430 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION NOVEMBER, 1966

The Psychodynamics of Family Interaction in Family Therapy*

SINCE the phrase "family therapy" may refer to did relate attitudes of overprotective mothers to
several quite different though related thera- the disturbed behavior of their offspring. These
peutic approaches, it becomes immediately impor- mothers, deprived in their own childhood, estab-
tant to define the approach in this presentation. lished a pattern by which they attempted to obtain
This paper will deal with "conjoint family ther- from their own children what they had not ob-
apy, "1 a term coined by Jackson which refers to tained from their mothers. One type of mother
the treatment of members of the immediate family was dominantly overprotective. The children were
together, in regular therapeutic sessions, by the passive and submissive at home, but had difficulty
same therapist. This may include on occasion non- making friends outside of the home. The second
relatives, if such people are at the time playing an type of mother was indulgently overprotective.
important role which affects the family unit. Treat- These offspring were disobedient at home, but well
ment of the family conjointly requires a socio- behaved outside of the home and usually made
cultural orientation and an interactive therapeutic good grades at school.
approach that utilizes the here-and-now to a de- The term. "schizophrenogenic mother," as far
gree than is generally used in many therapeutic as is known, was first used by Fromm-Reichman.4
approaches. She described these schizophrenic producing
Other forms of family therapy approaches: see- mothers as insecure, domineering, rejecting and
ing all family members together for diagnostic aggressive. The father in these families was de-
evaluation, following which assignments are made scribed as passive, inadequate and indifferent.
on an individual basis to different therapists; see- In the early 1950's, Abrahams and Varon con-
ing family members individually for diagnostic ducted group therapy conjointly with mothers and
and therapeutic purposes; and seeing the patient their schizophrenic daughters.5 During the sessions
individually and family members on occasion. it became apparent that these mothers had a great
From one point of view, the beginnings of deal of emotional dependence on their daughters,
family therapy are rooted in family studies of and they maintained their own feelings of su-
schizophrenic patients and their families. A his- periority by efforts to keep their daughters feel-
torical review of several of these important studies ing worthless. Refusal of the daughters to conform
is relevant to understanding the psychodynamics to such expectations resulted in acute anxiety on
of families that are disturbed. A simple and con- the part of the mothers.
cise expression of the course of these research ef- Also, in the 1950's, the biological term "sym-
forts was aptly put in a statement by Haley as fol- biosis" was borrowed and used to explain some of
lows: "A transition would seem to have taken the intrafamilial relationships. Symbiosis is de-
place in the study of schizophrenia from the early fined as the living together or in close association
idea that the difficulty in these families was caused of two dissimilar organisms, each of which is
by the schizophrenic members, to the idea that known as a symbiont. The association may be bene-
they contained a pathogenic mother, to the dis- ficial to both (mutualism), beneficial to one with-
covery that the father was inadequate, to the cur- out injury to the other (commensalism), or bene-
rent emphasis that all these family members are in- ficial to one and detrimental to the other (parasit-
volved in a pathological system of interaction."2 ism). Using this definition, it seems likely that
One of the earliest of these studies, that of family relationships which are mutual, and some-
David Levy,3 did not deal with schizophrenia, but what less likely that family relationships which are
commensal, will demonstrate psychopathology to
*Read at the 71st Annual Convention of the National Medi- the point that they would come to the attention
cal Association, Chicago, Ill., August 8-11, 1966.
