At the Edge of Safety: Moral Experimentation in the Case of Family Therapy
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“At the Edge of Safety” argues for thinking of structural family therapy as a “moral laboratory.” Borrowing a trope from Cheryl Mattingly’s recent book Moral Laboratories, the article reconsiders a therapeutic style that was once controversial by analyzing personal stories of supervision—i.e. professional training—in light of Mattingly’s suggestion that a social space in which people conduct experiments on themselves and their lives may be considered a moral laboratory. Family therapy is especially good to think with, because it is simultaneously a real and a metaphorical laboratory, physically lab-like in its use of visual technologies, yet moral in the way it puts the possibility for situational change in the hands of human actors. The technological apparatus stages evidence for sub-visible, interpersonal dynamics, while the provocative quality of not only therapeutic actions, but also of supervision, points to an ethos of experimentation. Stories of supervision reveal how personal of an experience being supervised can be. Trainees are pushed to become something otherwise, in learning to “expand” their styles. Sometimes the push is just right. Sometimes it goes too far. Whatever the case may be, the stories analyzed speak to anthropological questions concerning the uncertainty of human action and the many ways people can unknowingly injure one another with small hurts.
KeywordsPsychotherapy Family therapy Ethics Morality
In a key textbook for family therapists, Salvador Minuchin tells a certain story about a family he once treated in South America. The Ramos family was a family of five, and their lives revolved around the mother’s obsession with hand washing. “Whenever she touched something dirty,” Minuchin recalls, “she experienced nausea, palpitations, and sweating until she could wash her hands” (2006:76). He found her hands to be “red and raw from washing,” and learned that her revulsion toward dirt extended to the dirt her children came into contact with. They too had to wash their hands constantly to satisfy their mother’s concerns.
During this first session with the Ramos family, Minuchin also learns the family no longer eats eggs, because of where they come from. Minuchin poses what appears to be a reasonable question to Mrs. Ramos: what if the shells are removed?
She answers they would be clean to eat.
Minuchin asks, “Do you buy your chickens without their behind?” to which Mrs. Ramos replies, oblivious to the mischief behind his questions, “Yes. I buy only the chicken parts.”
This exchange hints at Minuchin’s signature style. He is famously controversial in the history of family therapy, known to be a gifted if irreverent therapist who works through confrontation and aggression. He once argued that a therapist must feel comfortable with being “‘ethically unfair’ in order to be ‘therapeutically correct’” (quoted in McLean 1986:182). If Mrs. Ramos has a revulsion against dirt, Minuchin has a revulsion against stasis. In reflecting on his 50 years of working as a family therapist, he offers as his single most important discovery the observation that, “People prefer not to change.” And this, for Minuchin, is at the heart of even the most serious of psychiatric disorders.
The provocative spirit behind structural family therapy in general, the school of therapy Minuchin is associated with, led the anthropologist Athena Mclean to write a dissertation on the development of the field. McLean was especially distressed by the outrageous behavior of master therapists in the demonstration workshops she attended while working as a clinical researcher before becoming a PhD student in anthropology. McLean was “intrigued as well as disturbed by the dehumanizing manner in which therapists sometimes related to families they were treating” (1986:179), and she discovered she was hardly the only one. Some of the therapists McLean interviewed for her dissertation reported “feeling sick” while watching a demonstration in which a family was being antagonized. Some had stopped attending workshops altogether. Family therapy was found to be a helping profession with a dark side.
This article aims to reassess the moral orientation of structural family therapy, using the textbook mentioned above as case material: Mastering Family Therapy: Journeys of Growth and Transformation, the second edition (2006). My purpose in this article is to test whether Cheryl Mattingly’s “moral laboratories” trope stands up against the hermeneutics of suspicion that has long given purpose to cultural anthropology. Insofar as Minuchin himself is concerned, families who have come to therapy to deal with a presenting symptom have to be jolted out of their habitual ways of relating to one another. Less concerned with solutions than with exploring and discovering “new ways of being” (88), Minuchin’s approach may be considered in light of “moral experimentation”—his provocations pit the possible against the predictable (Mattingly 2014:16).
This article is part of a larger ongoing project on the development of family therapy in the People’s Republic of China. It will not however deal with family therapy as practiced in mainland China, because I am still in the middle of fieldwork at the time of this writing. The article will focus instead on a key connection point between China and the United States: a figure known as the “godmother” of family therapy in Asia. Wai-Yung Lee trained with Salvador Minuchin, collaborated as a colleague on many projects, and the two remain dear friends to this day. (Minuchin is 94-years-old at the time of this writing.) Though Lee is primarily based in Hong Kong, she often travels into China to conduct training courses, while also serving as faculty at the Minuchin Center for the Family in New York. Lee tells a story in the textbook Mastering Family Therapy about her apprenticeship with Minuchin while enrolled in a supervision group that met regularly for two years. (“Supervision” is the emic term for training and mentorship by a senior therapist.) This story sketches a picture of Minuchin that corresponds with McLean’s account of structural family therapy in general, except the provocation takes place at two levels, between a therapist and a family, between the supervisor and his student.
