Set in a fine hotel in legacy southern Italy, the July 2023 conference had a title that said come-over-here-and-take-a-look-at-this!: ‘Family Therapy—The Road that Connects Individual and Social Resources. This was linked to the Assisi Manifesto, a statement prominently set out in the pre-conference publicity and conference program. The credo began: ‘Family therapy champions the family and affective connections in an age of labels and pills’. Attended by around 1000 registrants from around the globe, the conference was conducted in four languages: English, French, Spanish and Italian.
So far, so state-of-the-art. Here is a successful, media-savvy group of professionals gathered to salute their flag, and themselves, by marking the identity of their tribe as progressive and as other to the mainstream. Yet this presentation somewhat misrepresents what family therapy has become. What once promised to become a major therapeutic practice is now subaltern, almost footnote within the larger domain of health and human services.
The rise of family therapy
From the late 1960s through the 1970s and 1980s and into the 1990s, family therapy had a definite sunrise appeal. The single term has covered various approaches, all of which have involved a talking session with some or all of the members of a family unit, units of varying types and extents.
If one could sum up a key driver of family therapy it is the premise that cause-and-effect logic has no place in understanding the world of the living. As the post-Second World War anthropologist and systems theorist Gregory Bateson put it, linear thinking is fit for purpose if we want to understand what happens on a billiard table but incommensurate with the reflexive patterns that organise behaviour in living systems. His work on systems thinking would be very influential in what family therapy would become. The networks Bateson described are characterised by circularity—by patterns of reciprocal influence.
Drawing on general systems theory and anthropology as well as traditional sources—‘family casework’ in social work, professional-couples counselling and child guidance practices in psychiatry—family therapy become a semi-recognised entity with its own key journals (for example, Family Process, launched in 1962) and foundational texts (for example, Haley and Hoffman’s Techniques of Family Therapy, published in 1968, and Minuchin’s Families of the Slums: An Exploration of their Structure and Treatment, published in 1967). From the 1970s onwards, it began to spread through public and private health systems as a treatment option for various presentations. Its popularity and visibility became such that an early episode of The Simpsons, that compendium of popular culture, featured the whole family trooping along to a therapist.
By the mid-1980s, interested parties could sign up for a mosaic of intra- and international workshops or enrol in more or less formalised training programs. Not the least of the signs that family therapy was up-and-coming was that a good number of recognised professionals began to say ‘What I practise is family therapy’. Here was a new wave that was on about the smallest of collectives and whose enthusiasts were dismissive equally of rat psychology, Freudian snobbery and mainstream psychiatry. Revelling in an outsider status, non-hierarchical and multi-disciplinary, during this period family therapy had mongrel vigour; its origin story unselfconsciously, even admiringly, cited a suite of disparate, non-traditional sources such as the cybernetics of Norbert Wiener and Bateson’s fusion of communications theory and anthropology. For better and worse, this brew was also agitated by elements of the structural-functionalist tradition in sociology, and by humanistic psychology’s interest in the power of the here-and-now therapeutic encounter.
