using hypnosis in family therapy

Fam Proc 23:577-585, 1984

BOOKSFamily Therapy: Concepts and Methods, by Michael Nichols, New York, Gardner Press, 1984, 610 pp. $37.50 cloth.

One can measure the progress of family therapy by looking at its milestone overviews. It was only twelve years ago thatthe first text appeared, The Book of Family Therapy, (1) and with it the first attempt at classification: "conductors" vs."reactors," "analysts" vs. "systems purists." If that classification is inadequate today, it did catch the essentials. In 1976 wewere treated to Phil Guerin's influential Family Therapy: Theory and Practice (2). It represented the end of an era: For thelast time, such divergent practitioners as Bowen, Minuchin, Whitaker, and Weakland wrote about what they all called"family therapy." Terms like "structural" had already begun to appear but had not yet found their way into the literature. Itremained for John Steidl, at the 1977 Ortho Conference, to come up with the first systematic classification: communication,psychodynamic, structural, and Bowen. This has stood the test of time by being refined rather than discarded by others.

The Handbook of Family Therapy (3), which came out in 1981, clearly distinguished the major approaches, groupingthem into umbrella categories of psychoanalytic/object relations, intergenerational, systems theory, and behavioral. Whatthese pioneer overviews have in common is that major figures in the field describe their own theories and work. But whatabout their unacknowledged blind spots? The pioneers, like all of us, are engaged in three kinds of therapy: What weactually do, what we think we do, and what we would like to think we do. The last two dominate what we teach.

Ten years of acquaintance with many of the leaders in the family field have convinced me that most of them have a veryincomplete idea of what makes their brand of therapy successful. As Nichols says of Ackerman, for instance, "If teachableprinciples did underlie his work, they were probably inextricably bound up with his personal performance" (p. 60).

Thus, this 600-page book is a single author's thorough summary and analysis of the corpus familiarum. This is what thefield looks like to someone who has not participated in developing a major approach and thus has no particular investmentin any. Not that he is totally "objective"? one detects biases towards the multigenerational and structural, and some readersmay be startled by the substantial inclusion of Freud and by the lack of references to epistemology.

Nichols begins with three introductory chapters on the context of family therapy: historical, contemporary, andtheoretical. These are about as concise a summary of the field as a student could hope to get. He then presents his overviewof major approaches (one wishes he wouldn't call them "systems") and their leading practitioners. These are classified aspsychoanalytic (Ackerman, Alger, Lidz, Wynne, Nagy, Framo); group (Bell, Dreikurs); experiental (Whitaker, Satir,Kempler, the Duhls); behavioral (Patterson, Weiss, Jacobson); extended systems (Bowen, Guerin, Fogarty, Laqueur,Speck); communication (Jackson, Haley 1, original MRI); strategic (Erickson, Haley 3, present MRI, Selvini-Palazzoli);and structural (Minuchin, Haley 2). The list of names is actually much longer. Each chapter presents sketches of leadingfigures, theoretical formulations, perceptions of normal family development, theories of behavioral disorders, goals oftherapy, conditions of behavioral change, techniques, and evaluation of theory and results.

On the whole, this is successful in both design and execution. I do consider the term "psychoanalytic" a misnomer("psychodynamic" is more accurate), and since Nichols himself concedes that the "group" and "communication" approachesbelong more to the past than the present, he would have been better off enlarging on them in the historical chapter. Where Ifeel his classification becomes questionable is his "experiential" category for Whitaker, a maverick who neither fits into atheoretical framework nor wants to. Whitaker freely admits how subjective his theory is, and combining him with the othersis unconvincing. His operating assumptions are quite different from those of Satir, who would fit better in the group andcommunication categories, as they are from Kempler's work.

The book concludes with comparative analysis featuring valuable recommendations, a comprehensive reading list, and awelcome glossary. It all adds up to an exciting, highly recommended textbook at the advanced and postgraduate level. Forthis reviewer, it also raises some interesting questions for the future. First, I think it is high time family therapists stoppedpretending that Freud is irrelevant or at best a side issue. As the Roman proverb says, one vainly drives out Nature with apitchfork. Nichols is to be commended for including Freud's basic formulations as a framework worth knowing. It is alsorefreshing to see him acknowledge the seminal influence of Kurt Lewin's field theory, without which group,communication, and strategic work (including circular causality) could not have developed.

