Social Science

Family Therapy ConCepts and Methods

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iii

Family Therapy ConCepts and Methods

eLeVenth edItIon

Michael P. Nichols College of William and Mary

with Sean D. Davis Alliant International University

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Library of Congress Cataloging-in-Publication Data Nichols, Michael P., author. Family therapy : concepts and methods / Michael P. Nichols, College of William and Mary with Sean D. Davis, Alliant International University. — Eleventh edition. pages cm Includes bibliographical references and index. ISBN 978-0-13-382660-9 — ISBN 0-13-382660-0 1. Family psychotherapy. I. Davis, Sean D., author. II. Title. RC488.5.N53 2016 616.89’156—dc23 2015032118

10 9 8 7 6 5 4 3 2 1

Student Edition ISBN 10: 0-13-382660-0

ISBN 13: 978-0-13-382660-9

eText ISBN 10: 0-13-382681-3 ISBN 13: 978-0-13-382681-4

Package ISBN 10: 0-13-430074-2 ISBN 13: 978-0-13-430074-0

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v

The Stages of the Family Life Cycle xiii Major Events in the History of Family Therapy xv Foreword xxi Preface xxiii

PART One THE CONTEXT OF FAMILY THERAPY

Introduction The Foundations of Family Therapy 1 The Myth of the Hero 3 Psychotherapeutic Sanctuary 4 Family versus Individual Therapy 5 Thinking in Lines, Thinking in Circles 6 The Power of Family Therapy 6

1 The Evolution of Family Therapy 8 The Undeclared War 8

Small Group Dynamics 9 The Child Guidance Movement 11 Marriage Counseling 12

Research on Family Dynamics and the Etiology of Schizophrenia 13 Gregory Bateson—Palo Alto 13 Theodore Lidz—Yale 15 Lyman Wynne—National Institute of Mental Health 15 Role Theorists 16

From Research to Treatment: The Pioneers of Family Therapy 16 John Bell 16 Palo Alto 17 Murray Bowen 19 Nathan Ackerman 21 Carl Whitaker 21 Ivan Boszormenyi-Nagy 22 Salvador Minuchin 22 Other Early Centers of Family Therapy 23

The Golden Age of Family Therapy 24 SUMMARY 25

ConTEnTS

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vi Contents

2 Basic Techniques of Family Therapy 27 Getting Started 27

The Initial Telephone Call 27 The First Interview 28 The Early Phase of Treatment 30 The Middle Phase of Treatment 32 Termination 33 Termination Checklist 34

Family Assessment 34 The Presenting Problem 34 Understanding the Referral Route 35 Identifying the Systemic Context 35 Stage of the Life Cycle 36 Family Structure 36 Communication 36 Drug and Alcohol Abuse 37 Domestic Violence and Sexual Abuse 37 Extramarital Affairs 37 Gender 38 Culture 38

The Ethical Dimension 39 The Marriage and Family Therapy License 42

Family Therapy with Specific Presenting Problems 42 Marital Violence 42 Sexual Abuse of Children 45

Working with Managed Care 46 Fee-for-Service Private Practice 48

SUMMARY 49

3 The Fundamental Concepts of Family Therapy 50 Cybernetics 51 Systems Theory 54

General Systems Theory 55 Social Constructionism 55

Constructivism 56 The Social Construction of Reality 56

Attachment Theory 57 The Working Concepts of Family Therapy 60

Interpersonal Context 60 Complementarity 60 Circular Causality 60 Triangles 61 Process/Content 62 Family Structure 62 Family Life Cycle 63

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Contents vii

Family Narratives 64 Gender 65 Culture 66

SUMMARY 67

PART TWO THE CLASSIC SCHOOLS OF FAMILY THERAPY

4 Bowen Family Systems Therapy 69 Sketches of Leading Figures 70 Theoretical Formulations 70

Differentiation of Self 71 Emotional Triangles 71 Multigenerational Emotional Processes 72 Emotional Cutoff 72 Societal Emotional Process 73

Family Dynamics 73 Normal Family Functioning 73 Development of Behavior Disorders 74

Mechanisms of Change 76 Goals of Therapy 76 Conditions for Behavior Change 77

Therapy 77 Assessment 77 Therapeutic Techniques 80

Evaluating Therapy Theory and Results 85 SUMMARY 87

5 Strategic Family Therapy 89 Sketches of Leading Figures 89 Theoretical Formulations 91 Family Dynamics 93

Normal Family Functioning 93 Development of Behavior Disorders 93

Mechanisms of Change 94 Goals of Therapy 95 Conditions for Behavior Change 95

Therapy 95 Assessment 95 Therapeutic Techniques 97

Evaluating Therapy Theory and Results 107 SUMMARY 109

6 Structural Family Therapy 111 Sketches of Leading Figures 112 Theoretical Formulations 112

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viii Contents

Family Dynamics 115 Normal Family Functioning 115 Development of Behavior Disorders 116

