The loss of Salvador Minuchin encourages reflection on both his legacy and the future of the paradigm he pioneered. This article examines Minuchin’s work, as well as the developmental trajectory of family therapy (FT), and the circumstances through which it has become underutilized. This article suggests that, as the concept of “evidence-based” evolves, along with the widespread adoption of results-based accountability (RBA), there is an opportunity for the field of FT to galvanize itself and re-enter the spotlight. RBA, a framework widely utilized by governments and NGOs, offers tools to our field to track outcomes on a case-by-case basis, expanding the definition of creditable data. Just as Minuchin and his colleagues broke from the therapeutic orthodoxy in the early 1960s, the next generation of family therapists must be willing to challenge the assumptions of the current mental health treatment milieu and use a paradigm that produces positive outcomes for families.
Salvador Minuchin passed away on October 30, 2017, at age 96, still actively and passionately involved in family therapy. He was busy working on a keynote address for the Erickson Institute’s Evolution in Psychotherapy Conference, a speech he was to give to 8,000 eager clinicians.
There is so much that can be said about this larger-than-life, brilliant man, who, through his genius, gave so much to so many. To quote Jay Lappin, “For those of us who are Woodstock generation therapists, Salvador Minuchin’s death at ninety-six marked the end of an era. We are left with the painful awareness that we’ve lost not only our Jimi Hendrix but our Nelson Mandela, not only our Leonard Bernstein, but, yes, our Andy Kaufman” (2017).
I had planned to write about Dr. Minuchin’s major contributions to our field as well as our personal, decades-long association. For over 40 plus years, he was my mentor, co-author, and even best man at my wedding 35 years ago. Last month, my wife and I, along with the widow and daughter of another of the founders of structural family therapy, Braulio Montalvo, were planning to spend time with him after his keynote address. In these pages, I was prepared to share a few of my experiences with dazzling, caring, socially committed Salvador.
But I stopped short. Somehow, Sal’s death put an end to my desire to create simply a tribute—another reminiscence. With his death, I felt the need not to just chronicle his life, but to ensure that the healing flame of his work wouldn’t die with him. As I pondered my new approach, something else happened.
When I was teaching a group of child psychiatry fellows, one of them asked me to consult on a complex case that, for the last 3 years, had been puzzling the hospital’s community of medical, surgical, and mental health professionals. In the fellow’s words:
I’ll call her Maria. She’s a 15-year-old female with a history of chronic pain syndrome, which started after she and her family moved to our community 3 years ago. I was introduced to her when I consulted on her case when she was in the hospital. She had been hospitalized for a “wandering” pain that wouldn’t go away. This pain keeps coming back with increasing discomfort and frustration with each reoccurrence.
The original pain was in the legs, so there was some thought that maybe it was a neurological disorder. She would develop weakness but not fall over; it was localized initially. The specialists inserted a neural-stem implant (a neurostimulator adjacent to her spinal column) which seemed to be helpful for a short while and then quickly wasn’t helpful. She began to experience pain in other parts of her body; she missed more school. In fact, she had not been to school for most of the last academic year.
I last saw her in the hospital a few weeks ago for abdominal pain. The surgeons removed her gallbladder. This helped a bit with the abdominal pain, but then she started getting lower back pain that became unresponsive to medication. Most recently, she developed arm weakness; she was unable to return to school because of this pain.
She missed an appointment with one of our clinical psychologists who had been working with her with hypnotherapy sessions. The psychologists were going to do pen-and-paper tests on how her pain was affecting her on a daily basis. She didn’t keep the appointment because she was in too much pain; however, she was able to come to my session.
I asked the fellow about the patient’s family, and the picture then became clear: The mom is working and not around; the girl appears to be tethered to the dad. As he further described the family, there was evidence of these interactional patterns: protectiveness, conflict avoidance, rigidity, and triangulation.
