Intensive Family Therapy

Theoretical And Practical Aspects

Ivan Boszormenyi-Nagy, James L. Framo

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781134844975
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The chapters of this volume were written for the purpose of surveying the field of intensive family therapy. The book is not a compilation of previously published articles; all of the chapters are original contributions written at the request of the editors. The structure of the volume was determined by the editors' experience with family therapy and their continuous exchange with other workers in the field through symposia, personal discussions, and, in most cases, direct observation of their work.

1

GERALD H. ZUK

DAVID RUBINSTEIN

A Review of Concepts in the Study and Treatment of Families of Schizophrenics

Nearly a decade of experience has been gained in doing conjoint psychotherapy with families. This chapter aims to establish a sense of order in the historical development of work in family psychotherapy with particular reference to the problem of schizophrenia. Intended as an orientation to this relatively new area rather than as an exhaustive review of the literature, it is divided into three parts: (1) a review of concepts in selected studies which have dealt primarily with dyadic family relationships and in which family psychotherapy itself was not employed as a therapeutic and investigatory technique; (2) a review in greater depth of concepts in selected studies in which the family system was itself the object of therapeutic attention; (3) and, finally, a summary of some assumptions and general characteristics of studies on family systems. Throughout the chapter, the emphasis will be on the establishment of conceptual trends rather than on a critical evaluation of these trends or on a methodologic critique, both of which at this stage in the study of family systems might be premature.

Clinical experience and research in the family system has not yet reached a point of sophistication at which comprehensive and integrated theories are available. It may be said, however, that there is an extensive and active theorizing currently taking place which should eventually produce the desired integration of understanding. To date, psychoanalysis has provided the’ richest single source of theory, although recently existential theory has been playing an increasing role (see, for example, the study by Whitaker, Felder, Malone, and Warkentin, 1962). Four types of approaches have been made in the formulation of family process, by (1) communication theorists, who have been especially concerned with the relations and levels of meanings of verbal and nonverbal behavior; (2) role theorists, who have explored the effect of role development and assignment on identity formation; (3) intrapsychically-oriented ego theorists, who have investigated the more primitive emotional levels and attempted to define such concepts as self-nonself boundaries and individuation versus symbiosis; and (4) game or strategy theorists (see Haley, 1963) who have addressed themselves to the definition of those networks of relationships in which human beings place themselves and to the definition of the reciprocating behavior in the networks.

There have been three recent reviews presented, describing the stages which have led to the development of family psychotherapy as a method of treatment and psychological study. One by Parloff (1961) describes historical stages. The first stage occurred at the height of orthodoxy in psychoanalytic thinking: contact between therapist and family was discouraged, for it was thought to be poor technique to involve the family because disturbances in the patient-therapist transference and countertransference would be antitherapeutic. In the second stage, certain negative effects of caretaking persons (for example, mothers) were believed worthy of study. The third stage was ushered in with the development of the psychoanalytically oriented positions of Sullivan, Horney, Fromm, Erikson, and others, which gave increasing weight to the influence of culture and current life stress on personality. During the latter part of the second and in the third stage, new therapeutic techniques were tried out: Slavson paved the way for group psychotherapy and Moreno for psychodrama. Favorable experience with these techniques tended to diminish somewhat the anxiety about the effect on transference and countertransference of the presence of more than two persons, namely, the patient and the therapist, in the psychotherapeutic situation.

A review by Jackson and Satir (1961) cites several factors believed to he responsible for the current interest in family treatment of schizophrenia. Among these were the impact of psychologic and sociologic studies which showed differential rates of schizophrenia among social, ethnic, and other subcultural groups in the United States; the established practice of child guidance clinics of treating family members and the child concurrently; and the development of interpersonal theories, such as Sullivan’s, which gave greater weight to intercurrent difficulties in patients’ lives.

A neat summarization of the historical background of family treatment has been given by Haley (1959). He says that, “A transition would seem to have taken place in the study of schizophrenia; from the early idea that the difficulty in these families was caused by the schizophrenic member, to the idea that they contained a pathogenic mother, to the discovery that the father was inadequate, to the current emphasis upon all three family members involved in a pathological system of interaction” (p. 358).

Family Pathology Studies in the 1940’s and 1950’s: The “Pathogenic” Mother and “Inadequate” Father

David Levy was one of the first to clearly establish a relationship between a supposedly pathogenic trait in the mother and disturbed behavior in the offspring.