Mechanisms of Change 118 Goals of Therapy 118 Conditions for Behavior Change 118

Therapy 119 Assessment 119 Therapeutic Techniques 121

Evaluating Therapy Theory and Results 127 SUMMARY 129

7 Experiential Family Therapy 131 Sketches of Leading Figures 132 Theoretical Formulations 132 Family Dynamics 133

Normal Family Functioning 133 Development of Behavior Disorders 133

Mechanisms of Change 134 Goals of Therapy 134 Conditions for Behavior Change 135

Therapy 135 Assessment 135 Therapeutic Techniques 136

Evaluating Therapy Theory and Results 146 SUMMARY 147

8 Psychoanalytic Family Therapy 149 Sketches of Leading Figures 150 Theoretical Formulations 150

Freudian Drive Psychology 151 Self Psychology 152 Object Relations Theory 152

Family Dynamics 154 Normal Family Functioning 155 Development of Behavior Disorders 156

Mechanisms of Change 158 Goals of Therapy 158 Conditions for Behavior Change 159

Therapy 159 Assessment 159 Therapeutic Techniques 160

Evaluating Therapy Theory and Results 165 SUMMARY 166

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Contents ix

9 Cognitive-Behavioral Family Therapy 167 Sketches of Leading Figures 167 Theoretical Formulations 169 Family Dynamics 169

Normal Family Functioning 169 Development of Behavior Disorders 170

Mechanisms of Change 172 Goals of Therapy 172 Conditions for Behavior Change 172

Therapy 173 Behavioral Parent Training 173 Behavioral Couples Therapy 177 The Cognitive-Behavioral Approach to Family Therapy 180 Treatment of Sexual Dysfunction 184

Evaluating Therapy Theory and Results 185 SUMMARY 187

PART THRee RECENT DEVELOPMENTS IN FAMILY THERAPY

10 Family Therapy in the Twenty-First Century 189 Challenges to Traditional Family Systems Models 189

Erosion of Boundaries 189 Postmodernism 190 The Feminist Critique 190 Feminist Family Therapy 191 Social Constructionism and the Narrative Revolution 194 Multiculturalism 195 Race 195 Poverty and Social Class 196 Gay and Lesbian Rights 197

New Frontiers 198 Advances in Neuroscience 198 Sex and the Internet 199 Spirituality and Religion 203

Tailoring Treatment to Populations and Problems 204 Single-Parent Families 205 African American Families 207 Gay and Lesbian Families 209 Home-Based Services 212 Psychoeducation and Schizophrenia 213 Medical Family Therapy 215 Relationship Enrichment Programs 215

SUMMARY 216

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x Contents

11 Solution-Focused Therapy 219 Sketches of Leading Figures 219 Theoretical Formulations 220 Family Dynamics 221

Normal Family Development 221 Development of Behavior Disorders 221

Mechanisms of Change 221 Goals of Therapy 222 Conditions for Behavior Change 222

Therapy 222 Assessment 222 Therapeutic Techniques 224 Taking a Break and Giving Feedback 232 Later Sessions 233 Interviewing Children 235

Evaluating Therapy Theory and Results 236 SUMMARY 237

12 narrative Therapy 239 Sketches of Leading Figures 240 Theoretical Formulations 240 Family Dynamics 242

Normal Family Development 242 Development of Behavior Disorders 242

Mechanisms of Change 243 Goals of Therapy 243 Conditions for Behavior Change 244

Therapy 245 Assessment 245 Therapeutic Techniques 246

Evaluating Therapy Theory and Results 254 SUMMARY 255

PART FOUR THE EVALUATION OF FAMILY THERAPY

13 Comparative Analysis 257 Theoretical Formulations 257

Families as Systems 257 Stability and Change 258 Process/Content 259 Monadic, Dyadic, and Triadic Models 259 Boundaries 260

Family Dynamics 261 Normal Family Development 261

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Contents xi

Development of Behavior Disorders 262 Inflexible Systems 262 Pathologic Triangles 263

Therapy 264 Assessment 264 Decisive Interventions 264

Integrative Models 268 Eclecticism 268 Selective Borrowing 268 Specially Designed Integrative Models 269

Integrative Problem-Centered Metaframeworks (IPCM) Therapy 269 The Narrative Solutions Approach 270 Integrative Couples Therapy 271 Dialectical Behaviorism 272 Other Integrative Models 273 Community Family Therapy 274