I mused to myself, “My dear Salvador, your work is not done. These are the pathognomonic characteristic family interactions of the psychosomatic family you described 40 years ago.”
I told the fellow, “More surgery will not work. There needs to be a change in the treatment paradigm. This patient’s problem is very likely a family problem; this is a psychosomatic family.” I referred him to Minuchin’s book, Psychosomatic Families: Anorexia Nervosa in Context (Minuchin, Rosman, & Baker, 1978).
This adolescent girl and as her family had agonized for the past 3 years, resulting in following one piecemeal approach after another, each dealing with a different organ system. At one point, I suggested to the fellow, “There need to be some family therapy assessments and interventions before they take out her appendix next.” Smiling meekly, he replied, “It’s already gone—the surgeons got that last year.”
I introduced the group to the brilliant psychosomatic research in which Minuchin, along with pediatrician Lester Baker and psychologist Bernice Rossman, defined a syndrome where the family was the patient and observable interactions were the symptoms. And I began to rewrite this chapter.
In the Beginning
In the early 1970s, three medically unstable juvenile diabetic youngsters presented at the Children’s Hospital of Philadelphia. Their diabetes mellitus went out of control only once during the day: in the evening at home with their families. The Minuchin team reasoned that the family dynamics should be investigated. There were, however, also other children who repeatedly presented with episodes of out of control diabetes.
The Minuchin team postulated that there were actually three discrete categories of youngsters who manifested this lability:
- Those whose out of control diabetes was based on physiological reasons where the medical etiology had not yet been discovered;
- A group they called behavioral diabetics—children who deliberately exacerbated their diabetic symptomology for secondary gain, such as gorging on sugar so they would be excused from school; and
- The psychosomatic diabetics—children whose symptoms exacerbated on the basis of family dynamics.
The team further postulated that the psychosomatic diabetic families manifested specific, observable interactional family patterns: rigidity, perfectionism, triangulation, overprotectiveness, and conflict avoidance (Minuchin et al., 1978).
In order to determine if the postulated patterns of the psychosomatic family were discrete, the team utilized the method of family interactional tasks. The families were videotaped answering questions, such as when discussing a recent family conflict. The videotapes were then analyzed by graduate students who were blinded to the presumed types of patients. The researchers found significant differences in the interactional patterns between the psychosomatic families and the other two types of families in the study.
To further test these hypotheses regarding the relationship between family interactional processes and the medical symptomatology, they conducted diagnostic stress interviews with all three types of families. Working with the knowledge that an increase in fatty acids in the blood is an indicator of increased stress in the body, they conducted a unique test. In these sessions, the child and both parents had intravenous needles in their arms through which samples of blood were withdrawn at regular intervals; these samples served as a measure of the stress the family members were experiencing at each of the four segments of the task.
When the blood was subsequently analyzed for levels of free fatty acids, the researchers found that the physiological data confirmed their theory. When the therapist asked the parents to discuss a recent conflict, their free fatty acids would rise steeply. And at the point in the interview when the arguing parents diffused their conflict by involving their child, their free fatty acids (stress) fell, while their child’s rose even more steeply.
The triangulation of the child can be seen as serving a function in the system, stabilizing the parents’ relationship by decreasing their stress. However, the cost to the child was demonstrated by the rise in their free fatty acids and their ensuing symptomatology. At home, this exacerbation would lead to the potentially fatal ketoacidosis.
This was a clear, evidence-based demonstration of the interrelationship between the child’s physiology and the family’s interactional patterns. The triangulation sparked the stress, which led to their diabetes going out of control and leading to life-threatening ketoacidosis. Crucially, this occurred only in the psychosomatic families.
Another anecdote from this period shows how this process was also beneficial strictly as a diagnostic tool. The doctors at the Children’s Hospital referred an 11-year-old girl. She was losing weight, and they could not find a physiological etiology. The Minuchin team conducted an interactional family task and found that the family did not manifest the patterns of a psychosomatic family. After the team reported that the girl was not losing weight for psychological reasons, the doctors redoubled their efforts—and discovered she had a pineal tumor.