As aptly noted by Spiegel and Bell (1959), Levy’s (1943) study of maternal overprotection was a classic of the 1940’s. It showed a correlation between an overprotective attitude in mothers and deprivation of love in the mothers’ own childhood. The mothers’ own deprivation apparently set up a pattern in which they sought to obtain from their children what they had not obtained from their mothers. Levy distinguished between types of overprotectiveness: one type of mother was dominatingly overprotective, another indulgently overprotective. The children of mothers of the first type were submissive at home but had difficulty making friends at school and in the neighborhood; these children tended to have eating problems, but had a relative absence of difficulties relating to sleep or toilet training. Children of mothers of the second type were disobedient at home but were well-behaved at school and got good grades.

Exploratory studies of the pathogenic parent-child relationship were begun as early as the mid-1930’s (see, for example, the study of Kasanin, Knight, and Sage, 1934), but a pattern of results did not emerge until studies originated in the mid-1940s were completed. The so-called schizophrenogenic mother, a term first used apparently by Fromm-Reichmann (1948), was described as aggressive, domineering, insecure, and rejecting; by contrast, the father came to be described as inadequate, passive, and rather indifferent. One study (Reichard and Tillman, 1950) classified parents in three ways: schizophrenogenic mother—overtly rejecting type; schizophrenogenic mother—covertly rejecting type; and schizophrenogenic father—domineering and sadistic type. A study of 25 mothers (Tietze, 1949) of schizophrenic children resulted in a broad description of the mothers as rigid and rejecting. In a study by Gerard and Siegel (1950), exclusive attachment to the mother was found in over 90 percent of the cases observed. Thomas (1955) studied the mother-daughter relationship of 18 Negro schizophrenics and concluded that the mothers could not tolerate verbal expression of hostility. The mothers were excessively punitive with the patients after puberty. Interestingly, the majority of the fathers in these families had either died or separated from or deserted the mother. Galvin (1956) found that maternal overcontrol, which is not readily admitted by mothers of schizophrenic patients, is exerted by appeals to pity, shame, and guilt.

A few studies done in the middle and late 1940’s and early 1950’s dealt with the general adequacy of the families in which one of the members was schizophrenic. Lidz and Lidz (1949) found only 5 patients in a hospitalized sample of 50 who were considered to have had an adequate home life. In the case of 40 percent of these patients, one or both of the parents had died before the patient was 19 years old. Rosenzweig and Bray (1943), in a study based on a sample of 356 male hospitalized schizophrenics, found that 39 percent had experienced the death of a sibling. The authors suggested that intense feelings of hostility toward a sibling who subsequently died may have caused a sense of pervading guilt which triggered a psychotic episode. Ellison and Hamilton (1949) found in more than 30 percent of a sample of 100 cases that the stability of the family was disturbed by the early death of a member or by a divorce or separation. Three-fifths of the mothers in the sample were found to be excessively overprotective. One-third of the fathers were found to be overaggressive. Johnson, Griffin, Watson, and Beckett (1956) noted frequent instances of physical or psychological assault by parents on children who later became schizophrenic. Studies by Wahl (1954, 1956) give support to the suggestion that loss of a parent in childhood or adolescence may be a precipitating factor in schizophrenia. In a study often cited as a landmark in establishing the concept of transmission of psychopathology from parents to children, Johnson and Szurek (1954) pointed out that antisocial behavior in children was based on a superego defect which corresponded with superego defects in their parents.

A number of writers have called attention to the deficiencies in experimental control in the studies of the 1940’s and 1950’s. Sanua (1961), in his review, points to the need for caution in drawing firm conclusions from these studies. Important variables were often uncontrolled, such as, for example, social class, educational level, and ethnic and religious origin. A few investigators carefully described some of the limitations of their work. Kohn and Clausen (1956), in their study of experiences recalled from early adolescence by schizophrenic patients, took pains to present their results as suggestive rather than firm. They noted that their results were based on small numbers of patients and social class was not rigorously controlled. A positive feature in their experimental design, however, was that they did have a control group of subjects who had gone to the same schools as the schizophrenic patients being investigated. Their main finding was that schizophrenic patients, more frequently than normal controls of comparable background, reported that their mothers played a comparatively strong authority role in the family.