VOL. 58, No. 6 Family Psychodynamics 431

of a therapist. It is different wih parasitism. Bowen was one of the investigators who in the
Wherein parasitism implies a one-sidedness, that late 1950's stumbled into family therapy.9 His
is, it does not take into consideration the recep- therapeutic approach while working in the clinical
tivity of the host, the use of the term introduced division of NIMH varied with the workability of
a different means of describing families. Rather his hypotheses. His first approach, which was later
than to make individual descriptions of family discarded, was based on the hypothesis that the
members, investigators began to look more at the child was an unresolved symbiotic attachment to
dynamic interrelationships of the component parts the mother. Later he moved entire family constel-
of families. lations into a hospital setting for observation. The
Among the first studies utilizing this concept fact that these families made requests of hospital
was one by Hill who proposed that in children staff to run their lives for them during difficult
with schizophrenia, the mother was an internalized periods made it apparent that they were disturbed,
living presence within the child's ego.6 Although but, on the other hand, they also provided a clue
the mother indulgently and excessively gave to a means of intervention. When not bickering,
"love," it was conditional. The patient believed family members gave the superficial appearance
if he improved or got well, then his mother would of getting along, yet they were unable to share
get sick. In order then to preserve his mother's feelings with each other or, for that matter, toler-
well-being, he had to remain sick. ate one another when alone. The mothers in these
The aforementioned investigations deal almost families were unable to accept growth on the part
exclusively with schizophrenic children and their of their children, with adolescence being the
mothers. The family investigations of Lidz, Cor- critical period. Improvement on the part of the
neilson, Fleck and Terry shed greater light on the child occurred with the loosening of some of fixed
role of the father.7 This group studied intensively patterns of the parents followed by an increasing
14 middle-class families in which there was a responsiveness to each other.
schizophrenic member. Members of the family Wynne et al have contributed the concept of
were interviewed over a period of time which pseudomutuality to the array of causative family
ranged from 4 months to 4 years. The investiga- factors in schizophrenia.10 Pseudomutuality is a
tion included interviews, home visits, the use of type of relatedness in which the major preoccupa-
diaries, which were available, and protective testing. tion of the family is that of fitting together into-
Although this study originally concerned itself formal roles, but at the expense of individual
with the father as the noxious agent, the material identity. By comparison, true mutuality among
collected provided several examples of family in- family members permits a sense of personal iden-
teraction. Several years following the categoriza- tity, distinctness and separateness which does not
tion of these fathers into five different types, Lidz threaten the family unit. The pseudomutual family
and Fleck subjected their material to a critical gives the outward appearance of uniformity, but
analysis and found most of the families to be dis- the family demands are those of conformity. Di-
turbed.8 They further divided them into two vergence is not tolerated since it threatens to dis-
groups. One type, which was in the majority, rupt the family unit, hence individualization is not
called schismatic, was torn by conflict between the allowed. This is a general phenomenon which can
parents which divided the family into hostile be obsecved rather frequently from time to time in
camps, with each parent seeking to obtain the most families. It is on the other hand especially
upper hand. They set about their tasks by defying intense and enduring in families in which there
the other's wishes and undercutting the other's is a schizophrenic member. When an acute schizo-
worth in the presence of their children. They each phrenic episode occurs it represents, according to
also attempted to win the children and use them Wynne, a breakdown of pseudomutuality, an at-
as emotional replacements for the spouse in whom tempt to restore it, and an attempted individua-
they were disappointed. The other families, in the tion by the disturbed family member which is only
minority, were "skewed." By this it was meant partially achieved.
that the serious psychopathology of one parent was The difficulty in communication, both verbal
accepted by the other, and this led to exceptional and non-verbal, has been described by Weakland
and deviant ways of living and child rearing. as a contributing factor in families that produce a
432 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION NOVEMBER, 1966

schizophrenic child.1" Their theory involves the explanation of how the family preserves itself as
so-called double-bind. The double-bind requires a pathological unit. Bateson et al vividly describes
two or more persons and a situation involving the a mechanism by which this unit can be maintained.
following general characte-ristics: 1) the individual With the preceding review of investigations as
(victim) is involved in an intense relationship, background, we turn now to examine the psycho-
one in which he feels that it is vitally important dynamics of family interaction as seen in treat-
that the discriminate accurately the sort of mes- ment. The material to be presented is not the
sage being communicated; 2) the other person in psychodynamics necessarily involved just in the
the relationship expresses two orders of messages families in which a member is schizophrenic, but
which are contradictory but this incongruity is not rather those features noted are also common to
readily apparent; 3) the victim cannot escape most families as they try to maintain the status
(because of the meaningfulness of the other per- quo in spite of a dissident member.