The second consideration is whether a discipline called "family therapy" still exists. Just as "psychotherapy" ceased toidentify more than the vaguest of commonalities long ago, how can we call "family therapy" a field with such divergentassumptions and treatment procedures as psychodynamic, strategic, and behavioral? How far will the rubber band stretch?As Nichols points out, some of these approaches concentrate on the well-being of the individual within the treated systemwhereas others are directed only toward the system itself. Since few therapists are purists it might make sense to reorganizethe field on a different axis, by theoretical macroassumption rather than treatment modality. Perhaps brief strategic workwith families has most in common with brief psychotherapy of the individual, and behavioral family therapy with behavioraltherapy in general, and psychodynamic family work with other expressions of ego psychology.

Printed from The Family Process CD-ROM_______________________________________________________________________________________

Copyright © 1999 Family Process.1

I wonder what would happen if major conferences were held at which therapists started to look at their commonalitiesrather than emphasizing their differences. Considering the path we have already traveled since 1972 it is likely that the nextoverview of the family field will begin a step in that direction.

REFERENCES

1. Ferber A., Mendelsohn, M. and Napier, A. (Eds.), The Book of Family Therapy, New York, Science House,1972.

2. Guerin, P. T., Jr. (Ed.), Family Therapy: Theory and Practice, New York, Gardner Press, 1976. 3. Gurman, A. and Kniskern, D. (Eds.), Handbook of Family Therapy, New York, Brunner/Mazel, 1981.

Lothar Salin, M.A.The Psychotherapy InstituteBerkeley, California

An Introduction to Marital Theory and Therapy, by Leroy G. Baruth and Charles H. Huber, Monterey, Calif.,Brooks/Cole Publishing Company, 1984, 332 pp. $22.95 cloth.

After reading Nichols' sophisticated volume it was hard to warm up to this one, with its oilcloth cover, clumsy design,garish colors, and pedestrian writing. I regret agreeing to review them in tandem; vintage wine and vin ordinaire each havetheir separate uses, but not on the same table. Yet this is a workmanlike, competent textbook, on the introductory level.

Its sections include "Marital Theory and Therapy: Basic Assumptions"; "Dynamics of Marital Adjustment and Discord,"with psychoanalytic, social learning, and systems theory, and illustrations of how the same case would be worked in thesefour models; and "Comprehensive Marital Therapy," including the authors' own Process Model. A final section deals withclinical accountability, professional/ethical issues, research, and a listing of AAMFT standards, ethics, and programs.

This package will enable the beginning social work or psychology student to gain a basic understanding of maritaltherapy and to organize his or her career learning for several years ahead. It summarizes the things one needs to knowbefore embarking on clinical work with couples, but it is not a blueprint for practice. The limitations are most highlighted, Ithink, by the four parallel case vignettes: All the details are technically correct, but the authors describe only the form oftherapy without its substance. Mastering therapeutic practice, of course, reflects a level of expertise beyond graduate schooland can best be gained through field placements and first-rate supervisors. Nevertheless, I am concerned that Baruth andHuber do not sufficiently emphasize the elementary level of their text.

Lothar Salin, M.A.The Psychotherapy InstituteBerkeley, California

Handbook of Marital Interventions, by Luciano L'Abate and Sherry, McHenry, New York, Grune & Stratton, 1983, 404pp. $46.50 cloth.

L'Abate and McHenry have written an excellent book that reviews the field of marital therapy and also critically assesseseach model of practice. As Frank Pittman points out in the Foreword, this is a book that family therapists should knowbecause our field was established without a base of hard data. Without such a data base, our allegiance to some methods ofintervention is more a matter of faith than of science.

The first section of the Handbook comprises nine chapters on methods of training to develop educational and preventivesocial skills, including assertiveness training, communication training, contracting, encounter, relationship enhancement,enrichment, conflict resolution, problem-solving and treatment of sexual dysfunction. Each chapter summarizes the method,its underlying philosophy, and the research that supports it. All are well referenced.

