop was a live family therapy session broadcast to the audience via closed circuit TV Once the interview started, Minuchin's intimidating aura dissolved and he became a kind of therapeutic sleuth patient, respectful, infinitely curious, frequently playful, surprisingly gentle, but, above all, utterly focused on figuring out the puzzle of what was maintaining the problem the family was trying to resolve. Sometimes Minuchin leaned back in his chair and took long drags on his cigarette as he questioned the family a poor, black, single mother and her three young children about their presenting problem, the 8-year-old boy's disobedience and school difficulties. Hyperalert to the family's every gesture, every pause, every shift of mood, he seemed to drink in information through all his pores as he pursued his inquiry.

Toward the end of the session, Minuchin asked the defiant 8-year-old to stand up, explaining, "I am still trying to figure out what makes you so powerful." The boy smiled slyly as he rose to his feet, clearly delighted to take part in whatever game this curious man was devising. After speaking with the boy for a while and complimenting him on how strong and healthy he looked, Minuchin asked the mother to stand up. As she did, towering over her small child, Minuchin asked, "Where has he got the idea that he is so powerful? He is a healthy boy, but look, he is just a little kid who somehow has convinced you that he is much older than he really is." It was, I learned later, one of Minuchin's favorite gambits, but as I watched it unfold, I was stunned by both the power and the sweetness of the moment. Both mother and son were smiling, basking in the attention they were receiving, coming more fully to life as if renewed by the prospect of order being restored in the family. And later, as the mother, with Minuchin's gentle, persistent coaching, was finally able to lay down some simple rules in the session with a newfound authority in her voice, there was no doubt that she and her family had recorded a small victory in that room.

 

I am equally sure that over the next weeks and months, the therapists in that audience went on to direct hundreds of children and their parents through a similar routine, the image of Minuchin's mastery still alive in their memories. The fact is that once you saw Salvador Minuchin at work, a little part of him lived on indelibly inside you. Through family therapy's formative years, he became the standard against which therapists measured their best work, and when they failed miserably with a family, they asked themselves what Minuchin might have done. From his early work with delinquents and their families at New York's Wiltwyck School in the 1960s through his long stewardship at the Philadelphia Child Guidance Clinic, he was probably the most renowned and most imitated family therapist in the world.

For the past 15 years, although he has continued to write about family therapy, conduct workshops and direct a small training center in New York, Minuchin has seemed to be in search of fresh worlds to conquer. He spent some years traveling and pursuing his interest in play writing, seeing if he could transfer his flair for the drama of the consultation room to the theatrical stage. For more than a decade, he jousted with the New York City child welfare bureaucracy, trying to apply his ideas about family systems to reforming the foster care system.

Today, at 75, he speaks with some bemusement about his reputation for consultation-room charisma, as if fondly recalling a brash younger brother who had yet to learn some of life's later lessons. Fifty years of experience with families has smoothed the keen edge of absolute certainty that once gave his work its sense of urgency. These days, he sees himself less as an advocate for a particular clinical method or theory than as a philosophical meta-observer of a profession he, as much as anyone, helped to create and to which he continues to feel responsible. He has just completed his ninth book, Mastering Family Therapy: Journeys of Growth and Transformation, cowritten with nine of his supervisees, which offers his current take on the state of family therapy training. The interview that follows was conducted in the Back Bay town-house in Boston where Minuchin lives with his wife, Pat, a clinical psychologist who has been his collaborator in his efforts to revolutionize foster care, to whom he has been married for 45 years. Here, Minuchin reflects on some of the latest developments in family therapy, discusses his own evolution as a clinician and offers his perspective on nearly 50 years of the field's history.

FTN : How would you contrast your work with the approaches that are popular among younger therapists today?

MINUCHIN : I think I am much more interested in the exploration of conflict than many therapists today. My therapy grew out of the "try, try again" active therapy of the 1960s, with all its optimism and energy, experimentalism, creativity and naivete. I bring the family drama into the therapy room. I encourage members to interact directly with one another in the belief that the family is the arena in which people can most fully express themselves in all their complexity. So family interaction with all its potential for both destruction and healing continues to occupy center stage in my practice.

