Jay Lappin on Family Therapy—The Long View

Jay Lappin: Sure. I think that one of the constants has been around social justice and poverty. We see the effects of the political decisions being made by different administrations and their changing priorities, including most recently around immigration. One of the things that I remember from my interview with Sal Minuchin a few years ago was him saying that, back in the day when we first started doing family therapy, we thought that they could change the world one family at a time. There was this thoughtful pause, and then he said, "We were wrong." And that's what got him into doing larger systems work, and myself as well.

There are wonderful efforts by non-profits like The Annie E. Casey Foundation who are really taking this on, and it also still continues with family therapists who are doing home visits in impoverished communities which built on the early years of social work, and then on the work of Sal and others like Braulio Montalvo back in the '60s. But we haven't changed the world just yet.

JL: I think just being aware that social injustice exists, that there are commonalities among all families and their circumstances, but also as unique differences between families. That systemic perspective helps a lot. I just had a case involving a young man, a minority kid in a school system where there was a big incident. Because of my good fortune of working at the local clinic and being aware of the systemic issues, the line of questioning I used for the parent took a different turn. It was more of a talk about what the community was like and what it was like to be a minority family within a majority-culture town. And it really felt like things changed in the sense that there was space for that conversation. And I think that we can all make that space about those differences and be aware of them.

JL: I think so, especially for those of us that are majority-culture folks. I know enough that I know that I don't know enough about a minority family’s location in society. And I think to pretend that it's not there is doing a disservice to the family and to the process of therapy. And, you know, the thing in systems work and all therapy is that you read the feedback. So, what happens when we open up the space for that conversation and what does it lead to and how does it change what we're doing in the therapy? At the end of the day, they still want things to be better for their children, and that's cross-cultural. I think we can do better when we create space to have those conversations.

JL: Well, income differences. The vast majority of clients in my private practice, are majority-culture folks—middle-income and well-situated. The issues of social position, money and resources are still there, although on the other end of the spectrum. It's all a part of the soup that we live in. I don't see there's any downside to working with these clients necessarily, but it's very easy to get kind of a narrow lens just because that's who's in front of you.

I remember a story Sal told me years ago during an interview. When he was young he had a psychology teacher who was a fan of Rousseau who made the case that delinquents were part of a larger system and the social institutions in which they lived. During the time that Sal was in high school, his family went from very good circumstances to losing pretty much everything as a result of the Depression. They lived in poverty. Sal’s story was about reminding ourselves how lucky we are, but also the obligation we have to all members of society. As family therapists, we must be open to conversations with families around the issues that are important to them, ones around which we may have little direct experience.

JL: I think one of the great things about being a family therapist is that you get to bear witness, to be a part of that change that you're talking about. In family practice I see more and more of those denuclearized families that come in with different combinations. The classic '50s Ozzie-and-Harriet family is changing and in a big way. But at the end of the day, they are all still families. They still love their children, and that crosses those old boundaries. We still have to do our jobs, but the context is shifting, and I think it gives us more possibilities, too, to think outside of the box.

JL: Yes, I think that one of the ways that we get to do it is by working with different populations, because there is always the temptation of sameness. We do what we know. But, you know, there's that old saying, “if you want to know about water, don't ask a fish.” We can put ourselves in situations in which we feel different and that we experience other families. Home visits, I think, are a great way to do that. You can tell a lot about families, about how they live together, and it also stretches us a bit. I think both young and old therapists need to have an opportunity to do that. I think it helps our work and stretches us.

JL: I think it’s all about difference. A picture is worth a thousand words because the picture is what the talk and the words are about. So, for example, Sue Johnson's work with attachment understands that talk therapy is necessary, but it’s not sufficient—it’s really about the enactment. It's the felt experience of those different situations and pushing ourselves that challenges limiting patterns. You have your bag of tricks and you get reliant upon them, and, why? Because they work, after a fashion. So, it's about taking a risk.

And, that’s fair because it's a risk for a family to come for treatment. Sal had this great saying that families are wrong about two things when they come to see us. First, they're wrong about the location of the problem. It's not the kid. He or she is an identified patient, so it's the family system that's the patient. And second, families are mistaken about is who is going to fix it. They look to us, but our position is that the inherent strengths are there in a family, that they have all these over-determined patterns, which is what brings them to us. So, I think, in this respect, we're not asking any more of the families than we are of our ourselves, and I think that's more fair.