The second section deals with remedial techniques, including behavioral marital therapy and psychotherapy. The chapteron behavioral marital therapy is especially thorough in its discussion of major concepts and treatment methods. The chapteron counseling and psychotherapy emphasizes humanistic approaches that have not been prominent in other texts. Theseinclude experiential, existential, and Gestalt viewpoints. Traditional psychoanalytic marital therapy is presented, as areBowenian, object-relations, strategic, structural, and systemic marital therapies.

The counseling and psychotherapy chapter also has a thoughtful discussion of the research base for marital therapy ingeneral. The authors conclude that marital therapy research is lacking in both quantity and quality. Their major criticisms:use of instruments with little or no validity, use of self-report data, lack of control groups, and narrow treatmentpopulations. In addition, they cite the lack of replication studies; this situation obtains because often treatment has not beendefined precisely enough so that it can be replicated.

Section Three is entitled "Preventing and Dealing with Marital Breakdown: Premarital and Postmarital Interventions."



The authors observe that, while premarital interventions are seen as important, preventive therapy, they remain poorlydefined; most interventions lack research support for their preventive impact on future marital difficulties. This section alsohas informative chapters on divorce mediation and related interventions.

Section Four, "Issues in Marital Intervention," includes a review of marital interactional theories and research. Theauthors point out that the last decade has seen a significant increase in the empirical study of treatment outcome. Thenumerous difficulties and deficits in research design are examined with suggestions for improved methodology. Thischapter provides an excellent lead-in to the concluding essay that presents major issues future theorists and practitionersneed to address.

In summary, this is a scholarly and comprehensive study of the field of marital therapy. It accurately summarizes andcritiques existing models and points the way to future empirical and theoretical developments.

Bud Protinsky, Ph.D.Virginia Polytechnic InstituteBlacksburg, Virginia

Structured Family Facilitation Programs, by Margaret H. Hooper, Barbara L. Fisher and Sally H. Barlow, Rockville,Md: Aspen Corporation, 1984, 462 pp. $32.50 cloth.

The basic premise of this book is that healthy family systems do not develop easily and naturally by themselves. On thecontrary, structured training, skill building, and practice are needed to produce a healthy family. This view announces theemerging field of family wellness and prevention (1, 2, 3) that advocates educational approaches based on a public healthmodel. The authors' purpose is twofold: "... to provide professionals with the information and skills to help them plan,develop, deliver and assess a structured family facilitation program, and ... to provide a variety of programs that may beutilized, as they are written or modified, to meet the needs of a specific population" (p. xiii).

Family facilitation can be divided into three approaches: family life education, family enrichment, and family therapy.This book focuses on structured programs for family facilitation, a formal plan to help a family achieve specific,predetermined goals. These programs involve a group of several families, one or more facilitators, and a defined number ofsessions.

There are at least two advantages to structured programs. First, they are replicable, so that their effectiveness can beevaluated empirically; they can also be modified and refined for greater effectiveness. Second, the programs are costeffective. Knowing which programs produce effective outcome for specific problems saves time and money.

The book is divided into six parts. Part I covers the foundations for family facilitation. In a clear and straightforwardmanner, the authors cover the theoretical assumptions of family facilitation, family functioning, small group dynamics, andthe use of structure in family facilitation. They delineate the various approaches to family facilitation and have a persuasiverationale for their views. Their discussion of family functioning, on the other hand, is simplistic. Eight pages is too little toallot to the family as a system, the family life cycle, and healthy family functioning.

Part II describes how to design, deliver, and evaluate a family facilitation program. This is a useful "how to" manual forprospective facilitators. The authors' view is that professionals can learn to tailor their programs for the needs of particularfamilies.

Perhaps the weakest chapter is on program evaluation. The authors recognize the need for assessment but do not givethese instructions the same attention that they did to planning and delivering programs. The appendix on assessmentinstruments is also inadequate.

The remainder of the text (300 pages) gives examples of structured family facilitation programs by various authors.There are, for example, programs for couples coping with separation due to imprisonment; assertiveness programs forcouples; programs for dual career couples; and premarital education. Enrichment programs are illustrated for families withhusbands in management; families with school-age children; and families with extended social contact. Finally, treatmentprograms cover rape victims and their families; divorcing couples; couples in conflict; siblings in conflict; couples in crisisdue to a life-threatening illness; incest victims and their parents; stepfamilies; drug abuse families; religious communities.