Lee’s story is one of eight stories of supervision included in Mastering Family Therapy, intended to convey the point that academic training is hardly enough for producing a therapist who could survive “the heat and intensity of the therapeutic encounter” (Minuchin, Lee, and Simon 2006:95). Her own first-hand experience of Minuchin’s provocative style sheds light on the dictum “ethically unfair but therapeutically correct.” It is a story of how Lee “discovered that even aggression could be an act of intimacy” (Lee 2006:235). That a trainee could equally be a target of “abuse” is suggestive. In this profession, a therapist is morally responsible for much more than providing “support,” and a master teacher for training in a particular way. In revisiting “ethically unfair but therapeutically correct,” this article joins other contributions in this special issue in demonstrating just how diverse moral orientations and formulas can be. Diversity may stem from moral actors having different time-scales in mind, as in the case of scientists and technicians working in laboratories, juggling between the daily care of suffering animals with the future promise of scientific discovery and drug development (Svendsen et al. this issue; Sharp this issue). Or it may result from the unique particulars of a given life situation, as demonstrated by Grøn’s key informant Rita, who has cultivated a formula for managing weight loss and her own responsivity to the grander scheme of things (this issue).
The “moral laboratory” trope is especially relevant in revisiting “ethically unfair but therapeutically correct” because there is a more-than-metaphorical relationship between family therapy and laboratory practice. To begin with, psychotherapy is laboratory-like in its set-up: the physical space itself, scheduled appointments, and boundary maintenance all control for external disturbances and create a concentrated space for observation and exploration. Family therapy is uniquely laboratory-like because a technological apparatus—audio-visual technology—has always and continues to play a central role in practice and training; the historian of science Deborah Weinstein rightfully characterizes the profession as having an “optic orientation” (2013). Family therapists are keen to stage evidence for what they believe is true: the most significant of human interactions is also the most fleeting. I would further argue that family therapy is laboratory-like in both the literal and metaphorical sense, and the two dimensions are interrelated. Audio-visual technology not only helps to arrest the ephemeral for slow study, it also plays a central role in promoting a culture of moral experimentation. It is very common for trainees to watch videotapes and live demonstrations of master therapists at work. Trainees also expose their own work to their supervisors and classmates in supervision groups by way of video recordings, and receive feedback on choices made, opportunities missed, and personal style. Mediated by a technological apparatus, this culture of moral experimentation holds particular “goods” in mind—the “expansion” of a therapist’s style and repertoire, and cultivating the kind of toughness clinical work often requires. Not unlike the basic science laboratory, there are risks involved in the pursuit of future goods.
Family Therapy the Discipline, Moral Laboratories the Trope
Before I proceed with the analysis of Lee’s story in Mastering Family Therapy, family therapy the discipline, and moral laboratories the trope, shall be clarified. Family therapy is a clinically based therapeutic modality that offers an alternative or a complement to individual psychiatric treatment; its philosophical underpinnings are ecological rather than biomedical (Bronfenbrenner 1989; Hayes 1991; Ma 2007, 2011; Minuchin 1974). The profession traces its origins back to the mid-twentieth century, when a small number of psychiatrists began to adopt ideas from cybernetics and systems theory to address the problem of relapse amongst patients discharged from hospital care (Hayes 1991:28; McLean 1986, 1990; Weinstein 2013:27, 188).
While family therapy is considered as one amongst many other modalities of psychotherapy, it is also unlike psychotherapy in a number of ways. For one, family therapy was born out of a “revolt” against the “secrecy” of psychoanalysis (Minuchin, Lee, and Simon 2006:7). Its practitioners continue to insist on involving multiple family members in treatment, even while adapting to changing meanings of what counts as family. Two, family therapy practices a “politics of openness” (Weinstein 2013:174–175). The circulation of taped therapy sessions, treatment demonstrations for a live audience, and the use of one-way mirrors play a major role in training and mentorship. Family therapy’s “optic orientation” stems from experiments conducted in the field’s formative years with what could and ought to be observed in human interactions (Weinstein 2013), and from an enduring emphasis on understanding family patterns by observing interactional minutiae. Structural family therapy is defined by its conviction that there is no such thing as an individual, only interpersonal relationships where the “personality” and the behavior of one person is the resulting complement of another, and vice versa. “Structure” refers to patterns that have hardened over time in the form of a seemingly indisputable reality.
As in the case of psychotherapy more generally, schools and styles of family therapy are many. They differ according to a particular master therapist’s personality and technique—for example, Virginia Satir and those who follow her model use a technique known as “sculpting,” which involves the rearrangement of bodies in physical space to externalize relationship patterns and to create experiences (Chen 2015:60; Minuchin, Lee, and Simon 2006:42–43; Zhang 2014:293). Or they may differ according to the therapist’s understanding of the purpose of therapy. Minuchin, Lee, and Simon distinguish between two major camps in this respect: interventionist versus restrained therapy (2006:42–57). Gregory Bateson, a key figure in the creation of family therapy, was in their view a “cautious, restrained interviewer.” Anthropological sensibility and cybernetic thinking informed his deep concern for the issue of unpredictability: “introduce any perturbation… however minute and well intentioned, and from then on you have a bear by the tail” (9). Inspired by Bateson’s caution, the Milan School developed a system for restraining undue therapeutic influence, i.e. therapeutic teams consisting of many layers of supervision (teams observing teams), facilitated by the one-way mirror (54).
By the 1990s, social constructionism and the work of Michel Foucault helped to introduce even higher degrees of restraint to family therapy, well beyond Bateson’s level of restraint (12). In their account, Minuchin and his colleagues suggest that this direction has been unproductive. In their view, constructionist practice “focuses on the individual as a victim of constraining language that carries the invisible yet prevalent dominant discourse” (my emphasis), while Bateson’s systems perspective rightly implied “mutual responsibility, commitment to the whole, loyalty, family, and protection toward each other—belonging” (13). Defining their approach as interventionist, they argue that the therapist’s responsibility is to engage, rather than simply collect and connect stories, the result of a theoretical influence that had pushed pathology “outside the family into the culture that surrounds the family” (13). Minuchin and his colleagues argue, “therapy should be oriented toward action” (12).