JL: Oddly enough, the same two things. It's a challenge. Family therapy can be tough, because you have all these people in a room. One of my early fatal mistakes with a family was when I thought I was being this wise, young guy that could figure stuff out quickly. It was a family I'd seen only 10 or 12 minutes in which the father was a plumber. So, I start spouting off—“blah, blah, blah, you should do this, you should do that” and the man turned to me and said, “How can you tell? You only met with us for a few minutes.” And because I was young and even more stupid than now, I said, “Oh, well, you're a plumber.” And he said, “Yeah.” And I said, “How long does it take you to figure out that there's a leak in the basement?” And the guy just looked at me with a lot of anger. I never saw the family again. So, either it was a one-session cure, or it was an abysmal failure. But I remember that I really hadn't respected them. I hadn't taken the time to join, and I was trying to be show-off. “Look how much I know.”

So, I think it's always the read-the-feedback thing, and we learn from the families as much as they learn from us.

JL: We came from an academic tradition where you teach theory, you teach theory, you teach theory, and then you practice. And Jay Haley had this great idea that you have people do things first and then retrospectively go back and say, okay, what happened? What happened when you turned to the mother and asked her to talk with the son? What was going on with you?

So, it's more that style of teaching where you're consistent with the model of having people do things. When I teach, it's lots of role plays, making up families. And then I have just some basic rules that I've come up with over the years, like thinking of joining as a traffic light—you have a red light, a yellow light, and a green light—and when you're working with a family, you should always be in the yellow.

For instance, in New Jersey, you go through the yellow lights, and in South Philly, people don't stop at stop signs. You kind of roll through the intersection. And I say if it's green, that means it's a bit too easy—Lyman Wynne had this expression of the rubber fence where you're working with a family and you think, God, I'm really joined well, like it's really the strength of homeostasis. So, green, not so good. Yellow, perfect.

But I'll tell them if it's a red light, you have to rejoin. So, if you're trying to frame something or get an interaction going and you're just getting that red light, then you say, okay, I need to reconnect, find another way to make this happen. It's that constant reading of the feedback, and when you do role plays or approximations of families, then you can say, "What was that like when the family wasn't with you on that? What happened? What did you come up with?"

And then you'll go deeper with the students, and they can say, "Well, you know, it reminded me of this, where I felt this way." So, okay, how are you going to shift that, because you're going to be working with families. You're going to have that capacity to be flexible. It's like muscle memory almost, that you have to do it over and over again. 

JL: You probably don't have it down in Florida, but here in New Jersey and Philadelphia, we have row homes which all look very similar from the outside. They're each the same size and distance apart from each other, have the same foundations and the same layout. It's like a rectangle. But when I used to do a lot of home visits, going from one person's home to the next could be completely different. The next person's home could even be on the very same block. So, that for me was a metaphor because my foundation is in systems work and structural theory, but the larger framework, what’s in the house and how they live, is up to the families.

I think you have to just do it or it would be like reading about how to play guitar. That's great if you already know that “A” has three sharps, but unless you're playing it and having somebody saying to you, "What was that? Where were you going with that? What did you want to do? Let's see if you can come up with another way," you're not going to improve your skill set. I lament the loss of one-way mirrors and taping. It doesn't happen as frequently as it did back in the day. 

JL: I remember talking to Sal and Braulio about this. They had this idea that you could have what is called an alphabet of skills. The idea was if you taught these skills, you could be a competent family therapist. And, indeed, many people did and are.

But Sal said, that having an alphabet of skills is like teaching somebody the alphabet and then expecting that they can write sonnets. Like the idea of putting a room full of monkeys at typewriters who would type a Shakespeare play, by chance, after thousands of years. Having an alphabet of skills is necessary but not sufficient to practice competent family therapy. So, people need a bigger container. I think that what you're talking about is having the systems foundation. It's a deeper, bigger container to hold those ideas and to have the freedom to experiment. You’ve got to know where this stuff comes from, and I think it helps to have that foundation.

JL: I think first is finding an agency that values home-based family therapy. Back in the early days of clinic work, especially in the cities, you'd have people come for outpatient therapy, crowd the waiting rooms, and then you there’d be a large population of people that you could see.

The shift to home-based family therapy, which, as you know, followed in the social-work tradition of doing work in people's homes, changed things, so that people, especially poor families, didn't necessarily have to get to a clinic. By going to people's homes, you very quickly get a sense of what is happening. When I first went into private practice, I only had a handful of clients, so when I saw families, one of my requests was that they invite me for dinner. It was great, because, literally, within minutes, moments, you would have a whole set of new ideas. The theories I had about families when I went to the house was...

JL: Right exactly. It was very humbling at times. And I'd have the kids show their rooms and their stuffed animals and their toys. And it was just such a rich environment, and then we'd have a family session after dinner. I got dinner.

JL: Yeah, it was great. I think that the home-based work is really remarkable, and it's a challenge. I remember being a research therapist on one of Duke Stanton’s projects with heroin addicts and their families. In those days, you'd have these massive cameras and tripods and all that stuff that you'd be lugging into people's houses.

