Whatever Happened to Family Therapy?

On a Wednesday evening in 2004, I’m at The City College of New York, behind a one-way mirror. My doctoral student Jason is sitting on the other side with a mother, her two teenaged daughters, and her preteen son, Luis. Six months ago, the mother discovered that their father was involved in a long-term affair and threw him out. Overnight, Luis transformed from gentle and loving to bossy and argumentative.

In earlier sessions, the children have talked about their feelings of anger and betrayal over their father’s affair and their sadness that he never visits. Despite this acknowledgement, Luis’s rudeness has gotten worse. He’s being rude right there in the session, snapping at his sister to be quiet. My hunch is that the father was bossy and the boy is being bossy now as a way to get the family to talk more openly about the father, and perhaps to keep the father present in the family, so they miss him a bit less.

I call Jason on the phone and suggest he ask if the boy’s behavior reminds them of anyone in the family.

As soon as Jason poses the question, one of the daughters responds, “It’s just like our father used to be—bossy, always trying to get his way!” When Jason explains my hunch, the mother and sisters nod vigorously as if experiencing a collective insight. Luis, with a smile that suggests he agrees with the idea as well, goes into an exaggerated parody of his father’s behavior, and the family breaks out into peals of laughter.

After the session, flushed with excitement, Jason comes behind the mirror and declares, “That’s it! This is what I want to do with my career! Family therapy!”

Like Jason, I’d fallen hopelessly in love with family systems thinking—or rather, I was imprinted onto it, like a newborn gosling. Through the work of systems thinkers, I was introduced to a mind-bending, career-changing revelation: problems exist between, not within, people.

But unlike Jason, that idea wasn’t a part of my training. Instead, the notion that a child’s symptom—be it depression, stealing, anorexia, or even schizophrenia—served a functional role to camouflage or manage stresses in the family system, such as conflicts between parents, was an understanding that I stumbled on and then moved toward with an almost religious calling. Back then, it seemed to me and my fellow believers as though family therapy was about to radically change the world.

Between People

I became imprinted in 1984, in Durham, North Carolina, as a doctoral student at Duke University’s psychodynamically oriented clinical psychology program while working with children at a clinic. I was forbidden to meet with my clients’ siblings or compare notes with their therapists for fear of muddying the transference relationships. And after a single introductory session, I was discouraged from meeting with clients’ parents.

Over time, I became increasingly skeptical of my supervisors’ advice, which was based on the original psychodynamic Child Guidance model. Wasn’t it more important to reshape the real relationships within kids’ families than to help them work out their feelings in transferential play with me? Why couldn’t I talk to siblings› therapists? Could my supervisor really be right in blaming a kid’s problems on the inadequacy of his mother, who seemed pretty competent to me? I felt there must be a better way.

Then I came across Change: Principles of Problem Formation and Problem Resolution by Paul Watzlawick, John Weakland, and Richard Fisch of the Mental Research Institute in Palo Alto, California. This elegant little book, one of the first concerted attempts to apply communications theory and systems thinking to the practice of psychotherapy, challenged almost everything I’d been taught. Today, the basic tenets of family therapy have infiltrated the whole field, as most therapists accept that parents and children get into reciprocal coercive struggles, and that small changes in these cycles of interaction can lead to large changes in the behavior and emotional wellbeing of both parents and children, and elimination of diagnosable symptoms. At the time, those ideas seemed revolutionary.

The clients the authors described had run-of-the-mill problems, but unlike other authors of clinical texts, they illuminated that one essential viewpoint: problems existed between people, rather than within them. The notion that kids could influence their parents’ behavior just as much as parents influenced theirs was a revelation to me, as was another feature of the credo: that problems were frequently amplified, rather than reduced, by “more of the same” efforts to solve them. So it was critical to identify the pattern of circular interactions that kept the problem going, and then to challenge it—which could only be done in the room.

For someone trained to excavate the root causes of a patient’s psychopathology from vague memories of parents’ poor caretaking, this shift to the here-and-now cycles of reciprocal interaction was deliciously destabilizing. And as I absorbed the work of other systems thinkers, like Salvador Minuchin, now known as the father of family therapy, I felt something shifting irrevocably in the way I viewed the world.

I saw clearly how our dominant culture filters just about everything through the prism of individualism. Family therapist Carmen Knudson-Martin recalls working at a hospital early in her career and realizing how entrenched individualism is: each member of a family had an individual file, and she couldn’t create a family file, even when she saw their problems as connected. Insurance companies don’t allow the “identified patient” to be a family. And yet, as family therapist Dafna Lender says, echoing an idea that numerous family therapists have emphasized, “There’s no such thing as an individual.”