The word was out. By the mid-1980s, scholars and practitioners in Germany, the Netherlands, the United Kingdom and the east and west coasts of the United States, as well as in Perth, Sydney and Melbourne, seemed connected not just in method but in mission. In each of these locations, local students and practitioners were drawn into the excitement of a model that focused on process and context and avoided the individualism of both the traditional psychoanalytic and the rising cognitive-behavioural model. Figures can be deceptive, but the wave of interest is illustrated by the fact that membership of the American Association of Marital and Family Therapy increased from the hundreds in the 1960s to around 10,000 in the mid-1980s.i
For family therapists, a key conceptual pivot away from traditional therapies was the premise that the practitioner should not become mired in the pre-history of the ‘presenting problem’. Within the practice, this term had an emblematic meaning up to the late 1980s: that the particular family member—the mum who was depressed; the child who was refusing school—was not intrinsically damaged or ill. Rather, this person’s difficulty manifested and bore witness to an underlying family issue such as a stalled transition in the family’s developmental life cycle. That is, the ‘presenting problem’ was to be respected but should be understood as a sign, a metaphor, not as the tip of a dense pathological iceberg. The idea was that practitioners should free themselves from the assumptions that advocates said bedevilled traditional therapeutic approaches, and in particular divest themselves of the assumption that being depressed or refusing school were symptoms’ that knowing experts thought pointed to a basic disorder or illness that required long-term work to come to terms with, ameliorate or cure. Consistent with this, family therapy’s key figures seemed to be both transparent and spectacularly successful. Positive outcomes seemed to be demonstrated across an array of presentations, many of which had reputations as being ‘refractory’—from school refusalii and encopresisiii to schizophrenia.iv
At its best, this family therapy also had a political edge. Many in the business sought to meaningfully engage with and advance the wave of critical assessments of society and psychotherapy arising from second-wave feminism. For example, Deborah Luepnitz in the United States and Kerry James and Laurie MacKinnon in Australia for more than a decade insisted that the issue of power should be at the centre of debate and discussion beyond the consulting room.
In the language of the day, ‘a hundred flowers bloomed’. Certainly there were some fundamental differences among practitioners. For example, Virginia Satir, an experientially focused practitioner, advocated emotionally literate and direct encounters with family members to resolve issues. By contrast, Paul Watzlawick at the Mental Research Institute emphasised the importance of finely analysing, before non-confrontationally disrupting, unhelpful communication patterns. Different again were Helm Stierlin, a German psychiatrist, who argued for the psychoanalytic tradition to be integrated with ‘second-order cybernetics’—an approach which held that the therapist could never be an independent observer—and Ivan Boszormenyi-Nagy, an expat Hungarian, who originated a complex approach that combined acknowledgment of here-and-now systemic interactions with a theory of relational ethics, an unflinching logic that gets to be played out in a ‘multi-generational ledger’: think a bait-and-switch iteration of the Biblical idea that the sins of the father are visited on the son. The fact that these approaches, along with many other contenders, were more or less conceptually incompatible did prompt debate and, at times, degrees of friction. Yet the possibility of hostility and schism were belied by the sense that ‘hey, we’re all part of a new movement’.
Mindful that national and very local circumstances were also in play, from the early 1970s there was considerable exchange between the key players across international borders. For example, major family therapy figures such as Satir and Salvador Minuchin, another very prominent figure from the United States (via Argentina), held workshops in Victoria in the early 1970s. These events reportedly galvanised key figures, and an increasing audience in this country, as such exchanges also mobilised activities in the many sites that came to incubate family therapy from Scandinavia to New Zealand. For example, the Williams Road Family Therapy Centre was established in 1979 as Australia’s first dedicated private family therapy centre.
My own experience with family therapy began in 1980 while working in a traditional inpatient psychiatric institution. Stimulated by the idea that the governing assumptions of the service were wrong (‘a mental health diagnosis is a life sentence’), and by the comradeship and greater knowledge of a small, multi-disciplinary band of optimists, we experimented with and closely studied how family therapy could be practised in this and like settings. But we were not alone. It seemed that family therapy was a new light whose time had come: enthusiasts in many settings—in general hospital psychiatric units, in community health centres, in private practice—seemed to be on the same wave. Numbers attending the national conference were growing year on year; training programs became more formalised; steps were being taken towards establishing a clinical membership category within the local family therapy association.
Over time this trajectory was not sustained. A symbol of this decline in Australia was evident in ‘flagship’ services such as Williams Road and the Bouverie Centre dropping the term ‘family therapy’ from their mastheads. Hand in glove with this loss of confidence were a decline in local conference numbers, a fall-off in the vitality and adventurousness of papers in the local journal and a general loss of the buzz and comradeship that had been present earlier. Currently, there are few champions of family therapy in Australia, and little in the way of effective evangelism. This marked waning in verve and profile presumably reflects the fact that despite its early promise, family therapy did not accrue structural and institutional gravitas.
