family therapy


A few weeks ago, one of my posts received a comment that was worth a whole post:

I am also a therapist (though I’m still in training). I’m wondering if you would be willing/able to recommend some family therapy books you’ve found helpful. My program is very focused on the individual and I’m trying to fill in some gaps and find your perspective on therapy to be very resonant with my own.

I’d love to recommend some family therapy books! My program was extremely family-systems focused, which I’ve been grateful for since leaving school. If you want to see an exhaustive reading list (I can’t remember having been assigned a real dud), you can see reverse-order lists of everything I read in my first year here and my second year here.

I’ll try to create a bare-bones list for you here—much more useful for you and a good exercise for me. I should warn you before I begin that I am super nerdy when it comes to family therapy reading and I can imagine many in my cohort rolling their eyes at my “must-read” list. If you are nerdy like me, though, here goes:

Pragmatics of Human Communication: A classic and profound book by Bateson’s MRI team, the first and probably still the best attempt to apply system theory to human relationships.

Susan Johnson’s books The Practice of Emotionally Focused Couple Therapy and Emotionally Focused Couple Therapy for Trauma Survivors. Johnson combines system-thinking, Rogers-style experiential therapy, and attachment theory, creating one of my most-used therapy models.

John Gottman’s books, especially The Marriage Clinic and The Science of Trust. Gottman has taken up the project started with Pragmatics, largely abandoned by family therapy, and is doing it in fine style, with solid science.

Metaframeworks: This book presents my favorite meta-model of family therapy, combining the best parts of the many family therapy models.

A major work by each family therapy model-builder is also important reading: Haley, Madanes, Satir, Whitaker, Minuchin, Bowen, Selvini-Palazolli/Milan group, Weakland/Fisch/MRI group, deShazer/Insoo-Berg, Epson/White, and Hubble/Duncan/Miller. Keep in mind that their books are presentations of informed opinion, not science. Every one of these folks have got some things right and some wrong. They have also advanced the field significantly, and are the largest part the conversation on how to think about families.

Finally, a couple things that I was not assigned in school, but I found extremely helpful in making sense of the flood of information. First, a grounding in systems/complexity theory: Family therapists think of themselves as system-theory experts and throw around a lot of lingo that they may or may not really understand. It’s easy to get confused in this situation. The best introduction to modern system thinking is still Capra’s The Web of Life (though we’re overdue for an update). Also, check out Bateson’s books Steps to an Ecology of Mind and Mind and Nature. Second, familiarity with Wilber’s integral theory really helped me navigate the heated arguments about modernism vs. post-modernism and intervention at the level of individuals vs. family systems vs. larger systems. Check out Integral Psychology or A Theory of Everything.

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When I find myself in the presence of a new very smart person, my favorite question to ask is,”What is the most interesting question in your field?”* It both makes for great conversation and expands my sense of the envelope of human inquiry.

If you have an idea about the most interesting question in your field, I’d love to hear about it in a comment below. If you are the kind of person who creates and publicizes websites, though, what I’d like even more is for you to create a wiki-style site where folks can go, create a forum for their field or sub-discipline, and propose and vote on most interesting questions. This could generate what I want to look at: a home page that is a self-updating outline of what professionals believe are the most interesting questions in their field. If you want to go whole-hog, you could also let them vote on and link to what they believe are the best pieces of research on their question to date.

And since I posed the question, I should probably tackle it for my own field… I am a couples and family therapist, and I propose that the most interesting question in my field is, “What are the precise mechanisms of therapeutic change in couple and family systems?” In other words, how does therapy work? We know that it is helpful in most cases, and we have endless models and speculations about how it works, but virtually no evidence about the mechanisms of change. The best research I know about on the topic is the qualitative, two-part, “What Clients of Couple Therapy Model Developers and Their Former Students Say About Change,” by Davis & PiercyEdging into that territory from another angle is the research summarized in Gottman’s The Science of Trust.

*I stole this question from very-smart-person Ethan Mitchell.