 

But today therapists are wary of my brand of therapeutic interventionism. They seem to believe it is impossible for a therapist to produce specific, targeted changes in a family. They want to be noninterventionist and turn therapy into a simple conversation among people. The therapist asks questions that provide people the opportunity to reconsider meanings and values that up until then they have considered as "given" or normative. The solution-focused and the narrative therapists say, "Let's not deal with problems. Let's deal with solutions." But in the process, it seems to me, the therapist is restricted to operating only in a collaborative, symmetrical posture. Gone is the latitude to play, to give opinions, to be the complex, multi-faceted person in the therapy room that you are outside of it. All that remains is to be a distant, respectful questioner.

FTN : Janet Malcolm once wrote in The New Yorker, "Watching a Minuchin session, or a tape of it, is like being at a tightly constructed, well-directed, magnificently acted play." You seemed to relish dealing with explosive situations in therapy. What do you like about dealing with those situations?

MINUCHIN : I think what drew me to family therapy was the excitement. Every family represented an exciting puzzle. When I worked with delinquents and their families at the Wiltwyck school back in the '60s, the particular challenge was to help them find concrete ways to calibrate relationships. We were concerned with helping disorganized families to give more order to their relationships. So we would interrupt a fight in the family to say, "When your mother talks, you cannot talk. Okay, now you can answer." The emphasis was on guidance. At that time Virginia Satir had developed a very popular therapy that emphasized nurturance and the mid-wifing of feeling. But we felt that in the families we saw, people already knew how to nurture. The problem was that the parents were ineffective in taking control of their kids. What they did not have was the constancy that allowed them to give the children a sense of self-efficacy.

FTN : A lot of your reputation as a master therapist had to do with your getting seemingly resistant families to do what you asked them to do. How did you manage to accomplish that?

 

MINUCHIN : At the time I wrote Families of the Slums, I was full of political passion in defense of the underdog. I had an enormous amount of zeal and people responded to that. All of us back then were tremendously hopeful about teaching poor people to become competent in this social laboratory that was the family. We relied on techniques of moving in and out of the conflict, of being both an observer and a participant in the session. So we would say, "Mom, talk with Jimmy and find a way to make sure he really listens." The goal was to get the parents to exert competence in an area in which they could succeed. The more competent people felt, the more they would listen. Our naivete at that time was that we could not yet look beyond the boundaries of the family and recognize the impact of the larger culture. That came later.

FTN : When I think of the teaching tapes you made at the Philadelphia Child Guidance Clinic, what stands out for me is the art of the small victory going through some hellish struggle to get somebody in a family to do something they have never done before. Of all the cases that you treated, is there one that stands out for you?

MINUCHIN : There is a famous tape of an anorexic girl eating a hot dog. That was a family situation that was horrendous. There was this girl named Carol who was so underweight that she was in danger. So I said to the parents, "Unless she eats, she will die. You are the parents. Don't let her die. Do something." So I tried to help the family discover a new pattern of interaction by creating a crisis in which the parents had to do something that was novel for them. Now these parents were faced with an impossible situation. The mother starts by saying, "Carol, I want you to eat," but soon she and father are beginning to fight, so I say, "Look what's happening now. Carol is still not eating." And the parents now attack the girl, "You will eat!" And food is no longer the issue, and questions of power, autonomy and control become the central issue in this transaction. At that point, it is possible to enter by supporting the girl's autonomy not around eating, but around what her parents are doing.

FTN : But how did you get out of being stuck in the power struggle?