Realised in terms of recognised credentials and systems of remuneration, this kind of weight has been retained, and re-asserted, by the elite professions—medicine and psychology—but denied to those who contest the primacy of ‘the individual’ in understanding problem formation and resolution. Of course, a hegemonic cultural logic supports the ‘norm of autonomy’,v and, to a significant degree, the ascendance of this norm has contributed to family therapy not living up to its initial promise. More generally, a spaghetti junction of ideas about internal and contextual factors are in contention over what produced this situation. Mindful that ‘there is no first horse on the merry-go-round’—to recycle a quote from Lynn Hoffman, an esteemed early family therapist—one entry point for a formative commentary might be to review this year’s International Family Therapy Conference program and compare its menu with what was offered at a family therapy conference nearly forty years ago—the Australian Family Therapy Conference in 1985. Although the comparison is a little ad hoc, it yields interesting results.vi
Trauma/resilience/recovery was a prominent theme at the Assisi conference; at the earlier Australian conference, I spotted the word ‘trauma’ only once in the published abstracts, and the other two terms not at all. Similarly, there was more attention given to diverse sexualities in the later conference than the 1985 Australian one. More speculatively, there was a seam of regret and loss in several of the Assisi presentations that was not apparent in the optimistic ‘we’re taking the system on’ quality that was present in many of the abstracts from the earlier conference. For example, in one of the round-table presentations—‘The Italian Lesson: What Can We still Learn about Community Mental Health’—the background was the demise of the radical remodelling of psychiatric practices that had begun in several regions, although since rescinded. This said, the whole tone of the Assisi conference’s official announcements sought to assert resistance—to pills, labels, discrimination and control.
Leaving the two conferences to return to the issue of family therapy and its trajectory, as in other brands of psychotherapy, there have long been tensions between rival theory formations—between the attitudes of pluralists versus purists—that have arguably been an internal driver of how family therapy has evolved. This means that to outsiders, and even for some insiders, it is unclear what family therapy is (and is not). For example, what distinguishes family therapy from ‘ordinary psychotherapy’ in terms of who is seen? Early pioneers knew the answer: one rejected the outdated one-to-one orthodoxy in order to ‘see the family, the whole family, and nothing but the family’. Not long after this diktat was etched into a stone tablet, however, a heretic voice began to contend that ‘we can do systemic work with individuals. The issue is not who you meet with, but how you formulate, and act in relation to, that counts’. Touché, but a little later still a kind of good sense arose which was less binary: that one should engage in what Jenny Smith, then a Melbourne-based practitioner, termed ‘family-sensitive practice’—on condition one knew that the term ‘family’ was not to be understood in an exclusively legal or biological sense.
More central than the above has been a contest between the root metaphors that inform different practitioner groups. Crudely put, the dominant metaphor historically has been ‘systems’. In other words, family therapists, whether they actually work with families, networks or organisations, or only see individuals, say they engage in systemic practice. This allegiance may not be voiced using a strict nodes-and-network vocabulary. Mostly, the approach is understood using more everyday terms, such as ‘context’ and ‘interaction’. In terms of conceptual capital, the key figure in this history is unambiguously Gregory Bateson. It is his legacy that introduced ideas like ‘the pattern that connects’ and the ‘classification of processes’ (the symmetrical and the complementary) that are at the centre of ‘traditional’ family therapy thinking.
Within the systemic paradigm a whole array of practices were advanced. This loose set included those therapists who couched their formulations in terms of transgenerational/family-of-origin systems and those who privileged an experiential, here-and-now interactional view, or a perturb-the-system strategic focus, or a political or a specifically gender-centred attention. Then, quite suddenly, in the mid-80s a new contender unsettled this steady state. Reflecting larger intellectual tides, the edgy but still Kumbaya situation was challenged by ‘the narrative turn’. Championed by and identified with Michael White, a social worker from Adelaide, and New Zealand anthropologist David Epston, as this turn developed a broad international profile it resituated, if not entirely unseated, the systems metaphor. This was exciting—and, over the next years, also divisive, as narrative enthusiasts formed a cadre and established themselves as a distinct formation separate to family therapy. One insider—Brian Stagoll, psychiatrist and recent Order of Australia awardee—summed up the theory issue this way: family therapy was never, and could never be, a homogenous entity. Rather, Stagoll argued, many tropes and concepts had always, and would always, exist within this ‘rubric’.