As a family therapist, when I am presented with a child exhibiting symptoms of ADHD, I am trained to look at the child’s environment and history, especially their family relationships. How is it that these behaviors might be a response to the stresses that the child is experiencing? The point is that I do not just assume that the child has been genetically programmed to disrupt their classroom. I came across this study last year, though, that was a good reminder that “environment and history” are bigger than what happens in-between family members.

It found that children with higher levels of polyfluoroalkyl chemicals (PFCs) in their blood were more likely to have been diagnosed with ADHD. PFCs are long-lasting industrial substances that we accidentally eat and breath into our bodies from various coatings, foams, emulsifiers, and cleaning and personal products. Almost all of us have detectable levels of them in our bloodstreams. They are known to be toxic in other animals to the liver, immune and reproductive systems, and fetal development. It is also starting to look like they are neurotoxins as well.

The study was of correlations, so whether the PFCs caused the children to get ADHD diagnoses remains to be seen. ADHD may turn out to be a PFC-toxity-induced syndrome. Or it could be that PFC levels in mothers correlates with that of children, and that it is in-utero PFC levels that are critical. Or perhaps having an ADHD diagnosis causes children to eat and/or breath more coatings, foams, and emulsifiers. Or who knows what else?

Until the scientists know for sure, here are some ways to limit your PFC exposure, from Environmental Working Group:

Forgo the optional stain treatment on new carpets and furniture.
Find products that haven’t been pre-treated, and if the couch you own is treated, get a cover for it.
Choose clothing that doesn’t carry Teflon® or ScotchgardTM tags.
This includes fabric labeled stain- or water-repellent. When possible, opt for untreated cotton and wool.
Avoid non-stick pans and kitchen utensils.
Opt for stainless steel or cast iron instead.
Cut back on greasy packaged and fast foods.
These foods often come in treated wrappers.
Use real plates instead of paper.

Pop popcorn the old-fashioned way on the stovetop.
Microwaveable popcorn bags are often coated with PFCs on the inside.
Choose personal care products without “PTFE” or “perfluoro” in the ingredients.
Use EWG’s Skin Deep at cosmeticsdatabase.com to find safer choices.

Not Back to School Camp comes right before my birthday, so I often use our closing intention circles to make public goals for my personal new year. In 2010, I announced that I would sit and meditate for 30 minutes each day, every day, all year. I chose this goal for two reasons, one completely practical, and one speculative.

The practical reason was diligent self-care during my last year of grad school. I knew I would be working long hours, and wanted to remain as clear-headed and stress-free as possible, so that I could learn, write, and support my clients at the best of my ability. There is a sizable body of evidence that a regular mindfulness meditation practice could help. I also imagined that succeeding at this goal would help make this kind of self-care a permanent part of my lifestyle.

The more speculative reason came from reading meditation advocates like Ken Wilber, who claim that a mindfulness practice can be an engine of personal development. They conceptualize growing up as a process of continually refining one’s sense of self, becoming less egocentric and more compassionate. While practicing a mindfulness meditation you are learning to make objects of observation out of the contents of your consciousness that you normally inhabit with your identity. The sensations, emotions, and thoughts that you are become objects that you notice, distinct from your self. You can move, for example, from being anger about a certain injustice to having and observing that anger. This increase in perspective should be extremely helpful for family therapists like me–we need to be able to see all sides of the story: How does each person’s perspective on this problem make sense?

The only way I can present the results of my year-long experience in a clear-cut fashion is by the numbers, and in that way I failed in my goal. I meditated 30 minutes on 254 out of 365 days in that year. That’s 111 days of not meditating. Most of those days were during the summer that Reanna moved in with me. I found it hard to prioritize alone-time after two years of a long distance relationship.