SUMMARY 275

14 Research on Family Intervention 276 Research and Practice: Worlds Apart 276 Methodological Issues in Studying the Effectiveness of Family Therapy 277 Research Findings on the Effectiveness of Family-Focused Interventions 279

Family Interventions for Childhood Problems 279 Family Interventions for Adult Disorders 281 Family Interventions for Relationship Difficulties 283

Family Therapy Process Research 284 Common Factors 285 The Therapeutic Alliance 285 Critical Change Events in Family Therapy 286

Future Directions 288

Appendix A Chapter-by-Chapter Recommended Readings 290

Appendix B Selected Readings in Family Therapy 296

Appendix C Glossary 298

References 305

Index 342

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xiii

Family Life-Cycle Stage emotional Process of Transition: Key Principles

Second-Order Changes in Family Status Required to Proceed Developmentally

Leaving home: single young adults

Accepting emotional and financial responsibility for self

a. Differentiation of self in relation to family of origin b. Development of intimate peer relationships c. Establishment of self in respect to work and financial

independence

The joining of families through marriage: the new couple

Commitment to new system

a. Formation of marital system b. Realignment of relationships with extended families

and friends to include spouse

Families with young children

Accepting new members into the system

a. Adjusting marital system to make space for children b. Joining in childrearing, financial and household tasks c. Realignment of relationships with extended family to

include parenting and grandparenting roles

Families with adolescents Increasing flexibility of family boundaries to permit children’s independence and grandparents’ frailties

a. Shifting of parent–child relationships to permit ado- lescent to move into and out of system

b. Refocus on midlife marital and career issues c. Beginning shift toward caring for older generation

Launching children and moving on

Accepting a multitude of exits from and entries into the family system

a. Renegotiation of marital system as a dyad b. Development of adult-to-adult relationships c. Realignment of relationships to include in-laws and

grandchildren d. Dealing with disabilities and death of parents (grand-

parents)

Families in later life Accepting the shifting generational roles

a. Maintaining own and/or couple functioning and interests in face of physiological decline: exploration of new familial and social role options

b. Support for more central role of middle generation c. Making room in the system for the wisdom and expe-

rience of the elderly, supporting the older generation without overfunctioning for them

d. Dealing with loss of spouse, siblings, and other peers and preparation for death

ThE STAgES oF ThE FAMIlY lIFE CYClE

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Social and Political Context Development of Family Therapy

1945 F.D.R. dies, Truman becomes president World War II ends in Europe (May 8) and the

Pacific (August 14)

Bertalanffy presents general systems theory

1946 Juan Perón elected president of Argentina Bowen at Menninger Clinic Whitaker at Emory Macy Conference Bateson at Harvard

1947 India partitioned into India and Pakistan

1948 Truman reelected U.S. president State of Israel established

Whitaker begins conferences on schizophrenia

1949 Communist People’s Republic of China established

Bowlby: “The Study and Reduction of Group Tensions in the Family”

1950 North Korea invades South Korea Bateson begins work at Palo Alto V.A.

1951 Julius and Ethel Rosenberg sentenced to death for espionage

Sen. Estes Kefauver leads Senate probe into organized crime

Ruesch & Bateson: Communication: The Social Matrix of Society

Bowen initiates residential treatment of mothers and children

Lidz at Yale

1952 Eisenhower elected U.S. president Bateson receives Rockefeller grant to study communication in Palo Alto Wynne at NIMH

1953 Joseph Stalin dies Korean armistice signed

Whitaker & Malone: The Roots of Psychotherapy

1954 Supreme Court rules school segregation unconstitutional

Bateson project research on schizophrenic communication

Bowen at NIMH

1955 Rosa Parks refuses to move to the back of the bus; Martin Luther King, Jr., leads boycott in Montgomery, Alabama

Whitaker in private practice, Atlanta, Georgia. Satir begins teaching family dynamics in Chicago

1956 Nasser elected president of Egypt Soviet troops crush anti-Communist rebellion

in Hungary

Bateson, Jackson, Haley, & Weakland: “Toward a Theory of Schizophrenia”

Bowen at Georgetown

MAjoR EvEnTS In ThE hISToRY oF FAMIlY ThERAPY

(continued)

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xvi Major events in the History of Family Therapy

Social and Political Context Development of Family Therapy

1957 Russians launch Sputnik I Eisenhower sends troops to Little Rock,

Arkansas, to protect school integration

Jackson: “The Question of Family Homeostasis” Ackerman opens the Family Mental Health Clinic of