That simple yet profound premise challenges our most embedded assumptions, and it changed how I wanted to practice therapy. I stopped seeing clients’ problems as set-in-stone expressions of individual or group pathology: they were shaped by fluid interactions within small systems, and those were shaped by larger systems—the extended family, the social services system, the legal system, the medical system, and even capitalism itself.

An Unstoppable Movement

Family therapists have a major advantage in creating change and preventing future harms: instead of listening to one client narrate what can’t be the whole story, family therapists see with their own eyes that a one partner stonewalls, another blames, and a father can’t control his anger when his child can’t sit still. In a room with multiple members of a family, we can see the dynamics that clients may not recognize as remarkable enough to report; after all, none of us can see the water we’re swimming in. For children especially, the world their caregivers create is the only one they know.

When a therapist is watching a family fight unfold, “you can’t sugarcoat things,” says Erin Haase, who practiced in-home family therapy for ten years. “You’re seeing things unravel in front of you,” So instead of spending months listening to subjective reports and coaching an individual client on what to do next time, the family therapist must intervene in real time.

The real power of family therapy is how family members, especially parents, can learn that they already have the inner resources to repair rifts. Parents, not therapists, can become the healing agents within the family. As Daniel Santisteban, professor emeritus at the University of Miami, says, “It’s easier for the therapist to be an ‘expert’ and rattle off knowledge, but the therapist is going to be gone in a few months. The family is going to stick with the child, so the extent to which I can mobilize the family to be healing for their youth, the more change there’s going to be in the family.” Those changes help prevent children from carrying more trauma in their bodies into adulthood—and into their own future families.

For all these reasons, family therapy is enormously effective at getting at the root cause, not the symptom, of clients’ struggles. In fact, back in the late ’80s, I became convinced that family therapy was an unstoppable, revolutionary movement, which would radically change the mental health field, and even our larger society. I wasn’t alone in this. For the previous decade, all across the country, the family therapy movement—and it was a movement—had been scooping up community organizers, former seminarians, feminists, and all manner of status-quo disruptors pouring into psychology, psychiatry, pastoral counseling, and social work. For us, family therapist wasn’t a job description: it was a calling.

In the rebellious, innovative ’60s and early ’70s, family therapy had first flung itself onto the scene with adolescent hubris. Its iconoclastic founders—almost all of them self-confident, highly educated white men—had upended Freudian intellectual icons with all the glee of teenagers knocking over gravestones on Halloween night. Every therapeutic assumption had been challenged. Perhaps schizophrenia wasn’t biological, after all, but a behavioral artifact. Perhaps families could defeat poverty. Perhaps depression or alcoholism that had persisted for decades could be resolved in eight weeks or less. Perhaps in time, systems thinking would suffuse the culture and generate a velvet revolution.

It didn’t turn out that way.

Conducting an Orchestra

Today, individual trauma treatments like ACT, DBT, EMDR, Neurofeed­back, Somatic Experiencing, and anything related to meditation and mindfulness have won the day. We family therapists compete every day for clients (and diminished insurance dollars) with psychoactive medications and familiar, individual treatments, like psychodynamic and cognitive-behavioral therapies—and now a new wave of apps. Many free-standing family therapy institutes have shuttered. When taught in academic settings other than MFT programs, family therapy is often covered in a one-semester course, as just another (alternative) therapeutic modality, like group therapy, rather than as the central theoretical perspective on mental health and treatment.

Family therapy hasn’t disappeared. It’s a cornerstone of the counseling provided at social service agencies, youth programs, and addiction treatment centers across the country. In those settings, counselors take for granted that the issues expressed by the “identified patient” can best be addressed by repairing rifts within the family system. Knudson-Martin—who feels her decision to become a family therapist is corroborated by a 100-year-old passage by the sociologist Émile Durkheim about how suicide rates are higher in societies with less social cohesion—tells me that students graduating from Lewis and Clark’s MFT program, where she teaches, “don’t necessarily get wonderful pay, but they get hired quickly by agencies.” That’s because group and family treatment models make financial sense for agencies when a single counselor can, at least ostensibly, treat multiple people in one timeslot.

But if family therapy is so effective, why aren’t more therapists in private practice seeing families? Perhaps because the pharmaceutical industry outspent us. Perhaps because many of our models were originally based on a kind of 1950s conception of a white, middle-class family that’s all but obsolete. Perhaps we initially fell prey to the single-factor fallacy, staring through the keyhole at the minisystem of the family while ignoring the shaping power of internal biological systems and early childhood attachment—to say nothing of culture and economics. Or perhaps a movement so wedded to a concern with interdependence and social systems didn’t stand a chance in the America that’s still enamored by the fantasy of individual enterprise and self-sufficiency.