Also in the late 1940’s and early 1950’s some interesting new experiments in therapy technique were being undertaken. Among others, Ross (1948), Bauer and Gurevitch (1952), and Kirby and Priestman (1957) used the technique of group psychotherapy with schizophrenic patients and their parents. Abrahams and Varon (1953) studied the relationship between mothers and schizophrenic daughters in conjoint group psychotherapy. The mothers’ own great emotional dependence on the daughters was revealed in the sessions. The need of the mothers to feel superior was maintained at the cost of the daughters feeling worthless. Acute maternal anxiety was precipitated when the daughters refused to conform to expectations. On these occasions, some of the mothers reported that they had lost their sense of being alive, or of being a separate person. In 1956, Szurek and Berlin reported positive results in the simultaneous psychotherapy of more than 100 schizophrenic children and their parents.

At about the same time novel therapy techniques were being applied to marital couples one of which was neurotic or psychotic. Oberndorf (1938) and later Mittelman (1956) described numerous patterns of neurotic interaction between marriage partners, including the description, by Mittelman, of the couple one of whom is emotionally detached while the other has strong needs for affection. Bychowski (1956) has described the interaction in marriages in which the partners are psychotic or pre-psychotic. He was pessimistic about a good therapeutic outcome in the case of schizophrenic marital partners, since he believed the marital choice was based on pathologic motives in the first place. Neubeck (1954), Wolf (1950), Moreno (1954) and Whitaker (1958b) have also worked with marriage partners concurrently. The book edited by Eisenstein (1956) reports some interesting studies of the psychotherapy of marriage partners. (Reference is made in this section to authors of several chapters in the book by Eisenstein). A major concept underlying the work with neurotic and psychotic married couples was that the marriage was based on pathologic needs and expectations and that even the choice of the mate was determined in large part by prior pathology originating in a nuclear family situation.

The concept “symbiotic tie,” referring particularly to a pathogenic relationship between mother and child, came into currency in the 1950’s. The phrase was one of those which helped usher in a new period of greater attention to the pattern of pathogenic relationships within families rather than concern only with the isolation of an array of negative traits of individual family members. In children Mahler (1952) described the “symbiotic syndrome.” Of this condition she said that it aimed at restoring the symbiotic-parasitic fantasy of oneness with the mother. In the syndrome of “infantile autism,” Kanner (1949) stated that the child was unable to utilize the symbiotic relation with the mother to orient himself to the inner or outer world.

Limentani (1956) studied the symbiotic tie between adult schizophrenic patients and their mothers and found strong unconscious wishes to return to the infantile states, to remain attached to the mother or to the therapist in the fashion of small children. The passivity which the patients expressed protected them from the danger of opposing their mothers’ demands and acknowledging their own feelings of worthlessness. When the patient could accept the therapist as a person with whom he could establish a relationship similar to that with his mother, Limentani believed that the patient could recover from the overt part of the psychosis.

Hill (1955) gave considerable attention to the symbiosis between mother and child in cases of schizophrenia. He held that the mother is a living, internalized presence in the patient’s ego. He pointed out that the mother of the schizophrenic gives love excessively but conditionally. The patient believes that if he gets well, his mother will get sick. By staying sick, he preserves his mother’s mental, as well as physical, sense of well-being. But by meeting her conditions, the patient forfeits development of an independent personality. Hill’s description of the symbiotic tie goes in some respects beyond the usual interpretation of that concept by positing a two-way interdependency between mother and child. His formulation is more attuned to the current interest in the gestalt of relationships among family members, that is, in the interlocking and reciprocity of mutual needs.

In summarizing this section briefly, it can be said that...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Table of Contents
• List of Authors
• Preface
• Introduction
• 1 A Review of Concepts in the Study and Treatment of Families of Schizophrenics
• 2 A Theory of Relationships: Experience and Transaction
• 3 Intensive Family Therapy as Process
• 4 Rationale and Techniques of Intensive Family Therapy
• 5 Family Psychotherapy with Schizophrenia in the Hospital and in Private Practice
• 6 Family Dynamics and the Reversibility of Delusional Formation: A Case Study in Family Therapy
• 7 Some Indications and Contraindications for Exploratory Family Therapy
• 8 Countertransference in the Family Treatment of Schizophrenia
• 9 Mystification, Confusion, and Conflict
• 10 The Identity Struggle
• 11 Systematic Research on Family Dynamics
• 12 The Contributions of Family Treatment to the Psychotherapy of Schizophrenia
• Name Index
• Subject Index