What counts as action in structural family therapy?
An answer is forthcoming in the material I will soon present. For now it is worth noting that family therapy and cultural anthropology share something in common with respect to the issue of how to continue working in the wake of postmodern deconstruction. In the humanities, various scholars have found different routes out of what Brown and Tucker pithily call, “the semiotic and post-Foucauldian slough of despondency into which millennial social science lurched” (2010:248). Cheryl Mattingly offers “moral laboratories” as an analytic trope in her critique of the “skeptical ethos that has long dominated social and philosophical thought” (2014:202). Although the book Moral Laboratories presents ethnographic cases of African-American families in Los Angeles raising very sick children, with many stories that blindingly reflect structurally institutionalized racism and socioeconomic inequality, Mattingly refuses to give a “victim-focused account” (218). The families she followed cultivate their own “indigenous hermeneutics of suspicion as well as hope” (53), as they are drawn into circumstances that require all manner of critical reflection and practical action (e.g. fighting with schools and fighting for medical care). With rich empirical evidence, Mattingly reveals how circumstances fraught with hardship and despair also give rise to creative experimentation, what she calls “pitting the possible against the probable” (73).1
Many of the details in Moral Laboratories provoke moral outrage, the kind of moral outrage anthropologists normally channel by laying the blame on the various social institutions and mechanisms that allow for the reproduction of structural violence. In Mattingly’s ethnographic cases they include health disparities, conflicts with clinicians, dreams deferred, and street violence itself. While the intention is clearly a good one, dystopic social science narratives obscure all the ways in which on-the-ground actors engage in indigenous critique and moral experimentation. Ordinary people themselves, including “victims” of structural violence, do not find dystopic narratives helpful (Montoya 2015). To presume that something different is possible constitutes the basic precondition for human action itself; this is especially the case in trying circumstances. Here it is important to point out that presuming the possible is not a simple exercise in hope and wishful thinking. As Mattingly has argued, to hope is to make a judgment that a situation requires action. Hope imposes a moral burden and an ethical responsibility (Mattingly 2010).
It is here that we find a significant convergence between family therapy and “moral laboratories” the trope. Structural family therapists feel a strong sense of responsibility for doing something, even if that something may be “politically incorrect” (Lee 2006:220). The purpose of therapy is to stage evidence for the possibility of something new against the odds, usually a psychiatric diagnosis that makes a set of predictions for what can and should be expected and accepted. Minuchin’s approach is anti-pharmacological, anti-individualist, and anti-reification. It works toward unmasking the symptom as masquerade, and puts the possibility, if not responsibility, for situational change in the hands of human actors. Whatever the measurable outcomes may be for family therapy—the profession has an uneasy relationship with the evidence-based movement—the spirit animating the profession and the ethos conveyed in training deserves reconsideration, even if we are only left with ambiguity in the end.
Although Mattingly’s “moral laboratories” trope, inspired by struggling families in difficult life circumstances, may seem unsuitable for examining therapists and therapy, this article will demonstrate its exportability to other circumstances involving other mechanisms for engendering the new against the odds. Applying Mattingly’s trope to locate moral experimentation in a helping profession once seen as having a “dark side,” I hope to show how different paradigms truly do reveal different realities. Critical medical anthropology, animated by a hermeneutics of suspicion and a skeptical ethos toward the authority and assumptions of clinical expertise, has effectively exposed workings of power otherwise (supposedly) invisible to the untrained observer. But it is not only the workings of power that elude, but also “the profoundness that lies beneath the surface of the ordinary” (Mattingly 2014:206), and many other things that would spill over into what we might call the human condition, not the least of which is moral effort (218). This article joins other contributions in this special volume in documenting the many different ways people strive to create the good in their work and in their lives, even in the face of uncertain outcomes and moral paradox (Kuan and Grøn this issue).
What the case of family therapy will reveal, meanwhile, is the immanent vitality of material infrastructures and institutionalized techniques. In family therapy, shifts in experience would not be possible without walls that contain, doors that close, appointment books that set boundaries, couches that comfort, microphones and cameras that record, machines that play back, techniques that are passed down, and so on—thereby pointing us toward the means by which worlds, lives, and virtues are made in relation to, and in connection with, many other things (cf. Bray 2013). Moral experiments are necessarily laboratory-like, involving as they do a “concatenation of actors” (Latour 2005), each making some degree of difference in the observable world and the experience of it.2
The Case of a “Washroom Situation”
And now we come to Wai-Yung Lee’s story of supervision. Titled “The Shit-Painter,” her contribution depicts a “journey” in how she expanded her style in the context of experiencing feedback on a case. At the center of the case is a 24-year-old man named Bill with Down Syndrome. His mother has sent him into therapy because she is fed up with how her adult son responds to frustration—“he would go into the washroom and smear his feces on the wall” (Lee 2006:220). “The Shit-Painter” is one of eight stories of supervision intended to answer the question of how a therapist becomes a good therapist; how, according to Salvador Minuchin, a person becomes the kind of therapist who could help a troubled family.
Shortly into Lee’s introduction of the case, the reader gets a taste of the rebellious spirit behind structural family therapy. While the family of the feces-smearing Bill was intent on rehearsing his many behavioral problems in their first meeting with the therapist, Lee had already reinterpreted the symptom as “the most irrational and absurd problem” for a logic-loving military family to be given (221). The problem here was not Bill, but the fact that they were unable to “face his pain.” They “activated” Lee’s sense of absurdity, first nurtured in her experience of growing up in a large household full of strangers, including the friends her father entertained in his opium room. According to the childhood story she was asked to share for the purpose of the book, an assignment all trainees who contributed to Mastering Family Therapy were given,3 she often watched the many “absurdities of everyday life” right from her bedroom window.4
What to do with a family like this, when the “unspoken ethic” of the therapeutic profession asks therapists to be gentle and supportive “with those who have suffered greatly from the unfairness of life” (220)?