The most serious shortcoming of the book is that, out of 16 programs, only two have research data reported to assesstheir effectiveness. This is especially ironic since each program has listed materials and methods useful for its assessment.Thus, it is difficult for the reviewers to evaluate individual programs by any objective criteria. Many programs clearly meritfuture research. For example, using the parents as a support of single rape victims offers promise as a useful treatment.Until empirical evaluation is conducted, however, nothing can be said about its usefulness.

The programs also seem to have methodological flaws. Many do not include homework, though homework would seemto be essential for treatment generalization to occur. Also, none of the programs includes a stepwise demonstration ofeffectiveness before continuing to the next part.

The book is easy to read and well organized, but the index is incomplete. The reviewers found several mistakes in theindex and appendixes. Some references cited in the text were absent from the reference list.



This volume offers excellent ideas and guidelines for developing family facilitation programs. If the use of such programsis to come of age, however, it will be because their effectiveness for the consumer and the service provider is proven. Thatconfirmation is yet to come.

REFERENCES

1. Kahn, A. H. and Kamerman, S. B., Helping America's Families, Philadelphia, Penn., Temple University Press,1982.

2. L'Abate, L., "Prevention for Marriage and Family Problems," in B. Edelstein and L. Michaelson (eds.), Handbookof Prevention, New York, Plenum Press, in press.

3. Mace, D. (Ed.), Prevention in Family Services: Approaches to Family Wellness, Beverly Hills, Calif., SagePublications, 1983.

William L. Buchanan, M.S.Luciano, L'Abate, PH.D.Georgia State UniversityAtlanta, Georgia

(We are indebted to Deirdre Coleman, Elizabeth Heard, Michael Levis, Sean O'Sullivan, Fred Stevens, and StevenWeinstein for discussion and helpful comments incorporated in this review.)

Using Hypnosis in Family Therapy, by Michele Ritterman, San Francisco, Jossey-Bass, 1983, 351 pp. $19.95 cloth.This excellent book cured me of worrying about the etiology of a symptom I had had for twenty years. Ritterman's

mentor, Milton Erickson, cured me of the actual symptom, which was my naked terror in driving a car. I had consulted himabout another problem, but in the trance induction he threw in a bit about how hard it had been for me to learn to drive andhow natural it finally had become. I was startled into a deeper trance and thought that either the man is psychic and knows Idon't drive, or he is artfully weaving the roar of Phoenix traffic into the induction. (Erickson's house seemed to be at theintersection of every major American truck route.)

About five years later I did get my license, of course crediting Erickson, but no doubt helped by the birth of a third child,which had finally made bicycle transportation impossible. I was quite a competent and safe driver on the little island whereI summered (speed limit 30 m.p.h.), at least until a run-in with my next hypnotist, my family hypnotist, in this case my79-year old English mother.

The idea that family members can "entrance" each other was one I had never contemplated until I read MicheleRitterman's clear analysis of how the family hocus-pocus is done. Ritterman postulates that some families provide powerfulhypnotic indicators for their members, so powerful that they can create symptomatic behaviors. This in itself is not new inthe family therapy literature; Laing (2) and Bowen (1), for example, have in different ways described how powerful familymembers induce symptoms through suggestion, attribution of negative traits, mystification, or prophecies of dire events tocome. Watzlawick (3) has recently explored the nature of self-fulfilling prophecies, drawing on experimental data, and allin all it has become standard practice for family therapists both to be on the alert for such signals and also to don sheep'sclothing themselves, countering the family hypnotist with genial but confusing reframings.

Ritterman's original contribution lies in these areas:(a) Description of the specific hypnotic components of family interaction. Her linguistic analyses of family

communications reveal almost all the major trance-inducing phenomena including confusion, interspersal techniques,and embedded suggestions that refer to deeply understood family structures and rules of relating. She helps the readerattune his own ear to hypnotic suggestions as he watches client families or even his own.

(b) Ritterman has devised a counterinduction technique based on the family's language pattern. She attends to issues offamily structure so that hypnotic induction itself, although centered on an identified patient, also aims at multipleaspects of family functioning and may include suggestions for more than one member.