MINUCHIN : A therapist must walk both sides of the street. At the same time you are getting the parents to take control, you also talk about the girl's autonomy. You explain that good parenting is not just control, it is also about giving space. And while you encourage the girl's autonomy, you talk to her about the parents' need to be respected. Bringing the conflict into the therapy room is just the first step in challenging the old pattern and moving parents outside of the world of the girl. Maybe I'm thinking of this particular family because Carol just called me a few months ago to tell me that her father, whom I had not seen in 25 years, was dying and wanted to speak with me one last time. After all these years, he still felt connected to me and what had happened in the therapy. Somehow talking with me at the end of his life was his way of closing a circle. I am frequently surprised how long the memory of a therapist can last in the life of a family.

 

FTN : Your ability to handle conflict seems to come out of your skill at convincing both sides that you are with them. What keeps families from just seeing you as a manipulator?

MINUCHIN : For people to accept my interventions, they must know that I really see them. They must say to themselves, "Yeah, that's me. Yes, he has my number." I think that what it comes down to is that I really care. Once I work with a family, I am absolutely concerned for them. I suffer with them. I cry with them. Even though I am like Jiminy Cricket I am their conscience I also care for them. When Jay Haley wrote about Milton Erickson, he emphasized his inventive interventions and his command of hypnosis and metaphor. But when you look at tapes of Erickson with patients, what you see above all else is a man who is absolutely benign.

FTN : Since the early days of structural family therapy, you've been considered a champion of a here-and-now approach to change. So I was surprised to hear you say in your new book, "We have tended to overlook family history."

MINUCHIN : I believe that to understand the present one must always make incursions into the past, in order to become free of it. The analysts also believed this, but for them, the investigation of the past was open-ended and took a lot of time "First, tell me about your father. Now tell me about your mother." And one would go on exploring and exploring, weaving together all these strands to make an interpretation of the present. My idea of how to explore the past was different. I saw it not as an intellectual exploration, but as a search for new responses. You start by seeing the narrowness of people's responses in the present and ask, "How did you learn this narrowness?" You then explore the past, looking for something very specific and focused. The exploration is in search of a solution that will make the client more complex in the present.

F TN : So what exactly are you looking for in that exploration?

 

MINUCHIN : You explain to people that families make people into specialists. The specialty may be "I need to defend myself from criticism," or "I am accepted when I help others," or "I am acknowledged only when I am a winner." Each one of the these labels for the self comes with a view of the complementary roles others take and with certain preferred strategies for dealing with life. So people develop a set style of transacting with significant others, and while they may have other alternatives, they are specialists in this one. As a therapist, you look at the past in order to see how the past created constraints that are not useful now. And you say to the client, "Let's use that understanding to free you from the constraints that don't serve you anymore."

FTN : Does that understanding in itself free people?

MINUCHIN : It's basically Harry Stack Sullivan's concept of parataxic distortion, the idea that you are not really responding to the present, but seeing it through blinders that you have forgotten you are wearing. And the therapist says, in effect, "Let's take those blinders off."

FTN : What do you think of the statement by Jay Haley in his most recent book that "Rather than assume that insight into the past causes change, it's better to think of change causing insight into the past."

MINUCHIN : I think he is wrong and he is right. I am an old man, but I still have memories of my childhood that cannot be erased. Some of them are uncomfortable and I would like to erase them, but they don't go away even though I have changed and am experientially much richer. I know the way in which these early experiences still organize my thinking today. But to a certain extent, I am able to marginalize them so that they are not significant in the way in which I function. Still they are part of me, and I really do believe in the importance of understanding the past in order to give people the freedom to take their blinders off and see how the past organizes the present. From this perspective, I would disagree with Jay. But I also think he is right. There is something else that happens when you deal with memory. Not only do you change how people look at the present, you also rearrange the past.

FTN : What do you mean?