son) nor can he notice or respond effectively to When two people decide to solemnize their re-
the incongruity of the message. In time the victim lationship with marriage, they immediately set
may respond in kind, sending out his own double- about to establish a set of family rules. This be-
bind messages and the situation becomes indura- gins with the initiation of the premarital rela-
tive. tionship when the partners exchange clues that will
The application of this formulation involving allow each to define the consanguinity. Jackson
the typical family triangle might be hypothesized defines this resultant fluid sort of arrangement
as follows: a mother threatened with anxiety and which determines the roles, rights and manner of
hostility by the prospect of too much closeness responses to each other as the quid pro quo,13
from her child may deliver a set of incongruous meaning literally, "something for something."
messages. These messages infer a loving attitude For everything given, something is also received.
but at the same time keep her child at a distance Although a time sequence may be interposed be-
which she can tolerate and which does not stir tween giving and receiving, the expectation is built
her anxiety and hostility. The father, not being a on a trust that has evolved out of the manner in
very strong figure, cannot offer the child much in which the roles have been defined. From this
the way of support. The child may become aware point of view there then would be no marital re-
that this loving attitude cloaks an underlying hos- lationships which are unbalanced or impoverished
tility; however, if he is to retain whatever love for one spouse. The homeostatic equilibrium that
he is to receive, he must not permit himself to is established in a marriage is then dependent
communicate this knowledge to his mother. "The upon what each brings with him from his or her
child is punished for discriminating accurately own primary family and how they define the new
what she is expressing, and he is punished for relationship once they have decided to live to-
discriminating inaccurately-he is caught in a gether.
double-bind."12 Distress would occur in the marriage when the
The disturbances created by the double-bind may needs of one partner are not met by the other.
include: helplessness, rage, fear, frustration, exas- In an effort to have these needs met, the former
peration, etc. The mother may completely ignore may try to effect a change in the relationship. This
these responses, the father may become enraged; is resisted in favor of maintaining the status quo.
but because the relationship that he has estab- The first law of human relations as proposed by
lished with his wife is simply that of being ac- Harley is particularly applicable. He states, "When
cepting of her behavior, he is powerless to inter- one individual indicates a change in relation to
vene. The psychosis that the child develops is one another, the other will respond in such a way as
way of breaking the double-bind. to diminish the change." If needs remain unmet,
Although the three aforementioned groups of the distress may become chronic, resulting in a
researchers worked independently, their findings different equilibrium, with each partner alternately
are interconnected and appear to describe the frustrating the other. When this point is reached
same process from different points of view. Lidz the well-being of one partner is maintained only
and his colleagues offer a descriptive classification at the emotional expense of the other.
of disturbed families. Wynne provides a dynamic A child in this family may salvage the emotional
VOL. 58, No. 6 Family Psychodynzamics 433

well-being of the parents but at a terrible cost disruptive, causing the family to deal actively
to himself. In situations where there are several with this distraction. On the other hand, the pa-
children in the family, it remains undetermined tient might be tacit and passive while the family
why a particular member is chosen to become hovers over him with pseudo-concern. Invariably,
symptomatic, or, in other words, to express the however, the family's willingness to participate in
psychopathology for the entire family. According therapy is with the expectation that the therapist
to Borszomengi-Nagy, neurotic parents may util- will relieve them of their problem by bringing the
ize the peacemaker inclinations of their anxious patient "back in line."