Jewish Family Services in New York Boszormenyi-Nagy opens Family Therapy

Department at EPPI in Philadelphia

1958 European Common Market established Ackerman: The Psychodynamics of Family Life

1959 Castro becomes premier of Cuba Charles de Gaulle becomes French president

MRI founded by Don Jackson

1960 Kennedy elected U.S. president Family Institute founded by Nathan Ackerman (renamed the Ackerman Institute in 1971)

Minuchin and colleagues begin doing family therapy at Wiltwyck

1961 Berlin Wall erected Bay of Pigs invasion

Bell: Family Group Therapy Family Process founded by Ackerman and Jackson

1962 Cuban Missile Crisis Bateson’s Palo Alto project ends Haley at MRI

1963 Kennedy assassinated Haley: Strategies of Psychotherapy

1964 Johnson elected U.S. president Nobel Peace Prize awarded to Martin Luther

King, Jr.

Satir: Conjoint Family Therapy Norbert Wiener dies (b. 1894)

1965 Passage of Medicare Malcolm X assassinated

Minuchin becomes director of Philadelphia Child Guidance Clinic

Whitaker at University of Wisconsin

1966 Red Guards demonstrate in China Indira Gandhi becomes prime minister of

India

Brief Therapy Center at MRI begun under director- ship of Richard Fisch

Ackerman: Treating the Troubled Family

1967 Six-Day War between Israel and Arab states Urban riots in Cleveland, Newark, and Detroit

Watzlawick, Beavin, & Jackson: Pragmatics of Human Communication

Dicks: Marital Tensions

1968 Nixon elected U.S. president Robert Kennedy and Martin Luther King, Jr.,

assassinated

Don Jackson dies (b. 1920) Satir at Esalen

1969 Widespread demonstrations against war in Vietnam

Bandura: Principles of Behavior Modification Wolpe: The Practice of Behavior Therapy

1970 Student protests against Vietnam War result in killing of four students at Kent State

Masters & Johnson: Human Sexual Inadequacy Laing & Esterson: Sanity, Madness and the Family

1971 Twenty-Sixth Amendment grants right to vote to 18-year-olds

Nathan Ackerman dies (b. 1908)

1972 Nixon reelected U.S. president Bateson: Steps to an Ecology of Mind Wynne at University of Rochester

1973 Supreme Court rules that states may not prohibit abortion

Energy crisis created by oil shortages

Center for Family Learning founded by Phil Guerin Boszormenyi-Nagy & Spark: Invisible Loyalties

1974 Nixon resigns Gerald Ford becomes 39th president

Minuchin: Families and Family Therapy Watzlawick, Weakland, & Fisch: Change

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Major events in the History of Family Therapy xvii

Social and Political Context Development of Family Therapy

1975 Vietnam War ends Mahler, Pine, & Bergman: The Psychological Birth of the Human Infant

Stuart: “Behavioral Remedies for Marital Ills”

1976 Carter elected U.S. president Haley: Problem-Solving Therapy Haley to Washington, D.C.

1977 President Carter pardons most Vietnam War draft evaders

Family Institute of Westchester founded by Betty Carter

American Family Therapy Academy (AFTA) estab- lished

1978 Camp David Accords between Egypt and Israel

U.S. and People’s Republic of China establish diplomatic relations

Hare-Mustin: “A Feminist Approach to Family Therapy”

Selvini Palazzoli et al.: Paradox and Counterparadox

1979 England’s Margaret Thatcher becomes West’s first woman prime minister

Iranian militants seize U.S. Embassy in Tehran and hold hostages

Founding of Brief Therapy Center in Milwaukee Bateson: Mind and Nature

1980 Reagan elected U.S. president U.S. boycotts summer Olympic Games in

Moscow

Haley: Leaving Home Milton Erickson dies (b. 1901) Gregory Bateson dies (b. 1904)

1981 Sandra Day O’Connor becomes first woman justice of Supreme Court

Egyptian president Sadat assassinated

Hoffman: The Foundations of Family Therapy Madanes: Strategic Family Therapy Minuchin & Fishman: Family Therapy Techniques

1982 Equal Rights Amendment fails ratification Falklands war

Gilligan: In a Different Voice Fisch, Weakland, & Segal: Tactics of Change The Family Therapy Networker founded by Richard Simon

1983 U.S. invades Grenada Terrorist bombing of Marine headquarters in

Beirut

Doherty & Baird: Family Therapy and Family Medicine

Keeney: Aesthetics of Change

1984 Reagan reelected U.S. president U.S.S.R. boycotts summer Olympic Games in

Los Angeles

Watzlawick: The Invented Reality Madanes: Behind the One-Way Mirror

1985 Gorbachev becomes leader of U.S.S.R. de Shazer: Keys to Solution in Brief Therapy Gergen: “The Social Constructionist Movement in