Lee brings a VHS tape of her second session with this family to Minuchin for supervision. Minuchin challenges her right away, pointing out that she was doing to the family what the parents do to Bill: relying too heavily on talk. Minuchin wants her to strive for something called an “enactment,” bringing the family kitchen into the therapy room (Minuchin, Lee, and Simon 2006:88). A good therapist does not merely talk to a family but rather activates their usual pattern of interaction.
In the next session, Lee does something to make up for a missed opportunity from the previous session to explore the relationship between Bill and his older brother Michael, while also building on the absurd questions she had already asked about how he painted. She asks Bill to demonstrate how he would paint his brother’s face. Bill plays along, pretending to draw while providing some narration. “I’m using a big brush,” he imagines. Michael then asks Bill if he would use shit to paint his face. Bill exclaims that he wouldn’t. Their mother meanwhile sits with tension in her body, which leads into an exploration of why she is so bothered.
In a segment Lee plays for Minuchin, she has asked the mother why the “washroom situation” is difficult for her (2006:226).
Lee asks, “Don’t you think he knows that?”
The mother replies, “I don’t know if he knows that or not. He’s been told enough-”
Bill interrupts in protest, “Of course I know!”
Lee says to the mother, “He is telling you now.” And from this point on, the family begins to talk to one another, and most significantly for Lee, they talk to Bill—asking him about a certain job he was fired from, and why he smeared feces during a visit to a family friend’s home. Minuchin meanwhile is very pleased with what he is watching on the tape, even though his suggestions for other dynamics to activate were many. He says to Lee, “You are showing the process of depersonalizing the young man, and you are doing it very well. It’s very nice, I’m enjoying it” (228).5
Staging Evidence for the Subtle Violence of the Family
There are many layers to this story. There is a relationship between the family members themselves, a relationship between the family and their therapist, a relationship between the therapist and her supervisor watching her have a relationship with the family, and then there is the anthropologist looking in from the outside, acutely aware of her potential readers, who may include Dr. Lee herself.
Each relationship set involves some manner of technology. Between the anthropologist and her readers, there is the technology of print and digital publication. Between the therapist and the supervisor, there are camcorders, VHS tapes, and VCRs for playback. Between the family and their therapist, there is the physical space of the therapy room itself, which encodes cultural expectations for behavior—most significantly, scheduled meetings times and a commitment to working through a problem (cf. Bray 2013). The therapy room is not a place for a pizza party in other words, at least not for the sake of eating pizza itself.
For the purpose of the discussion at hand, the audio-visual technology found at the third level is most significant for understanding family therapy as laboratory. If, as Minuchin teaches his students, “enactment” is like putting a merry-go-round into motion (Lee 2006:226), and if the job of the therapist is to observe as it turns, “to think, and to decide whether she should come closer, stay away, or take whatever position that is deemed useful at the time,” then A/V technology may be understood as an apparatus for studying human interactions, which includes being tutored in how and what to look for. An apparatus is more than just a lens. An apparatus effectively stages the appearance of phenomena otherwise too small or too fleeting to be seen or noticed. In experimental physics, according to Peter Galison’s historical account, the 19th century tabletop apparatus eventually became the accelerator requiring laboratories the size of airplane hangars. Yet the purpose in experimental physics remained the same: to demonstrate and to persuade colleagues of the reality of an effect or “subvisible entity,” such as “neutrinos, positrons, and neutral currents” (1987:12, 22). Controlling for disturbing effects is then a basic precondition for conducting an investigation.
“An experiment, like every other event which takes place, is a natural phenomenon; but in a Scientific Experiment the circumstances are so arranged that the relations between a particular set of phenomena may be studied to the best advantage. In designing an Experiment the agents and phenomena to be studied are marked off from all others and regarded as the Field of Investigation.” [quoted by Galison 1987:24]
Therapy itself is an arrangement of circumstances, one that keeps social factors at bay.6 But family therapy is especially laboratory-like in using a technological apparatus to study human interactions. Circumstance and apparatus work together in creating a field for observation and intervention. To push the analogy further, we may note how persuasion was also an issue in the formative years of the field, as observed in the field of experimental physics (and it certainly continues to be). Deborah Weinstein explains, “the challenge in education was to help students shift not just from any individual perspective to any family perspective but more particularly from an interior, psychological (especially psychoanalytic) self to a view of the family as a system with patterns of interaction and communication, even cybernetic feedback loops” (2013:148)
A 1950s study conducted by Murray Bowen—an American psychiatrist party to the founding of family therapy—strongly suggests that “family therapy as laboratory” is more than mere metaphor. With funding from the National Institute of Mental Health, Bowen moved entire families into a hospital ward he called the “Laboratory of Adult Psychiatry” to study the role of the family in schizophrenia. Families left their homes, stored their furniture, and drove themselves to Bethesda just north of Washington D.C. to live as ordinarily as they possible could in a hospital environment. One of the conditions of Bowen’s study was that every family member would be free to come and go as they please, and he discouraged use of psychopharmacology. By putting families into a controlled environment in which they could do as they pleased, while the research and nursing staff took meticulous observational notes, Bowen’s study blurred the distinction between laboratory science and field research (Weinstein 2013:109–136).
I would argue that Minuchin’s preference for enactment over talk suggests a stronger tendency toward naturalistic research, with enactment activating “natural” dynamics in an experimental context.