MINUCHIN : I think that we are always rearranging our past. Some therapists, like Milton Erickson, would sometimes deliberately introduce through hypnosis old memories that never actually took place. But even outside therapy that happens automatically all the time. I'll give you an example. Years ago I paid a visit to my high school in Argentina, where I met a woman about my age who asked me what I was doing there. And I replied, metaphorically, "I am lassoing ghosts," which is a very Argentinean thing to say. As we talked, we discovered that we both had been in that high school at the same time. But even though she had told me her name, I could not remember who she was. So later I went to the office in the high school and asked for a roster of former students. As soon as I saw her name on the roster, the memory of her as an adolescent came full-blown into focus. Clearly her presence as an adult interfered with my memory. Suddenly all kinds of memories that had not come to mind for 50 years came back to me, not in the competitive and timid way in which I originally saw them, but from the perspective of being older and looking back. My memory created something very different in that moment from earlier memories of the same period.

 

FTN: So you think we're always "recovering" memories?

MINUCHIN : I think so.

FTN : So what do you think about the criticisms of "recovered memory therapy?"

MINUCHIN : The mistake some therapists make is to believe in the immutability of memories. I think that we always create memories that's a very normal, natural process. What I don't agree with is that once these memories appear in therapy, they represent truth or reality. Therapists must be very careful not to see memories as immutable truth.

FTN: Since the last interview we had 12 years ago, what have you discovered about being a good therapist?

MINUCHIN : During these 12 years, the certainty that I had when I was younger has disappeared. I no longer believe that I own the truth and I have become more accepting of other points of view. I know myself better and realize that when something new happens in the field, my first response is to oppose it and only later do I begin to incorporate it. My first response to the feminist group was to respond negatively to what I saw as its stridency, especially since I was the target of much of its criticism of the field. But I learned to incorporate many of the feminists' ideas. And even though I still have problems with the constructivists, as I was saying earlier, the same was true of the work of Michael White and Steve de Shazer. I begin with polemical opposition and move toward assimilating what I find useful.

FTN : So, for example, what do you find useful in solution-focused therapy?

MINUCHIN : I like looking beyond problems to solutions, saying to clients, "What if one day you get up in the morning and your problem disappears? What would that look like?" I use those questions sometimes, just as I have incorporated pretty much everything that has been written on family therapy, particularly the ideas of Jay Haley and certainly all the thinking of Carl Whitaker. Today, technically, I am much more complex than I was as a younger therapist. A lot of that, of course, is a result of age. As you get older, all certainties become question marks. You also begin to ask yourself fundamental questions like, "Would the world be different if I did not exist?" So you become less attached to your particular contribution.

 

FTN : How have you assimilated pieces of feminism in your work?

MINUCHIN : The feminists made me realize that I had put women in certain narrow categories and that my labels for women had gender biases: for me a mother's concern could too easily be dismissed as "overprotectiveness." I focused on men providing guidance and women nurturance, and my work emphasized the importance of guidance and took nurturance for granted. I don't think I do that anymore. I'm more aware of the messages of the labels and I pay attention to what I privilege. But I still work systematically, seeing how couples trigger each other in their interactions. I've always thought that working with the man is an important way to bring him closer to the family, make him more of a participant and ease the burdens of the woman, but I pay more attention now to making sure that her voice is heard, her pain expressed and her need for respect understood.

FTN : And what about the narrative approach?

MINUCHIN: Do you remember Nathan Epstein?

FTN : Of course.

MINUCHIN : Nathan Epstein had an extraordinary quality of inspiring family members and transforming them very, very fast into talmudim.

FTN : Into what?

MINUCHIN : Talmudim literally, it means, students, but I think of it as students of the rabbi. Epstein would say to his patients, "I want you to study your family," and somehow he managed to generate such a lively atmosphere of intellectual inquiry that everyone would get very involved. Externalization has the same ability to reduce emotionality and put people into a position of inquiry about the effects of the world upon them, while highlighting the intellectual possibilities of something new. It gives families the idea that the enemy is outside them and that family members are all okay, banded together against outside forces. I think that's very clever and very good.

FTN : So you've assimilated these various influences, but do you think your therapy has really changed very much?

MINUCHIN : Theoretically, I do what I have always done. I still look at the way in which the current transactions in a family support conflict. I am always saying to people, in one way or another, "There are more possibilities in you than you think. Let us find a way to help you become less narrow." But the ways that I say that today are less dramatic than they used to be. I ask more questions and give fewer prescriptions.