The other way I failed by the numbers was that I did not sit for 125 of those 254 days. When I said I would sit and meditate every day, I meant it. Pretty soon, though, I had a day when I was so tired that I really, really did not want to sit up. I decided that on the rare days like these, I would lay down and do a relaxation-meditation called yoga nidra that my friend Guyatri Janine had recorded. It turned out that days like that were not rare at all. (When I did sit, by the way,  I sat Vipassana as taught by S. N. Goenka from my birthday in September to the new year (42 days), and then zazen (79 days) as taught by my friend Debra Seido).

The third failure is that I have not continued meditating after my year was over–less than 30 times in the last four months. It’s easy to imagine this says something about the results I experienced from meditating. I apparently did not value what I got from meditating enough to continue prioritizing it when I had my fiance’s attention available, starting last summer, and even less after my official commitment to meditating was up in September.

But what I got from my meditation practice is by far the most difficult thing to be clear about. I can say that without exception I felt better afterwards than I did before I sat down to meditate. Sometimes it also seemed like I was “getting better” at meditating, that I was indeed training my mind at this very difficult task. I can’t say, though, how much it lowered my stress or changed my ego-centrism or compassion levels. I have no control group to compare myself to. I can say that I was fairly stressed out in grad school and that I did a good job with it–the writing, the learning, and serving my clients. I think I can also say that I am more compassionate than I was before that year, but more I’m inclined to credit the connections I made with my clients than my meditation practice.

The problem with evaluating this kind of program is more than just not having a personal control group. It’s also that the program advocated by Wilber and meditation teachers is very long term. “Don’t just sit a year and expect to know what’s going on,” I imagine them saying. “Try 20 years. That’s more like it.”

The skeptic in me replies, “That’s a very convenient way to make testing all this out extremely expensive.” The researcher in me says, “Well, let’s get to it! This could be important. Who’s going to design a huge longitudinal experiment, fund it, and run it? You can still get it done before I die!” The idealist in me says, “20 years, huh? I am strongly considering it.”

I am writing about a logical fallacy that I have been calling a “pinhole fallacy” and I would like to know what it is actually called.

The general form is this: First, a lot of empirically generated data is summarized into a few ideas, then those few ideas are then used to generate a lot of ideas which are assumed to be empirically generated because of their apparent origin in empirically derived data.

I’ve actually been calling it “family therapy’s Lambert-pinhole common factors fallacy” because I came across it in this form (greatly simplified, of course):  There has been a lot of research into what effective (individual-based) therapeutic modalities have in common. As far as I can tell, this research is pretty good, on the whole, though it has not come close to showing anything like causation, mediation, or mechanisms of change in therapy.  A guy named Lambert wrote a paper about this evidence, summarizing all of the many elements common to therapy modalities into four broad categories: the therapeutic relationship, model-specific factors, hope and expectancy on the part of the client, and extratherapeutic factors. Many writers in family therapy has gone on to take his summary as new data, creating new models of therapy based on the four-common-factor idea, and apparently thinking of this common-factor model as empirically generated and supported.

This process relies on a “hasty generalization” fallacy, and also a “post hoc” fallacy, but it seems to me that it should have its own name. What is it, logicians?

In the field of family therapy, most theorists these days are postmodern and take care to spell out their epistemological lens–how and why they think they know what they know. They know that their theories are colored by their beliefs, so they want their readers to know what biases were involved in creating their theory.

I’m on page 33 of a very promising family-therapy-theory book called Metaframeworks: Transcending the Models of Family Therapy. The authors describe four views of reality, how they relate to each other, and which one they choose. The four are:

Objectivism: The often unconscious belief that there is an objective reality and that we have direct access to it. This view is also called “naive realism.”

Constructivism: This camp generally believe that a reality exists out there independent of us, but that we can’t know what it is like because our access to it is completely mediated and limited by our senses and cognitive processes. This is also called “pessimistic realism.”

Perspectivism: There is a reality out there and we have only mediated, distorted access to it, but it is possible to map it to greater and greater degrees of accuracy. That is, some maps are better than others. This is the authors’ camp.

