The Pathological Family: Postwar America and the Rise of Family Therapy

by Deborah Weinstein

Cornell University Press, 2013. 280 pages.

In ‘The Pathological Family’, Deborah Weinstein argues that in mid-20^th century America, researchers and clinicians developed a new mode of therapy to treat families focusing on structural and relational aspects of family life.  In doing so, they implicitly acknowledged that the locus of illness had moved from individuals to the dynamics of family relationships and exchanges.  Earlier thinking situated pathology within individual selves and treated it somatically or through psychotherapies centered on a privileged relationship between a single therapist and a patient.  Weinstein argues that this move to problematise and treat the family developed in line with the contemporaneous social, political, and economic trends of post-WWII American society, whereby macro level tensions apparent in post-war American life became manifest at the micro level of the family.  Families represented healthy, “democratic citizenry” (p. 4) and the movement towards treating families did not merely parallel the social changes occurring at this time, but, Weinstein argues, was integral to these changes.  The increasing primacy of medical evaluations of normalcy and the popularisation of a psychologised view of the self dovetailed with the rise of the importance of families in the public gaze.  Cultural and social life did not develop separately, she argues, but rather, the therapeutic ethos developed alongside a popular fixation on the family.

She identifies key clinical practitioners and the dynamic interdisciplinarity evident between the social sciences and psychiatry in the formation of the field.  Weinstein details the origins and practices of systems theory and its adaptation to family therapy along with thinking about culture and families.  Why was the family a crucible for understanding the processes of larger events?  Weinstein details changes affecting family life following WW2, as seen in women’s workforce participation, the return of soldiers to family life, and increasing suburbanisation and migration, which markedly changed the social landscape.  Family was seen as a “means of repairing the social fabric torn by war” (p. 4).  She argues that the therapeutic ethos was joined to political culture as family therapy emerged following Cold War anxieties about family life, mass society, and political stability in the face of global threats represented by communism and fascism.

The book offers evidence for the development of family therapy in line with the rise of popular psychology as an accessible solution for problematic behaviour and changed perceptions about families and family life, whereby problems such as delinquency were believed to be produced within families.  As the American family became problematized, so too did parenting practices, which came to be seen as potentially deficient or at worst, contributing to the formation of pathology.  Psychiatric practice expanded as psychoanalysis became popularised and people took on psychologically oriented views of the self and family life.  The founding members of family therapy brought their expertise to the emergent field and moulded its progression, seeing families as communicating systems with the capacity for intergenerational transmission, focusing on mother and child dyads and the development of schizophrenia, and examining familial patterns of communication.  As the therapeutic ethos expanded, the family came into the therapeutic purview of clinical practice.

Weinstein highlights the interdisciplinarity evident in early family therapy thinking and practices, focusing initially on the anthropologist Gregory Bateson’s work on the double bind theory, which saw disordered communication affecting the development and maintenance of schizophrenic symptoms.    Families were seen as systems, as ‘communicational units’ with inputs and outputs aimed at maintaining homeostasis, even if this included pathological communications.  Emergent therapeutics aimed at disturbing disordered communications and this era established the family as a site of intervention.

Systems came to be replaced by ‘culture’ as a category of analysis, coopted because of its usefulness in examining familial similarities and differences along a range of indexes.  Family therapists used culture to contextualise family life.  This was coupled with the ‘family turn’ in psychiatry whereby families were pathologised as sites of disorder producing mental illness.  Weinstein shows how the idea of culture lent itself as a concept applicable to ever broader contexts, showing how families and culture were utilised in the production of universalising claims as the field made use of cultural variability and cross cultural comparisons.  Social factors were increasingly incorporated into pathological understanding of families as they were, for example, seen as the site for transmission of prejudice and perpetuation of social pathology.

Weinstein describes the increase of observational practices within family therapy in its clinical work, pedagogy, and research arms, from naturalistic observation where families were seen in their homes, to hospital settings where initially mothers and their schizophrenic daughters and then whole families were admitted and observed over lengthy periods.  Natural observation provided context, and non-clinicians were also involved, bringing perspectives of social critique.  Families now included normal as well as pathological forms to determine intrinsic communicational processes.  But the move was generally away from families with schizophrenia, and families came to be defined in political as well as clinical terms, incorporating typologies such as authoritarian, democratic, and anarchic to describe and typify their structures.  As practices of observation and classification changed, Weinstein importantly describes how visual technologies produced visions of family life.

Visual technologies, including one-way mirrors and film, helped family therapists to become catalysts of change, not merely passive observers and interpreters of familial interactions.  Therapists were now able to comment upon and manipulate therapeutic interactions aimed at changing family dynamics.  The use of visual technologies also highlighted the production of family performances and performance theory was applied to families as family sculptures, choreography and elements of visuality lent themselves to clinical interpretation and the development of insight into family lives.

The author succeeds in looking at therapeutic culture and family life, at how families came to be seen as the sites of disease and how family therapy arose to treat this.  The book makes a contribution to the literature in which histories have tended to outline the development of the discipline and its multidisciplinary base without situating it within broader social and cultural landscapes.  Recent feminist critiques of family therapy question some of the traditional assumptions about family structures, and this has challenged presumptions about gender roles and stereotypes within cultural contexts as well.

Increasingly, biological explanations of disease have shaped psychiatric theory and practice as neurobiological and genetic frameworks are explored to understand the nature, cause, and outcome of severe mental illness.  What kinds of families now are appropriate subjects for family therapy’s therapeutic processes? What has been the response of family therapy to the increasing biological, genetic and neurological explanations for disorders?  How has this been played out in therapeutic encounters and the interpretation of familial dynamics during this period?  And conversely, with its focus on lived experience and contextualised understandings of mental illness, how does a recovery orientation inform or challenge the suppositions of family therapy?  Bearing in mind these critiques, Weinstein’s work offers an important analysis of the contiguous events shaping the emergent field of family therapy alongside the social and cultural transformations of the post-war period in America.  Her work points to the ever-fascinating and changeable knowledge that psychiatry in combination with social science provides in examining, accounting for, understanding, and treating disorder within the complex category of the family.

Amanda Rosso Buckton coordinates medical programs in psychiatry and mental health at The NSW Institute of Psychiatry, North Parramatta, Australia. Her anthropological research focused on understanding the social and cultural contexts in which mental disorders and their treatment were experienced by women in Greece.