Larger social conditions have also influenced the trajectory family therapy has taken. For example, a key condition that enabled the practice of family therapy to develop in the 1980s was that human service organisations in the period tended to be ‘loosely coupled’: in other words, local, on-the-ground actors made decisions that were not subject to unilateral directions from centrally placed authorities in state Health Departments or the national headquarters that administered large voluntary service organisations. This absence of a strict control and command function allowed practitioners a relatively high degree of autonomy , which permitted certain adventurist practitioners the space to initiate novel forms of local service.
For example, apart from one designated service—the Bouverie Centre—in Victoria, there was never a budget line in state-funded services that said ‘family therapy’. No top-down fiat authorised this form of work in such services, nor did consumer demand introduce this product into private practice settings. Rather than a service’s formal policies, or the nature of its auspice—say, as a health centre or a non-government organisation—it was the presence of particular actors that saw family therapy introduced as the standard treatment that was offered to clients in this space. Thus family therapy took off in particular private practice centres, in some child psychiatric sites and in one or two services that, for a time, designated themselves specifically as ‘family therapy’. Notably, this period also saw several extraordinary, albeit not long-lasting, developments. For example, in mind-boggling defiance of accepted protocols and practices, whole families were admitted to the child psychiatric unit at the Austin Hospital in Melbourne for weeks at a time. However much conditions may have invited more experimentation than is possible today, to the degree that family therapy was able to dislodge received practices at all, this achievement was occasioned by the efforts of local actors. Chutzpah and charisma may have played a part, but nothing moves bottom-up change without organisational can-do and doggedness.
However one views the question of ‘warrant’ and ‘practitioner’ motivation, the above birthing process could not occur in today’s human services workplaces. Currently, policy and practice are tightly coupled, and there is far less room for professional discretion. As surveillance of budget ‘performance’, KPIs and the like increased, from the mid-late 1990s on, the scope for this experimentation began to narrow: the family unit at the Austin Hospital closed; beyond these shores, the lead international magazine—Family Therapy Networker—dropped ‘family therapy’ from its title; more broadly, the international preoccupation with individual trauma began to be interpreted in such a way as to sideline the importance of relationships.
More broadly, the trajectory of family therapy was subject to a residual and ever-strengthening cultural logic: the ideology that ‘it’s about the individual’. In championing the centrality of context and relationships, family therapy contested, and has lost to, the significant cultural process that has naturalised self-care, individual resilience and the ideal of self-reliance as commonsensical rather than as particular, and contestable, values. Clearly, the language of the ‘I’ has increasingly colonised subjectivity and the popular imagination. In this circumstance family therapy is forever an outlier, as it can never align with the ethos and the operating machinery that service the ideology of the sovereign self.
One example makes this clear. The UR (‘unit record’) recording system in health service settings requires that each individual attendee in a family session be uniquely registered. This application of bureaucratic process clearly undermines the founding ‘risk’ that a family therapy analysis takes, which is that the collective unit of the family is, in at least one crucial dimension, prior to its members’ manifestation as individuals within it. This expectation, along with the dense medico-legal complications of the increase in patient rights—such aseach party having a potential to access practitioner notes in the context of a family court or other dispute—makes it more likely that practitioners will default to working with individuals rather than engaging in forms of practice that are conjoint or collectivist in their orientation. Medicare and private insurance remuneration and registration arrangements are also relevant. Not only do these larger structures ‘feed’ the members of the professional groups who are recognised in these systems, their operations also instantiate a kind of double action in that certain ‘occasions of service’ are counted while others are not. Effectively, within the current regimes of billing and claim, ‘family therapy’ does not actually exist; it is not recognised. No statistics are available that document the instances in which family therapy is practised, and there are no reliable metrics that tell us how many practitioners declare their primary identity as ‘family therapist’. National bodies may count membership numbers—for example, there are currently approximately 1000 clinical members of the Australian Association of Family Therapy—but it is unclear what is signified by this figure.