Modern Psychology”

1986 Space shuttle Challenger explodes Anderson et al.: Schizophrenia and the Family Selvini Palazzoli: “Towards a General Model of

Psychotic Family Games”

1987 Congress investigates the Iran–Contra affair Tom Andersen: “The Reflecting Team” Guerin et al.: The Evaluation and Treatment of

Marital Conflict Scharff & Scharff: Object Relations Family Therapy

1988 George H. W. Bush elected U.S. president Kerr & Bowen: Family Evaluation Virginia Satir dies (b. 1916)

(continued)

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xviii Major events in the History of Family Therapy

Social and Political Context Development of Family Therapy

1989 The Berlin Wall comes down Boyd-Franklin: Black Families in Therapy

1990 Iraq invades Kuwait Murray Bowen dies (b. 1913) White & Epston: Narrative Means to Therapeutic

Ends

1991 Persian Gulf War against Iraq Harold Goolishian dies (b. 1924)

1992 Clinton elected U.S. president Family Institute of New Jersey founded by Monica McGoldrick

1993 Ethnic cleansing in Bosnia Los Angeles police officers convicted in

Rodney King beating

Israel Zwerling dies (b. 1917) Minuchin & Nichols: Family Healing

1994 Republicans win majority in Congress Nelson Mandela elected president of South

Africa

David and Jill Scharf leave Washington School of Psychiatry to begin the International Institute of Object Relations Therapy

1995 Oklahoma City federal building bombed Carl Whitaker dies (b. 1912) John Weakland dies (b. 1919) Salvador Minuchin retires Family Studies Inc. renamed The Minuchin Center

1996 Clinton reelected U.S. president Edwin Friedman dies (b. 1932) Eron & Lund: Narrative Solutions in Brief Therapy Freedman & Combs: Narrative Therapy

1997 Princess Diana dies in auto accident Hong Kong reverts to China

Michael Goldstein dies (b. 1930)

1998 President Clinton impeached by House of Representatives

Minuchin, Colapinto, & Minuchin: Working with Families of the Poor

1999 President Clinton acquitted in impeachment trial

Neil Jacobson dies (b. 1949) John Elderkin Bell dies (b. 1913) Mara Selvini Palazzoli dies (b. 1916)

2000 George W. Bush elected U.S. president Millennium Conference, Toronto, Canada

2001 September 11 terrorist attacks James Framo dies (b. 1922)

2002 Sex abuse scandal in Catholic Church Corporate corruption at Enron

Lipchik: Beyond Techniques in Solution-Focused Therapy

2003 U.S. invades Iraq Greenan & Tunnell: Couple Therapy with Gay Men

2004 George W. Bush reelected U.S. president Gianfranco Cecchin dies (b. 1932)

2005 Hurricane Katrina devastates New Orleans Steve de Shazer dies (b. 1940)

2006 Democrats regain control of U.S. House and Senate

Minuchin, Nichols, & Lee: Assessing Families and Couples

2007 Shootings at Virginia Tech Jay Haley dies (b. 1923) Lyman Wynne dies (b. 1923) Insoo Kim Berg dies (b. 1934) Albert Ellis dies (b. 1913) Thomas Fogarty dies (b. 1927)

2008 Barack Obama elected U.S. president Michael White dies (b. 1949)

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Major events in the History of Family Therapy xix

Social and Political Context Development of Family Therapy

2009 Worldwide economic recession Sprenkle, Davis, & Lebow: Common Factors in Couple and Family Therapy

2010 Earthquake in Haiti LaSala: Coming Out, Coming Home Dattilio: Cognitive-Behavioral Therapy with Couples

and Families

2011 Earthquake and tsunami in Japan Cose: The End of Anger

2012 Mass shootings in Newton CT Barack Obama reelected U.S. president

Betty Carter dies (b. 1929)

2013 Death of Nelson Mandela Affordable Healthcare Act

Alan Gurman dies (b. 1945)

2014 Ebola epidemic in West Africa Donald Bloch dies (b. 1923)

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xxi

In this volume, Mike Nichols tells the story of family therapy—and tells it very well. It’s hard to imagine a more readable and informative guide to the field.

Born in the late 1950s, family therapy seemed to spring fully formed out of the heads of a group of seminal thinkers. Over six decades later, both theory and practice show the uncertainties and doubts that define maturity. But in the beginning—as the story- tellers say—there was Gregory Bateson on the West Coast, a tall, clean-shaven, angular intellectual, who saw families as systems, carriers of ideas. On the East Coast was Nathan Ackerman, short, bearded, portly, the quintessential charismatic healer, who saw fam- ilies as collections of individuals struggling to bal- ance feelings, irrationalities, and desires. Bateson and Ackerman complemented each other perfectly, the Don Quixote and Sancho Panza of the family systems revolution.