The Minuchin team then focused on applying the psychosomatic family model to anorexia nervosa (AN). Their outcomes were published in the book Psychosomatic Families. Of 52 cases, 86% recovered in terms of weight and psychosocial functioning (Minuchin et al. 1978). This work has been protocolized and has evolved into the Maudsley method. The Maudsley method is the worldwide, evidence-based standard of care for adolescent AN (Le Grange, 2005).
I have used the psychosomatic family model countless times over the years, especially when treating AN. Minuchin and his colleagues called it the therapeutic lunch model (Rosman, Minuchin, & Liebman, 1975), and it involves both parents feeding their anorectic child during a therapeutic session. The theory behind this posits that the symptom serves a function in the family—diffusing conflict between the parents. When the parents feed their child, to the extent they are demonstrably together, the child takes a bite of the sandwich. When they are even subtly apart (e.g., the mother says, “Take a bite of the sandwich,” and the father says, “Does she really need to eat so fast?”), the child refuses the food. And when the parents return to working together, the youngster resumes eating.
As a young clinician, I was startled by the immediate effectiveness in getting the self-starving child to eat. Seeing these results over and over again convinced me of the power of this model—and of family therapy. Colloquially, one might say this intervention is a twofer—something that satisfies two criteria simultaneously. The intervention both corrects a structural split in the family and mitigates the symptom, the adolescent’s refusal to eat. From the start, I saw the effectiveness of this intervention as grounded documentation that the theory is valid: Repair the family structure, and the symptoms—even life-threatening symptoms—remit.
Another form of documentation would naturally be measuring the long-term effectiveness of the work. In 2004, I published a book called Enduring Change in Eating Disorders: Interventions With Long-Term Results (Fishman, 2004) for which I’d located former patients—some over 20 years post-treatment. These patients had been sufferers not only with anorexia but also with bulimia nervosa and compulsive overeating. After experiencing short-term outpatient treatment, the positive, asymptomatic conditions continued with all but 2 of the 13 families I located.
To me and to others who have used it, the psychosomatic model was conceptually brilliant and effective, yet it appears that its concepts and practice have been continuously ignored in medicine and psychology. When I google the phrase “psychosomatic family,” I see few references. Minuchin’s brilliant work appears to have been eclipsed over time in most medical and mental health practices. Yet, it has been profoundly effective in transforming many patients and families. What happened?
Somaticizing patients like Maria are a major mental health problem. A study in Belgium reported that somatization syndrome is the third highest psychiatric disorder, with a prevalence rate of 8.9% (Keskin, Ünlüoğlu, Bilge, & Yenilmez, 2013). So why is Minuchin’s brilliant legacy underutilized by therapists trying to help these patients and their families?
When I was a young person entering the field, learning about this research and other powerful ameliorations with tenacious problems, I was optimistic that the family therapy paradigm had a great future. I thought we were poised to make significant progress—indeed, to take over mental health treatment, here and abroad. We were sanguine that family therapy would be the gold standard psychotherapy for the future. Sadly, that was not to be. Instead, I see marginalization of psychosomatic research as indicative of marginalization of the field of family therapy itself.
Changes in the Therapeutic Field
In the 1970s, when our field was in its infancy, we thought our psychotherapy competition was psychoanalysis—one patient, in a long-term relationship with his therapist, behind closed doors, without input from family. We were wrong. Two other forces hit the field at about the same time. These were evidence-based medicine (EBM) and cognitive behavioral therapy (CBT).
EBM first caught the attention of researchers and clinicians in 1972, following the classic Archie Cochrane report, Effectiveness and Efficiency: Random Reflections on Health Services (Cochrane, 1973). His book led not only to the opening of the Cochrane Center but also to the acceptance of EBM as the “best” research model available (Feinstein & Horwitz, 1997). EBM took organized medicine by storm. Treatments were vetted as to whether they were evidence-based. CBT, with its well defined, explicit protocols and bountiful graduate-student data, fit well into this model.