children who, in their efforts to save the marriage, Despite the initial expectations of the family,
offer themselves as objects out of the parents' emphasis is not placed on the patient's problems
past.'4 The child may assume several roles in this but rather on the problems of the family. In
relationship, e.g., angry censor, support, etc. Nagy early contacts in spite of the family's efforts to
does not always see this as necessarily a "bad role," reveal only their better side (and the worse side
particularly if the assignment is to improve the of the patient), they manage to demonstrate in
relationship of the parents. In some less disturbed capsule form how they deal with each other. In
families, these children often tend to grow up to short they play out a brief panorama before the
be deeply introspective and sensitive adults. In therapist of the roles they assume in life away
severely disturbed families several members may from treatment. The therapist, by forcing the
consecutively become overtly disturbed. One can family members to deal with the underlying as-
say then that the patient in the family is the most pects of their verbal and non-verbal interchanges,
openly disturbed (symptoms are socially unaccept- demands of them an exchange which they have
able) at the time that the family is seen. avoided by the erection of elaborate maneuvers
Regardless of the way the patient is selected, and defenses. These resistances as revealed in the
this scapegoating role is the result of collusive ac- treatment hour may run the gamut in form and
tion on the part of several or all family members. affect but differ little from what is utilized in
It is to their emotional advantage to keep the pa- daily life. These may include subtle evasion, selec-
tient sick. The availability of this disturbed mem- tive inability to understand, displacement and pro-
ber through whom the family pathology can be jection as examples in the first instance and angry
discharged, allows the remainder of the family to outbursts, tears, indifference, etc., in the second.
remain intact. Any family member who is caught The avoidance of having the "boat rocked" is not
up in this pattern, is, of course, at a disadvantage merely an individual maneuver, it is a total family
in that he has to serve at the whim of the other operation with all members closing ranks so as
members. On the other hand, since the patient is to extrude the therapist-intruder. The patient is
the member who is deviant, he cannot be ignored. equally active in this collaborative endeavor. Al-
In disturbed families because of the symtomatology though he is the family scapegoat, he also has a
of the patient everything has to revolve around vested interest in maintaining the current state
him. Despite his position of disadvantage, he is of affairs.
at the same time in a position of power or domi- Persistence on the therapist's part gradually en-
nance. Using this dominance through behavior ables the family to examine the underlying mean-
that can be bizarre and extravagent usually brings ing and feeling that accompany their transactions.
the family to the attention of the therapist. The It is at such a point that other family members
patient often has to go to great lengths to force begin to reveal and talk about their own unmet
the family into action. A not infrequent maneuver needs. It is also at this point that the total burden
is to incorporate outsiders into the fray, e.g., for the family's difficulty begins to shift away
neighbors, employers, police, etc. Whether the pa- from the patient. Most often the patient makes a
tient is hospitalized or seen in an out-patient set- last effort to divert the focus back to himself, in
ting, is dependent upon the tolerance of the fa- order to re-establish the old family arrangement.
milial environment and the severity of his illness. This occurs despite the patient's earlier complaints
It is impossible to generalize in the description about other members being equally as sick as he.
of the family at the time of the initial contact. When family members begin to discuss openly
On one hand the patient might be obstreperous and their own needs, deprivations, etc., they may be-
 434 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION NOVEMBER, 1966

come symptomatic. The content of these revela- conflicts is dealt with only at this phase, as this
tions, etc., they may become symptomatic. The is a continuous process beginning early in therapy.
content of these revelations often produces sur- However, those conflicts that have not been han-
prise and amazement on the part of other mem- dled in the earlier phases and which become more
bers of the unit. The patient at this point becomes discrepant at this time have to be worked through
asymptomatic and frequently quite supportive of in order for the family to maintain its gains.
the "new patient." This improvement in behavior Family therapy is still two new a therapeutic ap-
is quite striking in children when the parents proach for there to be much information available
begin to interact emotionally with each other. pertaining to natural termination (unanimous
Following open admissions of long standing agreement by family and therapist). Although it
feelings, beliefs, secrets, etc., a calm descends upon is formulated in this presentation that the likely
the family; a new equilibrium has become estab- time for termination is at a point immediately
lished. Activities, remarks and other things which following the working through of those conflicts
before had caused conflict are handled easily which prevent adequate fulfillment of the newly
and without upset. During this period of serenity, acquired family roles, a number of patients have
families are reluctant to introduce anything that terminated prior to this step without subsequent
might possibly become a problem. On occasion, mishap. It is probably that in these families the
they express the feeling that treatment is no longer exchange of one homeostatic equilibrium for an-
necessary and indeed some families have termin- other of a lessed neurotic nature produces enough
ated at this time. improvement so that motivation for further formal
In an earlier paper, co-authored by this writer,15 psychiatric intervention ceases. This does not, how-
this period in treatment was called, "The Honey- ever, adequately account for the continual im-
moon Phase," while the preceding was labelled, provement of some families following the ap-
"Absolving the Patient from the Burden of parent premature termination. Likely the impetus
Change." A continuation of therapy allows the in making these changes was sufficient to continue
family to enter a third and final treatment period, the process without the need of a therapist.