Mastering Family Therapy begins with an insightful premise: people who live together develop routines for “Who passes the sugar, who checks the map for directions, chooses the movie, changes the channel,” to create “an economy of the energy it takes to relate” (Minuchin, Lee, and Simon 2006:34). This premise has implications for what the therapeutic encounter could and should stage; what unknown could and should be made known. According to the authors of the text, patterns of interaction are invisible, “because they are generally the essence of minutiae” (ibid). In the case of families who come to the clinic with a “designated patient,” minutiae provide clues for how the symptom may be related to troubled patterns of interaction, and for understanding the work a symptom performs in obscuring the trouble. In the case of Bill and his family, the “washroom situation” organizes everybody’s behavior. At the outset, Bill’s mother sends him into therapy hoping his behavior would be fixed. The family focuses on discussing Bill’s behavioral problems in their first meeting with Lee, attributing every problem to the fact that he is mentally disabled (Lee 2006:220). Lee, on the other hand, is only interested in their dynamics. She couldn’t care less about the diagnosis.
“He has parents who demand from him a higher level of functioning and at the same time treat him as a child. So the father is correct to say that there is a volcano, and the volcano can be shit or can become whatever it is. If I thought like that, I would join Bill in the expression of his feeling of impotence and rage to be put in that position in which whatever he does, he does not reach the mark” (quoted on 225).
Here in this comment we may spot the influence of Gregory Bateson, namely Bateson’s theory of the double bind (2000). In the original theory, a mother feels anxious and hostile toward her child.7 When the child responds to her hostility, she compensates with love as a way to deny her hostility. Doing so is a form of meta-communication, Bateson explains. It is a message about a message—a meta-message the child must not interpret accurately because that would defeat her effort to conceal her hostility. Either way, the child will be punished. He would be punished for reading the meta-message, but he would also be punished for interpreting the meta-message as a first-order message inviting him to draw closer to her. She does not want him closer to her, but she herself cannot accept such a feeling. As a consequence, the child who finds himself in such a double bind time and again unlearns how to distinguish between communication versus communication about communication.
Michael: The last time when you did it, it was at your last job placement?
Bill: Oh, yes, it was down at Queens Park…
Michael: That was where you last did it?
Bill (slowly): I believe so…
Michael: Did you know then when you did it that they were going to fire you?
Michael: You knew you were going to lose your job. Is that what you wanted?
Bill: All of a sudden it started to become boring.
Michael: It started to become boring, the job? How come, didn’t they give you different stuff to do?
The questioning goes on but this excerpt is enough to make the point that Michael’s questions are impossible to answer. If Bill were to answer “no” to the question of whether he knew, then the “no” would confirm his role as the disabled family member. But he says, “yes,” which still sets him up, because a “normal” person would not deliberately get oneself fired. Michael looks for clarification beyond the cognitive by asking a different question about intention. If Bill says “yes” to the question of whether he wanted to be fired, he would still confirm his role as the disabled family member. If he says “no,” then he presents himself as a person unable to match action with intention. So Bill gives an explanation instead, but his brother does not quite believe him. Like the child in Bateson’s theory, Bill is damned if he does, and damned if he doesn’t. Or, as Minuchin pointed out in his comment, missing the mark in everything he does (225). This is a family that simultaneously expects Bill to be like them, and expects that he cannot be like them. Bill is no schizophrenic—the destiny of Bateson’s double bind child—but he is certainly furious.
By way of A/V technology and the circumstance of therapy itself, something otherwise “subvisible” is staged. If Galison’s experimental physicists specialize in demonstrating the existence of neutrinos, positrons, and neutral currents, then structural family therapists are specialists in making a case for the subtle violence of the family. Violence here refers specifically to what we might call “ordinary violence,” the many ways people can knowingly or unknowingly hurt and injure one another in the course of everyday life (cf. Das 2012). It is inflicted in the unsaid and in the smallest of gestures, and extremely difficult to address because it has been routinized.
To push the analogy further, family therapists have a way of “reproducing” their results, suggesting at this level an experimentalist orientation. In attending live demonstrations conducted by Dr. Lee at the Asian Academy of Family Therapy (AAFT) in Hong Kong in recent years, I have been struck by how different sessions take on a similar form. There is almost always a dramatic shift in the energy of the interview room at some point during a session, when a long hidden conflict takes center stage, relating to a spouse’s loneliness or self-absorption, or mutual resentment or estrangement, and to a child’s steadfast concern for his or her parents—which had heretofore appeared in the guise of a behavioral or psychiatric problem. The diagnosis of the child or adolescent for which a family is seeking therapy will differ, as will a family’s pattern of interaction, but as one participant put it, “The problem always turns out to be the same.” Relationships are troubled.
The Irreverent Supervisor and the Irreverent Therapist
While the previous section discussed the way in which family therapy is laboratory-like, this section will explore family therapy as moral laboratory. Lee’s story of supervision in Mastering Family Therapy is a story of “ethically unfair but therapeutically correct.” Under Minuchin’s guidance, and later his intense provocation, Lee actively and deliberately provokes Bill’s family. At the end of the second session discussed above, Lee declares to the family that Bill has made “poo poo” of everyone. She continues to play with the meaning of the symptom in the third session—what if we frame Bill’s painting?—allowing for its reinterpretation in light of Bill’s emotional truth. Minuchin congratulates her for being an excellent storyteller, but he is still unsatisfied. He again suggests that she is doing to the family what they are doing to Bill: avoiding aggression. In Minuchin’s critique, feces smeared on a wall ought to be directly confronted as an act of aggression, not a piece of expression one might hang in an art museum. Minuchin wants Lee to push the family beyond their usual “threshold,” and to completely “upset” their usual way of relating to one another. He says to Lee: “Unless you accept that you are in the field of family therapy and that families are conservative, constraining organisms that cut people to pieces, you will not be able to help people to expand the niches that the family creates for them” (quoted on 231).