(c) Ritterman's cases illustrate skillful adaptations of Ericksonian technique to couples and families. I especially likedher gentle induction of a hemophiliac and his mother, in which the trance allows mother to continue her role byhealing her son's anxiety yet also establishes clearer boundaries between son and mother. (This is an especially usefulcase for therapists interested in families with painful or chronic illnesses.) In another case, an alcoholic husband,enuretic child, and despairing wife refused to be seen together, yet Ritterman works with the family, as it presentsitself, rather than fighting? and losing? a battle for control. Still another chapter, a full-length consultation with asuicidal girl and her family, clearly demonstrates trance induction in a family group context. (I did find this particularinduction a bit distasteful from the feminist perspective, with its Ericksonian emphasis on lipstick, nail polish, and



round bottoms as the chief markers of a woman's growing up.)

The theoretical chapters attempt to blend Ericksonian and structural principles and are less successful than the clinicalpresentations. It seems to me that, in the end, most family therapy ultimately does address issues "within" the individual,whether the therapist does so with large brush strokes or with detailed work such as formal trance induction. In all familytherapy there must be some kind of counterinduction to the belief system that underpins a dysfunctional family structure.The Milan-style therapist may accomplish this by asking confusing or unexpected questions. Whitaker might do it by actingoddly perverse in the face of family propriety, creating a confusing and thus potentially hypnotic context. I therefore couldnot agree with its being linked specifically to a structural model.

Now let me thank Ritterman in the Ericksonian tradition by finishing my tale. After many years of psychotherapeuticmusing on my driving phobia, I had concluded that unmet dependency needs were the villain of the piece: If you can't drive,someone has to drive you. What a relief to find, after reading this book, that the symptoms had a very simple,nonpathological explanation. Like Sleeping Beauty, I had been in a twenty-year trance. I discovered my trance state in thefollowing manner:

A few weeks ago, I was driving my mother somewhere for the first time. As I braked to round a sharp turn, she said inalarm, "Never accelerate going around a corner!" Suddenly confused, I began to wonder whether I had in fact mistakenright for left (or is it left for right?) and had pressed the accelerator instead of the brake. My heart started to beat rapidly,and I began to defend myself, denying that I had accelerated. But my darling family hypnotist added softly, "Because younever know what you will find lying in the road around the corner. You might hit a dead child." She shuddered as she gavethis ominous message and continued to emit little squeaks and shudders until we reached our destination. By that time I wasstruggling just to steer.

Later I realized that my mother had been my first driving teacher, and memories flooded back of similar warnings of thedangers that awaited me upon receipt of my license. I do not know why this gentle woman, who had driven all over the Alpsat the age of 16, sans accidents, was so terrified of her otherwise competent daughter's driving. But now that I understoodwhat she was up to, I began my own counterinduction, a mixture of laughter and teasing about her hypnotic endeavors. Thisended the anxiety for both of us.

REFERENCES

1. Bowen, M., Family Therapy in Clinical Practice, New York, Jason Aronson, 1978, pp. 379-382. 2. Laing, R. D. and Esterson, A., Sanity, Madness, and the Family, New York, Basic Books, 1964. 3. Watzlawick, P., The Invented Reality, New York, Norton, 1984. [To be reviewed in a forthcoming issue of this

journal -Ed.]

Gillian Walker, M.S.W.Ackerman Institute for Family TherapyNew York, New York

Adolescent Suicidal Behavior: A Family Systems Model, by Roma J. Heillig, Ann Arbor, Mich., U.M.I. ResearchPress, 1983, 155 pp. $34.95 cloth.

This book features a brief, interesting review of suicide as a human dilemma and calls for a family systems perspective tounderstand the broad ramifications of this problem. The chief theoretical views are those of Bowen, Boszormenyi-Nagy,and Kantor. Briefly, the author holds that the manifest symptom of suicidal behavior is an expression of family dysfunctionand that the dysfunction is uniquely related to issues of loss and separation.

Only one family was studied, through interviews focused in three areas: (a) history of loss and separation; (b) generalfamily maintenance, including defensive and coping styles; (c) specific suicidal behavior. In addition, the book presentscase material about two of the six adolescents whose suicidal behavior was studied.

The clinical material is interesting because it shows how in-depth investigation of suicidal behavior can be readilyavoided both by family members and by a researcher-author. At no time, apparently, was a suicidal patient seen with his orher family to determine what affects or associations had been generated in them by the suicidal behavior. Thus, the paradoxof this book is that the material? including verbatim transcripts? is interesting, relevant, and at times compelling, but itstruck this reader as terribly incomplete.