the "Reality Phase." "Conjoint family therapy" and other methods
During the last treatment period, two interre- of family approaches are becoming increasingly
lated factors of major importance have to be con- prominent among the methods available in the
sidered: 1) the readjustment of the family to therapeutic armamentarium. One aspect of its pop-
new roles; 2) the working out of unconscious ularity is due to its ability to offer tertiary, second-
conflicts relating to these roles. ary and possibly primary prevention simultaneous-
The role assumed by each of the parents in a ly. With the present trend nationally toward
family is based upon their respective identifications community mental health centers, this approach
and introjects from their own primary family and could easily become a major part of a center's
the compromises drawn up by the two of them treatment and preventive program. However, the
when the family rules are made. The role that answers to innumerable questions that arise from
each parent assigns the other is then colored by the frequent production of significant results with-
these family rules and the expectations that they out fully adequate explanations await more elabo-
have of each other as a result of what they have rate follow-up and evaluative studies.
learned in their own primary family situations.
The changes in the system brought about by LITERATURE CITED
therapy provide a clearer dilineation of family 1. JACKSON, D. D. and J. H. WEAKLAND. Conjoint
roles, but on the other hand, leave the parents Family Therapy. Psychiatry, 24:30-45, 1961.
2. HALEY, J. Family of the Schizophrenic: A Model
with their own introjects. The degree to which System. J. Nerv. and Ment. Dis., 129, 357-374, 1959.
these introjects interfere with adequate functioning 3. LEVY, D. Maternal Overprotection. Columbia Uni-
within the new equilibrium established by the versity Press, New York, 1943.
family determines 'the extent to which unconscious 4. FROMM-REICHMAN, F. Notes on the Development
conflicts have to be dealt with in order to insure of Schizophrenia by Psychoanalytic Psychotherapy,
the continuous well-being of the family. This is Psychiatry, 11, 267-277, 1948.
5. ABRAHAMS, J. and E. VARON. Maternal Depend-
not to imply that the handling of unconscious ency and Schizophrenia: Mothers and Daughters in
VOL. 58, No. 6 Family Psychodynamzcs 435

a Therapeutic Group. International University Press, (Eds.). Exploring the Base for Family Therapy,
New York, 1953. Family Service Assn. of America, 95-115, N.Y., 1961.
6. HILL, L. B. Psychotherapeutic Intervention in Schizo- 11. WEAKLAND, J. H. The "Double-Bind" Hypothesis
phrenia. Univ. of Chicago Press, Chicago, Ill., 1955. of Schizophrenia and Three Party Interaction, in D.
7. LIDZ, T. and A. CORNEILSON, S. FLECK and D. 0. Jackson (Ed.) Etiology of Schizophrenia, 373-
TERRY. Interfamilial Environment of the Schizo- 388, Basic Books, New York, 1960.
phrenic Patient. I. The Father. Psychiatry 20, 329- 12. BATESON, G. and D. D. JACKSON, J. HALEY and
242, 1957. J. H. WEAKLAND. Toward a Theory of Schizo-
8. LIDZ, T., and S. FLECK. Schizophrenia, Human In- phrenia. Behavioral Science I, 251-264, 1956.
tegration and the Role of the Family, in D. D. 13. JACKSON, D. D. Family Rules. Arch. Gen. Psych.
Jackson (Ed.) Etiology of Schizophrenia, 323-345, 12, 589-594, 1965.