In spite of the general acceptance of EBM, there is considerable controversy regarding its authority. From my perspective, some of the most compelling work on this subject is that of physician and statistician Dr. John Ioannidis. In 2001, Ioannidis began challenging the statistics in many of the most prestigious scientific journals, such as Nature and the New England Journal of Medicine. He found that as much as 90% of the published medical information that doctors rely on is flawed (Freedman, 2010). Further, one-fourth of randomized controlled trials (RCTs) were later refuted. Unsuccessful attempts at research replication are common. Ioannidis, who has published over 1,000 peer-reviewed articles, brings this to light in his classic article “Why Most Published Research Findings Are False” (Ioannidis, 2005). It has been the most accessed article in PLoS (Public Library of Science), and to date, it has over 2.5 million hits.
Likewise, as Benedict Carey (2015) stated in his article in the New York Times, many psychological findings are not as viable as their proponents claim. Carey found that an attempt to reproduce the results of 100 studies in three leading psychological journals revealed that 60 of those findings did not hold up to retesting. This research may, indeed, have troubling implications for current psychological theory.
In spite of the skeptical data, the insistence on EBM outcome data from government funding agencies and HMOs continues.
CBT still fills that need for EBM outcome data for government agencies and HMOs. But the tide may be turning. Evidence is now coming to light that throws doubt on the infallibility of this belief. A recent article by Leichsenring and Steinert (2017) published in the Journal of the American Medical Association challenges the vaunted title of gold standard for CBT. The authors found that the American Psychological Association’s (APA) task force lists CBT as the only treatment with strong research support, in almost 80% of psychological disorders. The authors contest this APA statement. For example, they state that a recent meta-analysis listing criteria using the Cochrane Risk of Bias tool found that only 17% of 144 RCTs for anxiety and depression were of high quality. Further, while CBT was found to be effective in 80% of cases using a waiting list control group, they reminded readers that rationales based on these criteria are the least reliable design. CBT was found to be less efficacious in high-quality studies, mostly reducing the efficacy of CBT in panic disorder and social anxiety disorder. In the high-quality studies, CBT achieved large effect sizes only in comparison with waiting list conditions. Compared with treatment as usual, effect sizes were only small to moderate (0.30–0.45). Thus, the additional gain of CBT over treatment as usual is limited and may eventually even be the result of allegiance effects. According to the authors, a first-line treatment is usually clearly more effective than any other treatment; yet there is no clear evidence from high-quality studies that CBT is more efficient than any of the other psychotherapies for depression or anxiety disorders.
We in the trenches see that family therapy is a more effective treatment. We transform systems; we don’t just sit in a room revising cognitions. Why isn’t family therapy seen as the gold standard we know it to be? Where did we fall short? In brief, we family therapists rode off in all directions.
In 2011, Evan Imber-Black published her excellent article on the evolution of family therapy, “Eschewing Certainties: The Creation of Family Therapists in the 21st Century” (Imber‐Black, 2014). The article describes the development of models, ranging from the inspirational founders to the “model wars” which, according to her, emphasized differences rather than similarities. It’s not clear in the article, as the author describes the progression, why family therapists adopted the new models. Did the “evolution” transpire because newer models provided better therapeutic outcomes as in other fields of medicine? Did new data lead to the adaptation of more effective models?
As I further review the literature, I find sparse evidence suggesting that was the case. Was it their novelty or their intrinsic interest? Mysteriously, in my search of the literature, family therapy theories seem to have changed based on factors other than their practicality to create positive change. Had we fallen for process, rather than data, offering substantiation of our theories? I don’t understand, but I know it’s not science! Innovation per se was not what our clients needed; they needed good outcomes. Better service!