For all the diversity of the 1960s that saw the new clinical practice called family therapy take a variety of names—systemic, strategic, structural, Bowenian, experiential—there was also a remarkable solidarity in the shared beliefs that defined the field.

As family therapy succeeded and expanded, it was extended to encompass different client popula- tions, with specific interventions for various special groups—clients with drug addictions, hospitalized psychiatric patients, the welfare population, violent families, and so on. All posed their own complexities. Practitioners responded to this expanded family ther- apy with an array of new approaches, some of which even questioned the fundamental allegiance to sys- tems thinking.

The challenges to systems theory (the official sci- ence of the time) took two forms. One was purely the- oretical: a challenge to the assumption that systemic thinking was a universal framework, applicable to the

functioning of all human collectives. A major broad- side came from feminists who questioned the absence of concepts of gender and power in systems thinking and pointed to the distorting consequences of gender- less theory when focusing on family violence. The other challenge concerned the connection between theory and practice: a challenge to the imposition of systems theory as the basis for therapeutic practice. The very techniques that once defined the field were called into question. Inevitably, the field began to re- open for examination of its old taboos: the individual, intrapsychic life, emotions, biology, the past, and the particular place of the family in culture and society.

As is always characteristic of an official science, the field tried to preserve established concepts while a pragmatic attention to specific cases was demand- ing new and specific responses. As a result, today we have an official family therapy that claims direct de- scendance from Bateson and a multitude of excellent practitioners doing sensitive and effective work that is frequently quite different from what systems theory prescribes.

I see the therapeutic process as an encounter between distinct interpersonal cultures. Real respect for clients and their integrity can allow therapists to be other than fearfully cautious, can encourage them to be direct and authentic—respectful and compassionate— but also at times honest and challenging.

This conception of the therapist as an active knower—of himself or herself and of the different family members—is very different from the neutral therapist of the constructivists. But, of course, these two prototypes are entirely too simplified. Most prac- titioners fall somewhere between these two poles of neutrality and decisiveness.

The choice between action and interventionism, on the one hand, and meaning and conversation,

FoREwoRd

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xxii Foreword

on the other, is but one of the questions the field is grappling with today; there are many others. Are the norms of human behavior universal, or are they cultur- ally constructed products of political and ideological constraint? How do we become experts? How do we know what we know? Can we influence people? Can we not influence them? How do we know that we are not simply agents of social control? How do we know that we are accomplishing anything at all?

These questions and the rich history and contem- porary practice of family therapy are explored in Family Therapy: Concepts and Methods. It is a thor- ough and thoughtful, fair and balanced guide to the

ideas and techniques that make family therapy such an exciting enterprise. Dr. Nichols has managed to be comprehensive without becoming tedious. Per- haps the secret is the engaging style of his writing, or perhaps it is how he avoids getting lost in abstrac- tion while keeping a clear focus on clinical practice. In any case, this superb book has long set the standard of excellence as the best introduction and guide to the practice of family therapy.

Salvador Minuchin, M.D.

Boca Raton, Florida

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xxiii

PReFAce

One thing that sometimes gets lost in academic dis- cussions of family therapy is the feeling of accom- plishment that comes from sitting down with an unhappy family and being able to help them. Begin- ning therapists are understandably anxious and not sure they’ll know how to proceed. (“How do you get all of them to come in?”) Veterans often speak in abstractions. They have opinions and discuss big issues—postmodernism, managed care, second- order cybernetics. While it’s tempting to use this space to say Important Things, I prefer to be a little more per- sonal. Treating troubled families has given me the greatest satisfaction imaginable, and I hope that the same is or will be true for you.

New to This edition

In this eleventh edition of Family Therapy: Concepts and Methods, I’ve tried to describe the full scope of family therapy—its rich history, the classic schools, the latest developments—but with increasing empha- sis on clinical practice. There are a lot of changes in this edition:

New Digital Enhancements in the Pearson eText

♦ Videos: Links to video clips of therapists have been embedded for students to view throughout the chapters of the Pearson eText. Students are prompted to reflect on and analyze the videos via an accompanying question.

♦ Chapter Quizzes: At the end of each chapter Summary, students will find two self-assessments marked by a checkmark icon. In the Pearson eText,

they click on the icon and the quiz appears. The first one prompts them to test their knowledge of chapter concepts by taking a multiple-choice quiz.

The second quiz icon prompts them to apply their knowledge of chapter concepts by responding to open-ended questions by typing their response and submitting it for immediate feedback. These self- assessments can reinforce understanding of key chapter concepts and support application of newly learned content.