Basic Books, New York, 1960. 14. BORSZOMENGI-NAGY, I. A Theory of Relationships:
9. BOWEN, M. A Family Concept of Schizophrenia in Experience and Transaction, in I. Borszomengi-Nagy
D. D. Jackson (Ed.) Etiology of Schizophrenia, and J. L. Framo (Eds.). Intensive Family Therapy,
346-372, Basic Books, New York, 1960. 33-86, Harper & Brother, New York, 1965.
10. WYNNE, L. C. The Study of Intrafamilial Align- 15. WILKINSON, C. and C. REED. An Approach to the
ments and Splits in Exploratory Family Therapy, in Family Therapy Process," Dis. Nerv. System, 26,
N. W. Ackerman, F. Beatman and S. H. Sherman 705-714, 1965.
PHYSICIAN MANPOWER: MEDICAL SCHOOL APPLICANTS
For the first time in a four-year period, the number of applicants to U.S. medical schools failed to show an
increase over the previous year's total. The 18,703 individuals making application to the 1965-66 first-year medical
school class submitted a total of 87,111 applications for a record average of 4.7 per individual. Slightly more than
48 per cent of all 1965-66 applicants were offered admission. The ratio of 2.08 applicants to one acceptance was
exceeded in the 13 years only by the previous year's ratio of 2.12 to one.
Table 1 presents a summary of the application activity occurring for each of the classes from 1953-54 through
1956-66. It is likely that the decrease in applicants to the 1956-66 class represents a single year's phenomenon. The
number of individuals taking the Medical College Admission Test (MCAT) is a reasonably accurate predictor of the
number of applicants for subsequent years. The number taking the test in 1965 was not appreciably different from
the number of individuals taking the MCAT the preceding year. Therefore, no significant change is anticipated in
the number of applicants for the 1966-67 entering class.
Noteworthy at this time of great national interest in increasing the supply of physicians is a decrease of 76 in
the total first-year enrollment for 1965-66. Analysis of the data from individual schools, however, indicates that
only 33 fewer first-year students entered school for the first time in 1965-66. The number of previously enrolled
first-year students fell from 249 in 1964 to 206 in 1956-66, accounting for the other 43 students. Three schools,
which reduced enrollments in an attempt to strengthen their programs, account for all of this decrease in net enroll-
ment. Eighty-five schools made either no change or only minor changes in the size of their entering class. In con-
sidering these findings, it should be remembered that the Health Professions Educational Assistance Amendments were
not enacted until October 22, 1965. The dircet effect on class size of the large improvement grants of that legislation
will not be evident until the enrollment of the 1967-68 first-year class.
TABLE 1.-SUMMARY OF APPLICATION ACTIVITY 1953-54 TO 1956-66
Appli- First Per Cent
First Total cations Total Accepted Year of Total
Year Appli- Per Appli- Appli- Enroll- A pplicants
Class cants Applicant cations cants inent* Accepted
1953-54 14,678 3.3 48,586 7,756 7,449 52.8
1954-55 14,538 3.3 47,568 7,878 7,576 54.2
1955-56 14,937 3.6 54,161 7,969 7,686 53.4
1956-57 15,917 3.8 59,798 8,263 8,014 51.9
1957-58 15,791 3.9 60,951 8,302 8,030 52.6
1958-59 15,170 3.9 59,102
8,366 8,128 55.1
1959-60 14,952 3.9 57,888 8,512 8,173 56.9
1960-61 14,397 3.8 54,662 8,560 8,298 59.5
1961-62 14,381 3.7 53,834 8,682 8,391 60.4
1962-63 15,847 3.7 59,054 8,959 8,642 56.5
1963-64 17,668 4.0 70,063 9,063 8,842 51.3
1964-65 19,168 4.4 84,571 9,043 8,836 47.2
1965-66 18,703 4.7 87,111 9,012 8,760 48.2
* Includes previous enrolled students.
Enrollment for 1953-61 based on AAMC-AMA Liaison Questionnaire data.
Enrollment for 1962-66 based on AAMC Applicant Study data.
-Datagrams, v. 8, no. 4, Oct., 1966