So, in the middle of these intense moments, you'd think, oh, boy, this is really it, we're going to tip the scales here. And then the dog would run through the scene or somebody's diaper was wet, or the phone would ring. So, you would have all these multiple things happening at the same time, and you would have to figure workarounds. And you would really get a lived sense, an experienced sense. As opposed to talking about it, you were experiencing it.

JL: Yeah, you're right. It could be very chaotic at times, noisy...I just think it's such a privilege to see the family in total, because when you see the kids individually—and, certainly, there's a place for that in the context of family work—it's not the same. You get so much more if you can see the whole family. For me family work is the best, and one would hope, even from those rarified clips, that people get excited about it and want to do it.

JL: There was a recent piece in The Inquirer about a Yale study on children that were anxious. The bottom line of the study was that they figured out that one of the principal causes of the kid’s anxiety was the parents. And I thought, are you kidding me?

JL: So, their treatment model was having the parents figure out ways to help the children tolerate anxiety so that they were no longer hovering or helicoptering. And, really, when you think about it, it's more of a systemic version, but it's under the heading of teaching the kids.

Years ago at the clinic where I worked there was research on pain. This fellow Sam Scott, who was one of my supervisors, a brilliant guy, had studied some with Erickson. Sam and Ken Covelman and Bruce Buchanan, who was my partner in teaching at the clinic, were working with families to develop ways to have kids who were experiencing extreme pain through psychosomatic and physical illnesses, get calmer.

Sam and the crew had developed this wonderful script that accounted for systemic interactions between the parents and the kids. The parent would say, "What we're going to be working on today is helping you to feel more relaxed." And then, in parentheses, the parent would have something that they would read to themselves that would say something to the effect of, "And while helping my child to relax, I want to breathe more slowly and thoughtfully."

Just inserting that spacing or that timing helped the kids and the parents simultaneously to relax, which is different from the kind of individualized mindfulness training where you're just teaching a kid how to relax. The back and forth accounted for the relational context.

I was teaching a family therapy course a few years ago at Penn and Drexel, and I realized that there were no students in the class that were as old as our youngest child, and I thought, "Oh, God, I am so ancient." So, I created this thing called Appy Hour. At the beginning of class, the students would present apps that were helpful in teaching relaxation skills. It's corny, but it was great, because they were all about finding these very cool apps. And if I see a kid individually, I'll have the kid teach the parent how to relax and show what they learned on an app. As you were saying earlier, having that systems foundation just helps you think differently in a situation. 

JL: Yeah, there was a really good, two-part CD that Alan Cooklin and folks from England put together, and I had the privilege of interviewing Braulio Montalvo for it. I asked, "What are some of the seminal ideas about Minuchin?" This tape is called "Inviting the Family Dance." Braulio said, really, the most important thing for him was Sal's idea about part to whole. When you're working with part of the system, you always keep the whole system in view, no matter who is in the room. If you have the kid, a parent or both parents, you're always thinking of the whole system as kind of a backdrop. So, it’s reflected in having a kid learn an app and then teaching it to his parents or teaching it to her brother, moving from that idea of part to whole.

JL: I think, historically, one of the reasons that family therapy is around today is because, in its early years, family therapists took on the challenging populations—eating disorders, schizophrenia, delinquency, minorities—ones that for a lot of reasons resided at the margins of the prevalent psychodynamic and psychoanalytic models of the day. It was as if family therapy was being told, “Fine, do what you will—see if you can do better! And boy, did they. For Structural Family Therapy (SFT), the challenge to the status quo began in the Sixties at the Wiltwyck School for Boys in New York. Minuchin, Montalvo and others frustrated by the poor outcome with individual treatment decided, “This isn’t working—we have to do something different...”

With support from an NIMH grant, Structural Family Therapy researched the development of a family/systems-based model with poor, minority delinquents and their families. Their research and the early bones of SFT were published in the 1967, Families of the Slums. Absent the internet, there was tremendous synergy and cross pollination—Minuchin making his way out to MRI and meeting Bateson, Haley, Don Jackson; Murray Bowen doing his work with schizophrenics; Whitaker’s developing his Experiential model; Satir’s Conjoint Family Therapy published in 1964. It was as if a whole new language and culture were sprouting up, rules were broken, the one way mirror and the capacity to videotape changed everything. And, like Gil Scott-Heron said, “the revolution will be televised,” and it never stopped.

JL: I think there is a place for manualized care. Ultimately, I think that every therapist has to make their treatment their own. Sal would talk about the family dance, a “Tango.” Sue Johnson also has embraced tango dancing as a metaphor. And there’s some of us who are old enough to remember Arthur Murray’s Dance Studios where they would have the feet painted on the floor.