Content Changes in the New Edition

♦ New section on the impact of the Affordable Care Act ♦ Recommendations for establishing a fee-for- service

private practice ♦ Revised and expanded section on attachment

theory ♦ Questions to ask when doing a genogram ♦ More specific interventions from the MRI

approach ♦ Detailed guidelines for making a structural family

therapy assessment ♦ New section with guidelines on using family

sculpting ♦ More specific techniques used in object relations

family therapy ♦ Expanded section on spirituality and religion ♦ Expanded and updated section on families and

technology ♦ Guidelines for therapeutic letter writing ♦ New research chapter including a discussion of

why research has failed to influence practice and suggestions for bridging the research-practice gap

♦ New case studies

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xxiv Preface

Instructor Supplements

An instructor’s manual, test bank, and PowerPoint slides are available to accompany this text. They can be downloaded at www.pearsonhighered.com/educator.

Acknowledgments

Albert Einstein once said, “If you want to learn about physics, pay attention to what physicists do, not what they say they do.” When you read about therapy, it can be hard to see past the jargon and political packaging to the essential ideas and practices. So in preparing this edition, I’ve traveled widely to visit and observe actual sessions of the leading practitioners. I’ve also invited several master therapists to share some of their best case studies with you. The result is a more prag- matic, clinical focus. I hope you like it.

So many people have contributed to my develop- ment as a family therapist and to the writing of this book that it is impossible to thank them all. But I would like to single out a few. To the people who taught me family therapy—Lyman Wynne, Murray Bowen, and Salvador Minuchin—thank you. Some of the people

who went out of their way to help me prepare this eleventh edition were Yvonne Dolan, Jerome Price, Deborah Luepnitz, William Madsen, Frank Dattilio, Vicki Dickerson, Douglas Breunlin, and Salvador Minuchin. And I owe a huge debt of gratitude to Sean Davis for his extensive and thoughtful contributions to this edition. Sean has the rare combination of ac- ademic smarts and clinical sophistication that makes his perspective so valuable. To paraphrase John, Paul, George, and Ringo, I get by with a lot of help from my friends—and I thank them one and all. I am especially grateful to Julie Peters at Pearson for making a hard job easier.

Finally, I would like to thank my postgraduate instructors in family life: my wife, Melody, and my children, Sandy and Paul. In the brief span of forty-five years, Melody has seen me grow from a shy young man, totally ignorant of how to be a husband and father, to a shy middle-aged man, still bewildered and still trying. My children never cease to amaze me. If in my wildest dreams I had imagined children to love and be proud of, I wouldn’t even have come close to children as fine as Sandy and Paul.

M. P. N.

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I n t r o d u c t I o n

The FoundaTions oF Family Therapy Leaving Home

There wasn’t much information on the intake sheet. Just a name, Holly Roberts, the fact that she was a senior in college, and her presenting complaint: “trouble making decisions.”

The first thing Holly said when she sat down was, “I’m not sure I need to be here. You prob- ably have a lot of people who need help more than I do.” Then she started to cry.

It was springtime. The tulips were up, the trees were turning leafy green, and purple clumps of lilacs perfumed the air. Life and all its possibilities stretched out before her, but Holly was naggingly, unaccountably depressed.

The decision Holly was having trouble making was what to do after graduation. The more she tried to figure it out, the less able she was to concentrate. She started sleeping late, missing classes. Finally, her roommate talked her into going to the counseling center. “I wouldn’t have come,” Holly said. “I can take care of my own problems.”

I was into cathartic therapy back then. Most people have stories to tell and tears to shed. Some of the stories, I suspected, were dramatized to elicit sympathy. We seem to give ourselves permission to cry only with some very accept- able excuse. Of all the human emotions we’re ashamed of, feeling sorry for yourself tops the list.

I didn’t know what was behind Holly’s depres- sion, but I was sure I could help. I felt comforta- ble with depression. Ever since my senior year in high school when my friend Alex died, I’d been a little depressed myself.

♦  ♦  ♦

After Alex died, the rest of the summer was a dark blur. I cried a lot. And I got mad whenever any- body suggested that life goes on. Alex’s minister said that his death wasn’t really a tragedy because now “Alex was with God in heaven.” I wanted to scream,

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but I numbed myself instead. In the fall, I went off to college, and, even though it seemed disloyal to Alex, life did go on. I still cried from time to time, but with the tears came a painful discovery. Not all of my grief was for Alex. Yes, I loved him. Yes, I missed him. But his death provided me the justification to cry about the everyday sorrows of my own life. Maybe grief is always like that. At the time, though, it struck me as a betrayal. I was using Alex’s death to feel sorry for myself.

