“The evolving context of the family therapy field: An overview.”
American Family Therapy Academy Newsletter 77:9-10, 1999

Introductory presentation as part of the Presidential Plenary “Systemic Practices: Family Therapy Evolving”, American Family Therapy Academy twenty-first Annual Meeting, June 23-26, 1999, Washington, D.C.

THE EVOLVING BOUNDARIES OF FAMILY THERAPY: AN OVERVIEW

Carlos E. Sluzki, MD

Family therapy, born in the optimistic, humanistic, expansive post-war fifties, grew up during the romantic sixties and the hard-reality seventies, somehow endured the selfish, “me”, eighties and still survives during these mean, socially blind, nineties. But it hasn’t endured, survived and evolved without scars.

Throughout that time span, the ecological niche of our discipline, namely, the field of mental health (or psychosocial wellbeing) has changed dramatically. Access to care is progressively decaying from a focus on “health care system” to a full-fledged “disease management industry”. “Rights of access to quality care” is being replaced by “need,” with “need” being defined not by those who suffer or by the professionals but by a distant third party with vested interest in reducing access to services. Prevention is being subducted under the weight of its low short-term cost-benefit ratio. Emergency services are becoming more and more the place where the disadvantaged receive their “quality care,” generally too little and too late.

The backdrop of this move is a relentless, dramatic political shift to the right, with a drastic decay of the notion of social responsibility, accompanied by a sense of loss of alternatives. At a social level, progressive erosion of entitlement programs is desensitizing us from the plight of the needy and leading us to accept, with varied degrees of reluctance, the selfish world of individualism, in which social concerns become almost an object of nostalgia, a Emma Goldman memorabilia.

In our broad field of mental health, or of bio-psycho-social well being, that decay has been expressed, among others, by a shift in epistemological dominance, from what Leon Eisenberg called the “brainless psychiatry” of the ‘60s – everything taking place in the virtual space of the psychosocial world – to a “mindless psychiatry” of the ‘90s – with its assumption that our knowledge of the brain functions will provide us with the golden key to understand the world of behavior, cognition, emotions, and well-being. This decade has been called by the NIMH, in fact, “the Decade of the Brain,” which fits a political agenda permeated by a selective inattention to social issues, poverty, inequality, and, overall, to ignorance of contextual, evolutionary thinking.

The field of clinical practice, in turn, has been invaded and dominated by the indemnity insurance and managed care industry, with a policy of second-guessing and disincentives to care and an obfuscating rhetoric that is ultimately guided by money and not by rights, by control and not by need. And hospitals and we professionals are learning dutifully to limit advocacy and to talk about providers and consumers, about DSM-IVR and pre-authorizations.

The interdisciplinary nature of family therapy, once a generously enriching trait of our specialty, has yielded to market pressures toward a drastic disciplinary balkanization, if not an interdisciplinary war.

Psychiatry is being colonized by the pharmaceutical industry. The laboratories have at present a major hold on the American Psychiatric Association: moneys from the drug companies fund its annual meetings and good part of the research in the field. Psychiatric conventions talk now the skewed biological language of the drug industry. In fact, even the self-help, originally grass-root, organizations of patients and families are currently heavily funded by the pharmaceutical industry, and have loyally adopted a biological, a-contextual view of their own plight.

The American Association for Marriage and Family Therapy, in turn, has become a guild active in the defense of the interests of the MFT, the lower members of the professional totem pole – in the sense of the least expensive for the insurance industry. That advocacy has notoriously weakened that organization’s focus and voice on social concerns.

The American Psychological Association, representing its own guild squeezed in sandwich between psychiatrists and MFTs-SWs, is trying without too much success to stake a chunk of the territory of psychiatry by fighting for their arguable right to prescribe medications, hence biologizing and, in the process, de-socializing, its own rhetoric.

AFTA, in its own turn, has focused its energies on reflexive critical practices and creating internal diversity, perhaps at the expense of silencing other organizational needs but, more importantly, while having failed so far to join the concert of voices of concern over social policies that have affected so negatively the psychosocial well being of large segments of our society. The title of this Annual Meeting, “Healing Systems: New Visions for Connections,” may well be signaling a turning point in this respect.

Slicing the whole pie at a different angle, what about family therapy proper? Family therapy, as it professionalized, has somehow lost part of its youthful exuberance. It has become less popular, it appears less a challenging frontier and more a label for a type of practice that has its own serious problems in terms of evaluation of efficacy and reimbursement.

In the midst of all this grim picture – like in one of those doom and gloom science fiction stories in which, to our relief, in some remote crevices of the scorched earth, patches of flowers begin to bloom again – a variety of systemic practices inspired by the powerful ideas of the field of family therapy are growing here and there, are posing new challenges, pushing new envelopes. They are, in fact, expressing with new shapes the core paradigms cherished by our discipline, in a remarkable proof of the evolutionary survival resiliency of the systemic seed sawn by our field.

They are practices that, while enacted in different professional scenarios, have in common a view of (I) people-in-social-contexts – the immediate environment of the family and the personal social network, in turn affecting and being affected by the larger fabric of their socio-economical, political, cultural contexts – (II) people as part of shared systems of meanings – hence requiring a respectful joining of their collective worldview as a prerequisite for change, and (III) systems in constant evolution – meeting them in their evolutionary moment and not in a pre-assumed reality. And, in addition to a shared epistemology, these systemic practices share a vision. Rather than colonizing territories, their practitioners cherish a collaborative stance, and, as a result, their view enriches rather than threatens other views. Hence, these practices thrive in interdisciplinary arenas. They also materialize the social concerns inherent in any richly contextualized view of people, especially of people in pain. Hence – thinking globally and acting locally – there practices enact social compassion and social justice. Part of the practices of each of us may be located in that new, fresh territory, as we evolve away from our set ways.

I submit to you that these practices not only express the richness of the heritage of our field. They may also represent its future.

The rest of the presentations of this plenary panel will offer a sampler of some of these new systemic practices. While being particularly attractive, they are some of many shapes that systemic practices at the turn of the century may show.