JL: I think it's made me more appreciative and humble, and grateful for the work. It's the best job ever, really, when you think about how lucky we are to be part of people's lives. And I think being a parent and being married for 48 years has given me perspective that I didn’t have when I was younger and new to family therapy.

I think the aging process, being married a long time, having kids and grandchildren, the good fortune of amazing supervisors, mentors, students and clients, alongside experiencing painful losses of family, friends and clients, all of it gives you a certain perspective. Also, reading the Persian poet Rumi and Thich Nhat Hahn’s wisdom has slowly but surely shaped my appreciation of time and impermanence. I really value those present moments with families and with couples and individuals. I just continue to pinch myself about how lucky I am to be able to have that, and that people invite me into their lives to help them, and I do the best I can.

JL: Someone I see experienced a profound loss of a child. All of my own family-of-origin issues played out alongside the experiences of this particular family. My youngest brother was 5 when he died of leukemia, and it had a profound impact on my family. Our oldest son, after he graduated college, came down with non-Hodgkin's Lymphoma and he's fine, and I’ve had malignant melanoma.

Years and years ago, Sal and Pat Minuchin used to host these summer events at the end of the externship. People would come to the clinic for training from all over the world and Sal would host barbecues and there'd be teaching and learning. I was sitting in a group of students, and he was going around asking them about their families and their kids and so forth. He skipped me and went to somebody else. Afterwards, I said, "Sal, I know that you asked everybody about their families, but you skipped me. How come?" He said, "Because you don't have any children yet." And then he said, "It makes a difference." When you live that experience, your perspective, for better or for worse, changes. Of course, he was right. Once you have children, once you've experienced those kinds of losses, how can it not affect your worldview?

I think I've been more appreciative of that, and I think that shows in the way that I still challenge overdetermined patterns in the family, and challenge the ideas people have about themselves and always assume a strength-based model. It's the therapist's responsibility to come up with a context for those different slices, or, as Dick Schwartz would say, those parts of themselves that can be more manifest in a room, and then to recognize them when they happen.

JL: Larry, did I tell you the story of how I became a family therapist? My Jay Haley story? It's to your point of being Forrest Gump and just being aware. In 1972, my wife and I got married on September 2nd, and I was drafted into the Army on September the 20th. I was very lucky that one of the nice things that Nixon did, if we can say that, is that he said only people that volunteer to go to Vietnam would go to Vietnam. So, I thought, okay, I'll take my shingle, you know, shovel shit for the next few years, at least I'm not going to 'Nam.

So, I got out of being sent, and through a series of, again, Forrest Gump-like events, I wound up in Fort Gordon, Georgia and was assigned to work in the Mental Hygiene in the stockade and in the maximum-security block. I was seeing prisoners and thinking, "I have no idea what the heck I'm doing with these guys." I was sitting in cells smoking, 26 cents a pack, how could you not smoke, and thinking, "Shit, I'm really lost here."

So, I went to our psychiatrist, who was a man by the name of Art Warwick, who looked like—even then, Alan Dershowitz, who smoked a pipe. He had kind of fuzzy hair and wire-rimmed glasses, a brilliant guy. And I said, "Art, I'm lost with this stuff about how to see these guys." I said, "Is there anything I can read to help me be a therapist, because I have to counsel these guys?" So, he's smoking a pipe in a very cliché psychiatrist way and he puffed a few and said, "Get Strategies of Psychotherapy by Jay Haley."

So, I sent away for it and the thing finally arrived and I started reading about Haley and Erickson and I just thought it was incredible. I wanted to do this kind of therapy.

The years went by and lo and behold, I wound up working in Philadelphia Child Guidance Clinic. I meet Jay Haley, and my head was like a dirigible because I couldn’t believe I was getting to work at that clinic. So, Art and I stayed in touch. I went to see him and we were sitting drinking beers, and talking about Army days, and I said, "Art, by the way, when you recommended Strategies of Psychotherapy to me, is that because you saw me as a good, strategic, structural family therapist?"

So, Art had this shit-faced grin on. He was smoking a pipe again. He kind of looked at me and said, "No." I said, "No? how come," and he said, "Well, your name is Jay and Jay Haley's name is Jay and I thought it was kind of funny."

JL: Yes. Sal was a poet, as was Braulio. I think I would say, do family therapy—it's the best job you'll ever have. And whatever job you have after that, it will help you. It will help you with the people that you serve. It'll help your family. It'll help your children. There's no aspect of your life that it won't touch, and in a good way. And it's a gift, and you'll say your thanks for it.

JL: Thank you, Larry.