Radical Constructivism: As far as we know, “reality” exists only in the mind. We are not qualified to make any statements about what actually exists or goes on “out there.”

I’m taking a couples assessment class this summer, and right now I’m reading about a tension between family therapy models that Sciarra and Simon (in Handbook of Multicultural Assessment) call either idiographic or nomothetic.

Nomothetic models say that families have problems because they get out of whack in ways that families do. That is, each nomothetic model has its own list of ways that families can get out of whack and a therapist using that model is to keep a sharp lookout for those things. Structural therapists look for dysfunctional boundaries, for example. Strategic therapists look for incongruous hierarchies. Bowenians look for emotional reactivity. Emotionally-focused therapists look for maladaptive attachment styles. Each nomothetic model says that the therapist needs to assess for these underlying problems, treat them, and therapy should be successful.

Idiographic models call nomothetic models “cultural imperialism.” That means nomothetic therapists are just teaching (or tricking) their clients into thinking, feeling, and acting like them. Nomothetic therapists are forcing their culture on their clients. Calling someone a cultural imperialist is about as close to an accusation of pure evil as a post-modernist will make. Further, idiographic models say that culture (any culture) is oppressive of individuals, and that this oppression is the only reason families seek therapy. The ideographic therapist’s job (Sciarra & Simon list language-systems, solution-focused, and narrative therapies as idiographic) is to have a conversation with families about the ways they are being oppressed by their culture.

There are a couple of funny things going on here, but to understand it, first you need to know that nomothetic models are mostly “old-school” models that emerged in the 1950s and 60s, while ideographic models are newer, postmodern, all the rage, and emerged as a consequence of this nomothetic/ideographic conversation. In the 1980s, postmodern family therapists started saying that family therapy was arrogant and hierarchical and created the idiographic schools.

The first funny thing is that the old-school, nomothetic family therapy models emerged in much the same way, as a reaction to the arrogant and hierarchical field of psychiatry. The founders of family therapy said to psychiatry, “Human problems exist in the context of families. Your pathologizing medical model is not appropriate here.” Now the ideographic models are saying to the nomothetic founders, “Human problems exist in the context of cultures. Your pathologizing medical model is not appropriate here.”

Who is right? Well, that depends on your epistemology. So far, the nomothetic models have more experimental evidence to support them, and they are undeniably effective. To be fair, they have had more time to collect evidence, so in time things may go either way. And to be extra-fair, real post-modern idiographs can reject experimental evidence on philosophical grounds; experiments are so modern, so medical-model. What value system produced your research questions, anyway? That’s funny thing number two.

Funny thing number three is that, as Ken Wilber says, everyone may be right. Perhaps problems happen at every level of complexity, from our bodies to our minds to our families to our larger social systems, and nomothetic models just specialize in the family level, while idiographic models specialize in cultures. It’s a neat idea, possibly too neat, and difficult to tease out. I’ve written a little about it here.

The fourth funny thing is that the idiographic models, while broadening the scope of consideration in some ways, put the focus back on the individual in therapy. They say that culture is intrinsically dehumanizing, and that dehumanization is what an idiographic therapist talks about, but the other parties in the process are not part of the conversation. If I’m a narrative therapist and you send your depressed son to me, we will talk a lot about that depression. We will externalize it, maybe give it a name like “Mr. Funky,” talk about how Mr. Funky speaks with the voice of oppressive culture, talk about times when your son was able to overcome Mr. Funky’s influence and work on ways of increasing that ability. In the end, if I’m a good therapist, we have probably helped your son, but we’ve also focused on how your son thinks, feels, and behaves, where a nomothetic therapist would have been focusing on the whole family–how do they interact? Do the parents get along? How might this symptom of depression make sense in your son’s immediate system of relationships? Who all has a stake in this behavior and can we get them in the room too? And so on. There is a way that by ostensibly moving the location of pathology out of the family to the larger culture, ideographic models have brought the clinical focus back to individuals, which may seem like regression to the founders of family therapy.

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