In fact, my initial reaction to Adolescent Suicidal Behavior was a feeling of mental inadequacy. I simply could notdiscover the point of the book. The individual attempting suicide should, I believe, be the beginning source of data aboutthe suicide. Material that would be basic to that approach never appears, things like the contents of the suicide note, thedetails surrounding a suicide threat, or details of the actual attempt. I finally concluded that my head was O.K., but that thebook is not really about suicide; it is about the cognitization of human experience and mainly demonstrates that the jargon



of psychological research can be more confusing than helpful. A clinician might well wonder how this very expensive bookcould actually be used in a clinical situation. I did like the thirteenth-century Islamic poem at the beginning.

Norman Paul, M.D.Lexington, Massachusetts



OTHER BOOKS OF NOTEDie mehrgenerationen-Familien-therapie, by E. Sperling, et. al., Göttingen, Germany, Vendenhoeck & Ruprecht, 1982.

This book originated from a major German family therapy center connected with the university in Gouml;ttingen. Theauthors first summarize existing ideas of intergenerational family therapy, both psychodynamic and systemic, and then theyadd their own concepts. Ten cases are presented in depth, emphasizing psychosomatic and physical problems. Although Idid not always agree with the authors' moves in therapy, I was impressed by the solidity of their theoretical base and clinicalexperience. Intergenerational aspects of family therapy have not been in the forefront of American thought in recent years,and it is interesting to note their significance abroad.

For information on obtaining this book, contact:Fr. Dagmar Friedrich, LektorinVerlag für medizinische PsychologieTheaterstr. 13, Postfach 437D-3400, Gouml;ttingen, GermanyNorbert Wetzel, Th.D.Princeton, New Jersey

Family Therapy Techniques for Problem Behaviors of Children and Teenagers, by Charles E. Schaefer,James M. Briesmeister and Maureen E. Fitton, San Francisco, Jossey-Bass, 1984, 475 pp. $25.95 cloth.

In this unusual bibliographic review, articles centering on young people's problems are summarized and evaluated undernew titles. For example, a 1974 article that its author, Harry Aponte, called "Organizing Treatment Around The Family'sProblems and Their Structural Bases" becomes Problems, Participants, and Pledges: A Family Therapy Approach toJuvenile Delinquency. The next entry line shows Aponte as the author, but the original title does not appear until the end ofthe entry, where it is listed as "Source." This format may prove tedious to a researcher, because it involves a lot of thumbingthrough the index, but it did allow the authors to classify the dozens of articles into thematic sections such as"Impulsive-Aggressive Behaviors," "Running Away," "Delinquency," and so on. Each article is summarized in theme,theoretical content, case material, and treatment results. The author/editors add their own comments, and further reading issuggested at the end of each section.

Parting: The Aftermath of Separation and Divorce, by Graham B. Spanier and Linda Thompson, Beverly Hills, Calif.,Sage Publications, 1984, 310 pp. $25.00 hardback.

Recycling the Family: Remarriage After Divorce, by Frank F. Furstenberg, Jr. and Graham B. Spanier, Beverly Hills,Calif., Sage Publications, 288 pp. $25.00 hardback.

These books are of a type we've seen a lot recently: statistical surveys of a special population illustrated with quotationsfrom personal interviews. Any therapist ought to know that divorce, like war, is hell, and that remarriage, like peace, istough; in case anyone needs to have it proven, Spanier and colleagues give more than enough data. These books would alsobe particularly useful for young trainees who may not understand from clinical or life experience just what the norms arewhen life shreds up or when people try to put their context back together again.

Structural Family Therapy, by Carter C. Umbarger., New York, Grune & Stratton, 1983, 208 pp. $24.50 hardback.A review of SFT that is dedicated "for Susan and Jessica" but could as well have been "for Sal, Harry, and Braulio."

Umbarger's writing is clear and concise, so my puzzlement is not about the author but about the publisher: Why use all thisenergy to remake Families and Family Therapy when it was done so well the first time? But don't mind me, I had the samecomplaint about Wuthering Heights.

R.S.



using hypnosis in family therapy

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