At this point, Minuchin does to Lee what he wishes Lee would do to the family: he provokes her. Lee does not quote his words on the page, but Minuchin apparently attributed avoidance of aggression to being Chinese. Lee was furious. She recalls, “For 2 weeks, I kicked dogs and walked with a two-by-four, hitting anyone in sight. I waited for the family to come back, and when they did, I tied them up with a roll of string that I found in my office. Like a spider, I set up my web and waited for the moment to attack” (231). One reason for Lee’s fury is obvious—culturalist stereotyping, while the other more significant reason has to do with Minuchin’s assessment of her session as being too “sugary” (i.e. weak in aggression), which made no sense to Lee given her formative experiences. She explains, “I would not have minded being seen as unreasonable, irrational, or irresponsible. […] But sweet and sugary! It just blew my mind” (231). I would further speculate beyond the clues given in the text that there was some disappointment here, as Lee and Minuchin share similar sensibilities, a likely reason for their connection throughout the years.
Subsequently, Lee challenges Minuchin on his interpretation at the next supervision meeting, and proves him wrong with the content on her tape. At least twice, Minuchin stops the tape to make a point to the supervision group about Lee’s “expansion” of style, recognizing that she has successfully added “one-to-one confrontation” to her gift of poetic language (234–235).
Lee began the session with the purpose of upsetting the family’s “equilibrium,” and she asks a question about how they express their love to Bill, and to one another. The metaphor she uses in sharing her impression is not well taken by the family. “I feel implicated in the way you sort of accuse us of being false about our feeling for each other,” Michael says. To which Lee responds, “I don’t know what your feeling is, but I sense that you kill Bill with words—” (232) The “heat” in the session continues to intensify, with Lee pushing an exploration of Michael’s close relationship with his father, even going as far as to explore its influence on his failed marriage.
This session led Minuchin to feel that his supervision of Lee’s work was complete (235). But it is not until her next session with the family that we see a full mirroring between the supervision relationship and the therapist-family relationship. Bill had arrived early and shared with Lee that “he felt rejected by his ‘folks,’” so she encourages Bill to tell his parents what he has told her (235–236). While the mother’s response was to insist that the notion of rejection was artificially planted in Bill’s mind, Bill’s father admitted to his ambivalent feelings: “Well, sure, disappointment maybe. I am sure I got over it a long time ago, but there is still… there is still an element there of… of… shame. […] So what the hell can you do? (Changing the subject): Listen, I admire Bill for having the guts to speak up and say his mind” (236).
Seeing this opportunity, Lee encourages the father to congratulate his son. She recalls, “The father leaned forward to Bill. He gave Bill his hand and proceeded to hug him. But I saw that as soon as he had done that, he patted Bill on the shoulder in a chummy gesture, indicating that the whole thing would be over. It was at that point that I said, ‘Don’t sweeten it’” (236).
The father is furious with Lee and begins to yell at her. He insists he did not do anything wrong. Michael tries to intervene, and then suddenly, the father says: “Yes, I am emotional now, I am emotional! If the bloody Chinese are huggers or not, it doesn’t matter…” (237). This triggers a “shouting match” between Michael and his father, which leads to another outburst from the latter, because Michael asks, “Why can’t you just hug him?” The father insists on his innocence by insisting Lee had missed the vulnerability registered on his face when he went in for the hug, and accuses Lee for always “spoiling the moment.” Having maintained her calm through all the emotion, Lee transforms the insult that was just thrown at her into a device. She identifies what has happened as “a change” in pattern, and then leaves the room to find her own breath. The session then goes on, in its reincarnation as a videotape, to create “much rattling” and even “chaos at supervision.” Having staged evidence for her own capacity to change, Lee recalls, “I knew that I had surpassed what Minuchin had once considered to be my low tolerance for intensity!” (238).
“Ethically Unfair But Therapeutically Correct” as Moral Experimentation
If experimental physicists work hard to control, or at least measure, disturbances to their field of investigation, then structural family therapists differ in deliberately creating disturbances that upset family systems, within a controlled environment. What does it mean to upset a system? For Minuchin, it can be any number of things as long as it differs from a family’s usual pattern of relating to one another, because set patterns are understood to be responsible for maintaining the presenting symptom in the first place. As Minuchin’s own signature style consists of direct confrontation, what Lee retraces resonates with the live demonstration Athena McLean described in her 1986 Social Science and Medicine article, wherein a consulting therapist had “observed the powerful position of control that the mother enjoyed in the family,” and then “proceeded to conduct therapy with the family in a way that successfully provoked a hysterical outburst from the mother” (180). McLean had explained the outrageous behavior in relation to family therapy’s theoretical foundations—General Systems Theory and cybernetic thinking, which has the effect of dehumanizing people in therapy. She further argued, drawing on literature from the then relatively new subfield of medical anthropology, “In an ideal healing relationship, the doctor aims to comfort the patient in the experience of illness, while at the same time combating the disease…” (183). Given what medical anthropologists have discovered about the significance of personal meaning and experience in healing processes, “ethically unfair but therapeutic correct” could not possibly promote healing.