Of course, there are outstanding exceptions. In addition to the Maudsley method mentioned above, there are other models for troubled adolescents, such as multisystemic therapy (Henggeler et al., 2009) and functional family therapy (Alexander & Robbins, 2012)—and the models of family psychoeducation for adult psychiatric syndromes.
In spite of criticisms such as those discussed above, the dual hegemonies of EBM and CBT continue to keep family therapy at a disadvantage. In spite of these major advancements, family therapy remains marginalized: it is certainly not considered the gold standard.
In the 1990s, government agencies, facing the question of which treatment was best, decided on a different approach—Results-Based Accountability (RBA). RBA is a framework that focuses on converting data into an actionable plan. The RBA approach is versatile. In fact, it has been applied to a variety of treatment models and services in numerous U.S. states and in countries such as Canada, Australia, the Netherlands, New Zealand, Norway, and the United Kingdom. The goal of this approach is to improve services demonstrably.
RBA was developed by Mark Friedman in 1995. In 1996, he published Trying Hard Is Not Good Enough: How to Produce Measurable Improvements for Customers and Communities (Friedman, 1996/2005). Thus far, it has sold over 60,000 copies worldwide, providing a framework to measure the effectiveness of services provided by public agencies over the years, positively impacting these services throughout the world.
Friedman worked at the Maryland Department of Children Services for 18 years, with 6 years as chief financial officer. He became increasingly dissatisfied with the level of services young people were receiving. He asked, “Are the programs accountably benefiting the children they claimed to help?” (Friedman, personal communication, 1996). Friedman left his government job and created RBA, a framework to help agencies produce their best outcomes.
RBA asks, “What needs to be better?” and then works backwards to develop a plan to ensure the goal is achieved. RBA is a framework that seeks to promote a common language between partners who are working towards a common goal. The central tenet of the model includes a collaborative plan of action to be arrived at by all of the partners—with performance tracked using measurable, objective data. For example, the overarching goal might be a well-functioning young person. The clinical team works backwards to implement the necessary steps to reach the desired goal. Indicators are utilized to measure and benchmark progress. The strategy consists of the coordinated actions—usually referred to as the treatment plan by clinicians.
RBA has revolutionized government services. Can it do the same for family therapy? It is the premise of this article that our field has been more focused on the process dimensions of our respective family therapies than on our outcomes. With RBA, we have a new tool to readily change that orientation without being obliged to engage in expensive academic research.
Data for the Rest of Us
One of the most promising tools central to RBA is the Turning the Curve tool, a means of tracking performance from an initial benchmark. Each client is their own control. Inherent in its framework is the ability to track the overall performance of the therapeutic program as well as the individual. For example, in our residential program for troubled adolescents, we track the functioning of the young people quarterly, using the Child and Adolescent Functional Assessment Scale (Hodges & Kim, 2000). (A downward shift of the curve denotes improvement in functioning; see Figure 1.)
FIGURE 1. Example of the Turning the Curve tool: clients in a residential program.
The Turning the Curve tool is resoundingly simple. RBA, with its straightforward principles, starts work with all stakeholders agreeing on and working towards the same goal. Every action is based on whether it is achieving the agreed-upon outcome, the progress being tracked by turning the curve. These simple, commonsense ideas are transforming government services worldwide.
The Value of Heresy
My charge to young therapists requires some heresy—some challenging of the status quo. As we’ve seen by the failings of research—even research in the most prestigious journals—there are flaws. Is the therapeutic model you are using getting the desired outcomes? If not, there are other models available. For example, by using the RBA Turning the Curve tool, therapists can readily audit their own work.