In our rush to change family systems, if not the world, we family therapists didn’t anticipate that we too would be thwarted by structural forces. Because family therapy training never became the standard, the problem becomes recursive: since students aren’t learning about family therapy, they don’t know to seek out postgraduate training in it, and then there’s less demand for family therapy programs.

One thing is clear: because we were studying systems, many of us operated under the delusion that we were somehow immune to them. After its glorious adolescence, our movement was buffeted by changes in the time-and-money microsystems of individual families—and by political and economic shifts in the therapeutic economy and in the wider world. As Jay Lebow, family therapist, senior scholar at The Family Institute at Northwestern University, and editor-in-chief of Family Process, explains, “There’s always been a disconnect between the obvious virtues of a systemic way of working with multiple people and what insurers are willing to pay for and who medical systems are willing to hire.”

The logistical challenges to seeing families instead of individuals (or even couples) also add up to major disincentives. Getting numerous people in a room means a therapist often has to engage each family member before the session. That requires a careful dance, especially when parents are affronted by the notion that their child’s behavior could have anything to do with their own behavior. As Lebow puts it, “The art of family therapy is the art of engagement.”

Then, once all parties are on board, the therapist must somehow be available at an hour when everyone is free, often during an evening or weekend. During the session itself, young children may dissemble, adults may run out of the room, and so it’s almost guaranteed that frequently, if not always, the session will threaten to go off the rails and run overtime. Therapists can’t book family therapy sessions back-to-back the way they might with individual sessions. Lender summarizes: “Therapists need to work a lot harder in order to make ends meet.”

And, of course, there’s the work itself, which is a radically different experience from sitting with one client telling one story. Haase says that being in a room with a family in conflict “is where the rubber meets the road when you’re a clinician. If you’re activated and scared, and you haven’t done groundwork and pacing with the clients, and you’re not on top of your work on yourself—you’re screwed!” Kids, in particular, “can smell your weakness” and as a defense mechanism won’t hesitate to undress a therapist with their judgments. “It’s impressive!” he adds, laughing, “Things it took me years to figure out in therapy, kids have figured out about me in two minutes!”

But therapists who haven’t dealt with their own issues can easily be undone, rendering them less able to help their clients. “When you’re watching people arguing, you’re watching your parents and replaying the tensions of your childhood,” Lender explains. “As children, we often felt powerless, helpless, unseen, so when you’re in there watching families fight, it can be really, really triggering and difficult.”

She points out, “When you’re working one-on-one with clients, they’re looking at you; they’re talking to you; you’re the most important person in the room; you feel influential.” That allows the therapist to have more basic social engagement, like eye contact, that fosters a sense of connection and meaning—the very reasons many people go into this profession in the first place. A family therapist, meanwhile, is one player among many, and frequently sidelined by screaming parents or children.

A family therapist, Lender says, is like the conductor of an orchestra (a metaphor that Minuchin often used), constantly listening and trying to balance numerous simultaneous notes, “telling the woodwinds to tamper down, the violins to amplify, and sometimes tapping your baton and saying, ‘Wait a minute. Stop. We’re not in harmony. You can’t do that.’” To conduct sessions that way, Lender says, “You really have to hold yourself to the center.”

It takes a certain person to want to be a family therapist—and a real calling to keep the flame alive over years. Being with families requires extra vitality and presence. You have to be strong enough to step in and try to stop an angry diatribe, and you also have to be empathetic enough to build an alliance with each person involved in a conflict—which can be especially difficult when one family member has inflicted abuse on another. But there’s nothing like being in the room with a family, because there’s nothing more enlivening than watching people interact.

Without Casting Blame

In the United States, family therapy—notoriously challenging as it is—is routinely left to unlicensed or early-career clinicians. At agencies across the country, these clinicians work with “the most difficult kinds of cases with trauma, family conflict, and under-resourced families,” said Santisteban. The kinds of family therapy programs offered vary widely between settings, but most agency therapists see clients whose counseling is mandated by the state, so they have to “build trust and convey that they’re not part of a larger punishing system, which is how kids and their parents often perceive it.” Then, Santisteban says, “a therapist has to be really competent and sensitive, and explain to parents how we think their presence in therapy can be healing without suggesting they’re to blame for the problem at hand.”

The real story of family therapy is “each generation trying to do the best they can after being handed generational trauma and generational poverty,” Haase says. In the case of extreme poverty, in-home counseling is beneficial because it lowers the barrier to attendance. Anything from a work schedule to the absence of public transportation can prevent clients from showing up to a center. Being in a family’s home also changes the power dynamic because clients aren’t coming into a professional office that may feel foreboding, especially if they don’t see their participation as fully voluntary.