Here I would like to revisit “ethically unfair but therapeutic correct” by drawing on a resource found in the anthropology of morality, which takes the moral as a dimension in social life to be studied empirically (see the introduction to this special issue for a longer discussion). In the spirit of the anthropological method—thinking through comparison by selecting from a promiscuous array of cases—I propose an analogy between the provocative family therapist and the Urapmin Big Man, as described by Joel Robbins (2004). For the latter, it is often not possible to be the nice guy, since political leadership involves creating the context for social relationships in the community, and the big man must use his will (san) and sometimes his anger to persuade people to do things in the interest of the larger group, a moral risk due to the ambiguous status of the will for Urapmin people.8 The Urapmin liken anger to a knife, and like a knife, anger is dangerous but effective when used properly. The big man who can persuade and mobilize grows his community, and the larger the community can grow, the happier people are because Urapmin “generally feel that the social life in larger villages is richer” (201).
With the embrace of Christianity, the ambiguity of anger has been eliminated because any form of anger, even unexpressed anger, has been redefined as sinful. Robbins’s story of a man named Rin is illustrative. Being the son of a leading big man who recently died, Rin was in a good position to take up his father’s position in serving as a political leader for the community. But Rin decided not to pursue this career path because it would have ruined his Christian life. Rin may have saved himself from taking the moral risks that come with being a big man, but at the cost of withdrawing from social engagement.
In the case of family therapy, one must take the discomfort of some insiders with the behavior of performing therapists seriously. Why a live audience member might feel sickened, or what could happen when the wrong person or less experienced therapist adopts this style are very real concerns (McLean 1990:58, 333). It may be possible that Lee was unfair to Bill’s father, but this is the whole point of “ethically unfair but therapeutically correct.” By the time Lee left the therapy room the father was in tears and “the entire family was talking together” (2006:238). And in a meeting with the parents three years later, Lee learned that Bill was no longer painting with shit; “he only pulled the fire alarm once or twice” (239). Both Lee and Minuchin recognize this case as having been a major turning point in Lee’s journey of transformation; a family therapist was made in this story of supervision. Lee went on to have a successful career practicing family therapy in Asia, tirelessly conducting training courses and building institutions, working with and inspiring new generations of trainees with her own unique signature of fearlessness.
How to make sense of the moral ambiguity in this story? What is the relationship between the “moral” logic behind Minuchin’s approach and its unintended consequences? I argue for thinking of structural family therapy as a moral laboratory, where families are asked to pit the possible against the predictable (Mattingly 2014:16). Thinking of family therapy as a laboratory for experimentation illuminates how the “good” and the dangerous form two sides of the same coin. Moral risk in this case differs from what Robbins describes of the big man, as the status of anger is unique to the Urapmin’s pre-Christian moral system. Risk in the case at hand refers instead to the uncertainty over what actions help or hurt. This uncertainty of action affects the therapist-family relationship just as much as it affects the supervision relationship.
To illustrate what I mean by this, I turn to another supervision story in Mastering Family Therapy. The story is written by another former trainee named Gil Tunnell, who brought his work with a Jewish family of five for supervision with Minuchin: the Hurwitz family. The identified patient was the youngest child in the family—a 22-year-old man who has been hospitalized for self-injury, specifically eye gouging.
The supervision relationship in this story is marked by tension from the very beginning: Tunnell in the first session came up with a clever metaphor for getting the family to see they were “enmeshed”—like a set of Christmas lights wired in series, if one bulb goes out the whole string goes out. Minuchin not only saw the metaphor as culturally inappropriate, but downright useless (Tunnell 2006:165–166). A clever metaphor would be ineffective for a family that is “undifferentiated in internal structure but strongly defended against the outside” (Minuchin, quoted on 166).
Like Lee, Tunnell was also very eager to learn, and so he tried to increase intensity in the next session by exploring the Oedipal theme. He “told the family that David ‘unconsciously’ was curious about the parents’ sexual relationship” (which turned out to be true), and he connected this curiosity to his eye-gouging, “David was sticking things where they didn’t belong” (167). This provocation, documented on videotape, did not please the supervisor. Tunnell recalls, “Sal was visibly angry. He stood up and pretended to pour coffee over my head, shaming me before the other trainees” (167).
In Minuchin’s view, Tunnell was still being too nice.
“Sal began to unbalance the power structure by deliberately ignoring the intrusive Stella [the mother]. When she insisted on speaking he interrupted her. When she asked whether David’s compulsive behavior might be due to his eating massive doses of carbohydrates, Sal said that was crazy. David wasn’t crazy. The family was. He left the room at that point. The parents began to fight.” 
Was Minuchin unfair to the mother in this family?
We learn from Tunnell’s story that she was in fact furious at Minuchin and remembered “how he had called her crazy” (172). But in a session that took place one year after Minuchin’s consultation, Stella thanks Minuchin for what he had done. At that point, the family had experienced a number of positive changes, including David’s discharge after 18 months of hospitalization and his remaining symptom-free. Almost ten years later Mrs. Hurwitz passes away from ovarian cancer, and we learn that she had written about Tunnell in a letter to her children read at her burial. She spoke of the therapist who helped her family, and recalled the metaphor of the Christmas lights—ironically it helped. Needless to say, Tunnell was “deeply moved” that he was remembered in this way, but he also gives credit to his supervisor for “firing up” his assessment of the family. They were activated at a deeper emotional level, allowing Tunnell to work with Minuchin’s “prophecy” in subsequent sessions.
Does this story offer a happy ending, an ending that justifies “ethically unfair but therapeutically correct”?
Unlike Lee’s story of supervision, Tunnell’s story of his relationship with Minuchin is much more ambiguous, though he too went on to have a successful career, specializing in couples therapy for gay men. We learn in the postscript all traineess were asked to write that Tunnell “spent the rest of that supervisory year healing from that day of confrontation,” when Minuchin pretended to pour coffee over his head. He explains, “Sal didn’t know it at the time, but I was privately struggling with my own self-doubts about whether a gay man could be a family therapist” (174). The mock pouring incident reenacted painful childhood memories, Tunnell recalls experiencing Minuchin’s dissatisfaction with his softness as “one more attempt for a father-figure to ‘make a man out of me’” (174).