♦  ♦  ♦

What, I wondered, was making Holly so sad? In fact, Holly didn’t have a dramatic story. Her feelings weren’t focused. After those first moments in my of- fice, she rarely cried. When she did, it was more an involuntary tearing up than a sobbing release. She talked about the future and not knowing what she wanted to do with her life. She talked about not hav- ing a boyfriend, but she didn’t say much about her family. If the truth be told, I wasn’t much interested. Back then, I thought home was a place you left in or- der to grow up.

Holly was hurting and needed someone to lean on, but something made her hold back, as though she didn’t quite trust me. It was frustrating. I wanted to help.

A month went by, and Holly’s depression got worse. I started seeing her twice a week, but we weren’t getting anywhere. One Friday afternoon, Holly was feeling so despondent that I didn’t think she should go back to her dorm alone. I asked her in- stead to lie down on the couch in my office and, with her permission, I called her parents.

Mrs. Roberts answered the phone. I told her that I thought she and her husband should come to Rochester and meet with me and Holly to discuss the advis- ability of Holly taking a medical leave of absence. Unsure as I was of my authority back then, I steeled myself for an argument. Mrs. Roberts surprised me by agreeing to come at once.

The first thing that struck me about Holly’s parents was the disparity in their ages. Mrs. Roberts looked like a slightly older version of Holly; she couldn’t have been much over thirty-five. Her husband looked sixty. It turned out that he was Holly’s stepfather. They had married when Holly was sixteen.

Looking back, I don’t remember much that was said in that first meeting. Both parents were worried about Holly. “We’ll do whatever you think best,” Mrs. Roberts said. Holly’s stepfather, Mr. Morgan, said they could arrange for a good psychiatrist “to help Holly over this crisis.” But, Holly didn’t want to go home, and she said so with more energy than I’d heard from her in a long time. That was on Saturday. I said that there was no need to rush into a decision, so we arranged to meet again on Monday.

When Holly and her parents sat down in my office on Monday morning, it was obvious that some- thing had happened. Mrs. Roberts’s eyes were red from crying. Holly glared at her and looked away. Mr. Morgan turned to me. “We’ve been fighting all weekend. Holly heaps abuse on me, and when I try to respond, Lena takes her side. That’s the way it’s been since day one of this marriage.”

The story that emerged was one of those sad his- tories of jealousy and resentment that turn ordinary love into bitter, injured feelings and, all too often, tear families apart. Lena Roberts was thirty-four when she met Tom Morgan. He was a robust fifty-six. The sec- ond obvious difference between them was money. He was a stockbroker who’d retired to run a horse farm. She was waitressing to support herself and her daugh- ter. It was a second marriage for both of them.

Lena thought Tom could be the missing father fig- ure in Holly’s life. Unfortunately, Lena couldn’t ac- cept all the rules Tom wanted to enforce, and so he became the wicked stepfather. He made the mistake of trying to take over and, when the predictable ar- guments ensued, Lena sided with her daughter. There were tears and midnight shouting matches. Twice Holly ran away for a few days. This triangle nearly proved the marriage’s undoing, but things calmed down after Holly left for college.

Holly expected to leave home and not look back. She would make new friends. She would study hard and choose a career. She would never depend on a man to support her. Unfortunately, she left home with unfinished business. She hated Tom for the way he treated her mother. He was always demanding to know where her mother was going, who she was going with, and when she would be back. If she was the least bit late, there would be a scene. Why did her mother put up with it?

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Blaming her stepfather was simple and satisfying. But another set of feelings, harder to face, was eat- ing at Holly. She hated her mother for marrying Tom and for letting him be so mean to her. What had her mother seen in him? Had she sold out for a big house and a fancy car? Holly didn’t have answers to these questions; she didn’t even allow them into full aware- ness. Unfortunately, repression doesn’t work like put- ting something away in a closet and forgetting about it. It takes a lot of energy to keep unwelcome emo- tions at bay.

Holly found excuses not to go home during col- lege. It didn’t even feel like home anymore. She buried herself in her studies. But rage and bitterness gnawed at her until, in her senior year, facing an uncertain future, knowing only that she couldn’t go home again, she gave in to hopelessness. No wonder she was depressed.

I found the whole story sad. Not knowing about family dynamics and never having lived in a step- family, I wondered why they couldn’t just try to get along. Why did they have so little sympathy for each other? Why couldn’t Holly accept her mother’s right to find love a second time around? Why couldn’t Tom respect the priority of his wife’s relationship with her daughter? And why couldn’t Lena listen to her daugh- ter’s adolescent anger without getting so defensive?

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