Santisteban explains that he spent the first half of his career trying to persuade leaders in the field that family therapy is powerful, and now that its power is accepted, the ongoing challenge is finding ways to deliver that therapy consistently over time in many different kinds of agencies. To deliver family therapy, agencies have to figure out their own logistics, from the mundane, like whether they have big rooms with enough chairs, to the clinical, like how comprehensive their training programs can be.

One of the biggest challenges to providing high-quality family therapy is the low pay for challenging work. Santisteban has heard colleagues compare agencies’ turnover rates to those of fast-food restaurants, and the evening hours make it difficult to retain experienced staff. Even Haase, a passionate champion of in-home family therapy, now supervises family therapists but doesn’t see families anymore because she can’t swing the evening hours while caring for her kids. Constant turnover drains agencies of skilled practitioners and means quite a lot of family therapy is being practiced by green therapists, creating a constant need to recruit and train, a time-consuming and expensive process. Knudson-Martin argues that it tends to leave a lot of people not getting the level of treatment they need.

Reaching families with different cultural backgrounds is another undertaking in a field where the majority of practitioners are white and most of the foundational theories about what counts as healthy were crafted by white men. Santisteban says that the cultural awareness that’s been discussed more in recent years isn’t enough. Therapists need to do more to integrate cultural factors directly into their conversations with families. To pull that off, they need to receive training that isn’t culture blind and that provides concrete examples. Recent immigrant families, for instance, have often been separated during the immigration process, and family therapists have developed psychoeducational models to use with them. But before working with immigrant families, therapists need to learn how to implement those models, so they’re not left with a vague understanding that they need to respect immigrants’ culture of origin but guessing in the moment what exactly to say.

Despite these challenges, therapists in agencies create real change in family systems and clients’ lives. Haase remembers a teenage boy who kept running away from home, committing petty crimes and winding up in jail, and then in juvenile detention when he didn’t stop. One day, he told a counselor that his father often got drunk and screamed criticisms at him. A family therapist was then able to work with the son and father, who needed help understanding how his treatment of the boy—which he said was better than how his own father treated him—was harmful. A useful question we can ask such a parent is, “How can you parent your child in the way you wished you had been parented?” Although it took several sessions for him to be able to ponder this, the father stopped verbally abusing his son, and the son stopped running away and getting arrested.

Fostering Resilience

If family therapy hasn’t been, as we believers once dreamed, a solution to all social ills, it nonetheless provides a special opportunity for helping clients, especially kids, tap into resources that can help them navigate an unjust world. “The cool thing about family therapy is that it can really help families be resilient in the face of oppressive societal forces,” says Santisteban.

If an adolescent is dealing with an instance of racism, for example, instead of talking with the child individually, Santisteban will bring up racism when the family is together. He’ll turn to the elder family members and say, “You’ve been dealing with this for years. You may not be used to talking about it directly, but why don’t you take a shot now? What are some things you’ve learned over the years?” Then, instead of hearing a therapist speak as an authority, children can hear the wisdom of their grandparents, parents, and siblings, allowing them to feel the knowledge and strength that already exists within their family. “Families often already have wisdom that they just don’t know how to articulate,” he explains, and the family therapist’s job is to ask themselves questions like “What are protective family processes here?” and “How can I mobilize parental guidance and mentoring?” so that they can provide an opening for that wisdom to be shared.

That kind of conversation is a corrective for a notion that permeated some earlier iterations of family therapy. As Knudson-Martin puts it, “For a long time, it could’ve seemed as if we were blaming the family for larger social issues. As if we could just teach people how to be better parents, everything would be all right. We family therapists missed emphasizing the social determinants of health.”

Now, especially after the COVID crisis has laid bare how deep social inequities affect every aspect of health and wellbeing, Knudson-Martin sees an opportunity to better integrate increasingly accepted systems thinking about race, gender, and class with the foundational concepts of family therapy. She sees the possibility for a renaissance in family therapy if those newer clinicians embrace therapy models that deemphasize the individual and seek to heal families and communities. “This moment is almost like in the beginning of family therapy, when people like Salvador Minuchin were talking about not just the family but about how the social context affects people.”

Despite the challenges of conducting, teaching, and disseminating family therapy, I remain as passionately devoted to it as I was three decades ago. Why? Because it just makes more sense to work with people and their troubles in their real-life social contexts. Along with directly addressing the high rates of couple and family conflict, “individual symptoms” such as anxiety, depression, trauma, and addictions always have much to do with the quality of people’s relationships. Transforming those relationships can rapidly effect a change in those symptoms. And one thing is for sure: family therapy is never boring!

***

Let us know what you think at letters@psychnetworker.org.

PHOTO © ISTOCK/DOCKEN