 

FTN: As you look at the way family therapists practice today, what most disturbs you about the direction the field is taking?

MINUCHIN : Let me give you a little roundabout answer to that question. I think that what therapists do is to make people respond to the tools they use. So if my favorite tool is the question, "Imagine that one day the problem has disappeared," then I will need to create an articulate patient that responds to this tool. The same is true of externalizing questions. I remember seeing Michael White do a very masterful session of narrative therapy, but it was like watching a sheep dog at work. He kept pushing people through a series of constructed questions into the groove of seeing their stories in the more positive way that he wanted for them. The therapist changes the old story and convinces the client that the new story is more true than the old. We all offer our patients a language, and we say, "Let's begin to see your life in this language, and I will give you solutions in this language." I do it. Everybody does it. What disturbs me now is that, as a field, we have gotten so interested in these therapeutic techniques and our particular language that we are paying little attention to the family therapist as a system and the therapist as an instrument of change.

FTN: Why do you think we have gone in this direction of what you call the "noninterventionist, restrained" therapist?

MINUCHIN: Some talk about doing a more "respectful" therapy that does not impose the therapist's biases. But I don't think it has anything to do with being more respectful of clients. I think it has to do with changes in social outlook. As citizens of this pessimistic society, therapists have lost their optimism and just have fewer expectations of effecting changes.

FTN : Does that include you?

MINUCHIN : No.

FTN : How did you manage to escape?

MINUCHIN : I grew up as the child of immigrants in a world that was expanding, where people felt that, through hard work, you could realize your dreams and control your destiny. To many people today, those beliefs seem naive. Maybe I am still a part of the 19th century. But I think it is also important that I stopped thinking of myself as a family therapist years ago and became interested in how the skills of systems therapists can be applied in the larger world. I went from thinking about the small unit of the family to thinking about the possibilities of affecting larger institutions. So by working in a field in which there are new possibilities, I still am optimistic. I am exploring with the Department of Mental Health in Massachusetts some ways of making home-based therapy more effective, which is the kind of challenge that I love. Probably if I were working only as a therapist, then I would need to respond to the constraints of the market just like everybody else. I would be tinkering with alternative therapy approaches that are easier to use or simple methods in which you can train people more cheaply.

 

FTN : We've been talking about trends in the therapy world today. I see a lot of therapists growing more interested in the connection between spirituality and psychotherapy. Is that a connection that interests you?

MINUCHIN : Not especially. My whole life I have been interested in logic and order. I have always been a very politically involved person. Maybe it comes from being Jewish, but being concerned about the underdog has always been important to me. I suppose my version of spirituality is connected to the dream of social justice. The kind of spiritual thing that you seem to be talking about has not been a big part of my life. Maybe that's part of my limitations.

FTN: How do you see your relationship today to the field?

MINUCHIN : I used to influence the field from the center. Now I do it from the periphery. I am now an elder. I support other people who are doing interesting work. I think it is part of being an elder to be a critic. I also think an elder is the carrier of the oral history of the field, so I feel bad when young therapists don't acknowledge the influence of people like Murray Bowen, Virginia Satir, Jay Haley, Carl Whitaker and Lyman Wynne.

FTN : Do you feel satisfied with life at age 75?

MINUCHIN : I thought that at 75 I was going to retire and become a full-time grandfather. But retirement is not a comfortable niche for me. Other people at 75 find that this is a time to paint, to play the piano. But that is not enough for me at this point. Pat and I have moved to Boston to be near our children and our granddaughter. My relationship with my granddaughter is very, very special. So there is renewal in that. But I am a person who likes to help other people. 1 don't find it useful to look too much at the past or way ahead to the future. I relate to the immediacy of the present. Even though financially we are okay, I need to work in order to maintain myself intellectually and because I love it. After all these years, if a family calls and wants to come to therapy with me, I still love it.

Richard Simon, Ph.D., is the editor of The Family Therapy Networker.