Now, however, we also need to get this data published so that the field changes. And, perhaps an even greater challenge involves how we convince the information gatekeepers, the journal editors, to expand their definition of what is creditable data. Perhaps we need to begin with a broader definition of credible data. Harvard Lecturer Lisbeth Schorr and Frank Farrow at the Center for Social Policy address this issue in their book, Expanding the Evidence Universe: Doing Better by Knowing More (2011):
When one examines the statistics regarding problems of our youth, including mental health problems and various other social problems, one must posit that with the vast amounts of effort, funding and wisdom available, the issues should continue to be so severe. While there are probably pockets of good news, nevertheless, the problems are daunting.
Shorr and Farrow postulate that, “Research and experience over the past two decades have provided more knowledge than ever about what it takes to improve the outcome for disadvantaged children and families, but despite the U.S. expansion in knowledge, we have not been successful in significantly better outcomes, at a magnitude that matches the need for crucial areas” (p. iii).
Their premise is that we have not been able to marshal the full extent of available knowledge, to apply it to complex problems and generate new knowledge because of information constraints. Their thesis is that “the boundaries which the prevailing framework draws around acceptable evidence too greatly limits the knowledge base available to policy makers, programme designers, evaluators and clinicians” (Schorr & Farrow, 2011, p. 1). Their position is that the enduring practices, policies, and strategies that are evidence-based must be undiminished, but the definition of what counts as credible evidence must expand, promoting informed decision making.
New ideas are often stymied. But this is just where we heretics must take a stand. I suggest that instruments such as the Turning the Curve tool be accepted as an alternative method of providing evidence for both clinicians and research. Currently, the domain of evidence-based work tends to be within academic settings, which are often well funded. This can function to limit creativity and functionality. Frontline clinicians and small programs—and even many government programs—often do not have the resources to do what is now the only accepted kind of evidence-based research. Beyond that, the subjects in evidence-based studies do not often correspond to the clients seen by clinicians working on the front line in very troubled communities. As Schorr and Farrow (2011) argue, the gatekeepers in academic, evidence-based journals, and their funders, must be open to alternative sources of evidence. To quote Mark Friedman, “The research world can only tell us a fraction of what we need to know. We need to make sure that we use our common sense, our life experience and our knowledge of the communities in which we live . . . There must be room in our community for innovation” (Friedman, 1996/2005, p. 42).
I implore the next generation to be heretics in the tradition of the founders of family therapy. Just as Salvador Minuchin and those with whom he worked did when questioning the power of psychoanalysis, we must fight the status quo. Minuchin and colleagues broke from the psychiatric orthodoxy in their book Families of the Slums (Minuchin, Montalvo, Guerney, Rosman, & Schumer, 1967). Likewise, going against the academic grain, the founders of the Philadelphia Child Guidance Clinic successfully trained people from the inner city to be family therapists. They believed that life experience could make up for much of university training. They looked not just at delinquent boys but at their families. All of these actions were true heresy in those days, where doing deep psychoanalysis for these adolescents was de rigueur.
In my opinion, the lesson we can take from Dr. Minuchin’s life, in addition to his brilliant writings and teaching, is his willingness to challenge groupthink—to confront therapeutic orthodoxy. After spending many years training in psychoanalysis, he threw it out. He came to see mind in context, and families as the delivery system for change. He sought to use objective, observable markers, like family structure, for his assessments. This was a seismic break from his colleagues and the psychiatric establishment.
Family therapists today can do the same. We need to use objective clinical data to track our outcomes. An important philosophy that emanated from America was pragmatism: “If it works, it’s true.” The same applies to our therapeutic endeavors. Use whatever clinical model you prefer, but always ask, “Does it produce the outcomes we are seeking?”
In closing, I offer an anecdote about Dr. Minuchin. One day, three boys were fighting in a hallway of the Philadelphia Child Guidance Clinic. Sal must have been in his late fifties at that time and the boys, strapping lads, were much bigger than the good professor. Sal assessed the situation, rolled up his sleeves, and dove in, breaking up the fight. I encourage our next generation of family therapists to similarly roll up their sleeves and dive into the fray. Our families need the best outcomes. We know family therapy is the gold standard treatment. Let’s prove it!
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