An additional factor that has degraded the prospects for family therapy should be briefly noted. Due to the fact that the funding game is rigged, family therapy has an underdeveloped research base. With little or no institutional grunt—it also has almost no academic base—it is hard to see this situation changing for the better.
This steady decline in family therapy practice has occurred at the same time as doubts have arisen as to the effectiveness of individual therapy. One influential meta-study from 2019 presented evidence that there had been almost no shift in the effectiveness of one-on-one therapy in key conditions over half a century. This research report concluded that
Mean effect size increased nonsignificantly for anxiety, decreased nonsignificantly for ADHD, and decreased significantly for depression and conduct problems. Moderator analyses involving multiple study subgroups showed only a few exceptions to these surprising patterns.vii
Such findings are subject to debate. But the possibility that individual-centred therapy is not becoming more effective speaks to the possibility that it is more the ‘common factors’ in psychotherapy—that combination of generic attributes including the quality of the therapeutic alliance and the therapist’s demonstration of empathy and positive regard—that make a difference than the public claims of the brand in question. If this is (broadly) accepted, it follows that attempts to broaden the project to include (as family therapists generally have been motivated to do) the close associates of the person who is struggling, and contest the premise that each of us is supposed to be a sovereign state, definitely have potential advantages.
One final observation is pertinent. Were family therapy to experience a revival, it would come into a world where not only are the centrality and worth of the family being questioned again—the ‘family abolition’ movement having something in common with the anti-psychiatry family critiques of the 1970s—but the mere use of the term, and its privileging of a certain type of arrangement, would be challenged. Nevertheless, in a period in which culture and society relentlessly atomise, and dominant forms of psychotherapy accept and even enforce that fact, it may well be time for a revival of a therapeutic process that begins from the premise that the collective and the other are prior to the self in the investigation of pathways to the good life.
Note: Andrew Firestone, a key pioneer of family therapy in Australia, provided a great deal of the background upon which this article rests. More generally, Andrew’s validation and general support have long been appreciated.
i Karin Jordan, ed., Couple, Marriage, and Family Therapy Supervision, New York: Springer Publishing Company, 2015.
ii Raymond Hawkes, ‘Treatment of school refusal by strategic-based family therapy’, Australian & New Zealand Journal of Family Therapy, 3(3), pp 129–133.
iii Michael White, ‘Pseudo-encopresis: From avalanche to victory, from vicious to virtuous cycles’, Family Systems Medicine, 2(2), 1982, pp 150–160.
iv Mara Silvini Palazzoli and Luigi Boscolo, Paradox and Counterparadox: A New Model in the Therapy of the Family in Schizophrenic Transaction, New York: Jason Aronson, 1994.
v Nikolas S. Rose, Governing the Soul: The Shaping of the Private Self, London: Routledge, 1990.
vi For the record, I presented a plenary address at the latter conference before going on to become the clinical coordinator at Bouverie, Australia’s preeminent family therapy centre, and to publish a dozen or so articles in the Australian and New Zealand Journal of Family Therapy.
vii John R. Weisz, Sofie Kuppens, Mei Yi Ng, Rachel A. Vaughn-Coaxum, Ana M. Ugueto, Dikla Eckshtain and Katherine A. Corteselli, ‘Are psychotherapies for young people growing stronger? Tracking trends over time for youth anxiety, depression, attention-deficit/hyperactivity disorder, and conduct problems’, Perspectives on Psychological Science, 14(2), 2019, pp 216–237.