This postscript is marked with a deep ambivalence. There are a number of instances where Tunnell no sooner acknowledges what Minuchin accomplished than his failure is indicated. In the case of the Hurwitz family, he recognizes that change was very much the result of a team effort, then in the same paragraph, states that Minuchin started a job he never finished. Tunnell attributes his ability to think like a structural family therapist to Minuchin. But, “Direct confrontation is not my strong suit. I can summon it if I have to, but it’s not my first, second, or even third strategy in working with families. After 10 years, I am no longer apologetic about it” (173).
I went through and marked attribution and denial with plus and minus signs on the edge of Tunnell’s postscript, and the resulting pattern looks like this: + − + − + − − − − − − − + − − + + ∓ − (172–176). The ∓ refers to a deeply ambiguous, but hopeful sentence: “We never did really talk about or ‘process’ the day of confrontation, yet in some way we were (and still are) working through a healing process” (176). Interestingly enough, this working through seems to have unfolded in a very public way, in a training textbook of all places, where the reader will find at the very back letters Minuchin penned to his former trainees in response to each postscript. His letter to Tunnell is generous in spirit: he not only admits to having felt “intimidated” by Tunnell’s non-clinical research background, but more importantly, he offers an apology. “To start,” the letter reads, “let’s agree that at the time of your supervision, the way in which I challenged students was harsh. Clearly, I was not aware of the pain that I caused you and for which I apologize” (263). Minuchin tells Tunnell that he has become softer over the years, offering the good apology that takes responsibility for one’s own flaws. But like Tunnell’s postscript, this letter is also ambiguous. The sequence of plus/minus signs does less flip-flopping in this letter, instead, ambiguity is extended over the whole: + + + ± − + −. In the end, it seems as if Minuchin is not apologetic for pushing his former trainee. It is one thing to hurt (for which he is sorry), but another to push. Beginning the very last sentence with a “however,” and taking up an analogy Tunnell used in his postscript to describe hard versus soft styles, Minuchin writes, “I think that other therapists working with the same population you do have found a different mixture of “Sun and Wind” that is equally effective” (264).
Family Therapy is Good to Think with
Is the last sentence in Minuchin’s letter to Tunnell the sign of a stubborn man, or, the stubborn hope of a professional whose work is made possible by the belief that a person could always be something otherwise? Whatever the case may be, to understand the provocative style of structural family therapy as dehumanization, and to identify it as an effect of the theoretical framework to which it subscribes—general systems theory and cybernetic thinking—may say more about competing paradigms in medical anthropology than anything else. Critical medical anthropology in the 1980s drew productively on Marx, Foucault and Gramsci—masters of suspicion—to expose how the institution of modern medicine reproduces social inequality along with its own power. Research in this period was successful in further identifying the medicalization of deviance and the mystification of exploitative relations behind reified disease categories in clinical transactions (e.g. Taussig 1980). Wherever medical anthropologists of this camp pointed their well-intentioned flashlights, something insidious may be found. Mattingly would call it a hermeneutics of suspicion.
It is important to note that McLean’s dissertation thesis offers a much more subtle argument than the one made in the 1986 essay; it provides a thorough and detailed study of knowledge production within a defined historical period (1937–1978). She also had the opportunity to interview major contributors in the field, exploring past intentions, aspirations and disappointments. Salvador Minuchin, who she had a chance to conduct original interviews with, is described as a “tragic figure.” Writing with sympathy, McLean observes that family therapy had tried to “escape from a reductionist epistemology” yet never managed to “escape the broader moral structure whose agent it became” (1990:401). McLean reveals how Minuchin was working hard at higher levels of social organization for systemic change, on top of working in the clinic and with students. Expressing disappointment over the direction his field had taken, particularly its over-emphasis on technique, Minuchin lamented that policy makers only ask for consultation for training rather than policy making itself: “And this shows exactly where family therapy is today. They think we are good at making small changes, but they cannot see that we have a theoretical tool they can use” (quoted on 329).
As this article is part of a special issue on the “moral laboratories” trope, it is not the place for describing the complex social and institutional factors that reduced family therapy into nothing more than a clinical modality in the United States.9 But I would like to echo McLean’s characterization of Minuchin as a “tragic figure,” to speak to the theme of this special issue. Moral experimentation begins with hope but risks the possibility of tragedy, not because the laws of necessity will rear its ugly head, but because consequences cannot be predicted let alone controlled in the realm of human affairs (see the introduction to this special issue). As Hannah Arendt had so insightfully understood, human action is always cast out into a web of already existing relationships composed of an innumerable number of distinct and unique individuals with their distinct and unique intentions (1998:184). Or, to borrow from another neo-Aristotelian, Bernard Williams, “One’s history as an agent is a web in which anything that is the product of the will is surrounded and held up and partly formed by things that are not” (1981:29).
The structural family therapist does not and cannot fear the uncertain, because the work would then be impossible. Fearlessness, the stories of supervision suggest, is a basic precondition for therapeutic action, otherwise a highly resistant family could make minced meat out of you, toss you around like dirty clothes in a washer. I once heard a joke in my current fieldwork, made by an admiring trainee, that the reason why senior therapists prefer to work with another colleague in the room is to have someone to talk to when a family refuses to listen, i.e. is not yet ready to explore a sensitive area. My interlocutor likened this practice to a gang fight (da qunjia), and even went so far as to imagine that in some situations, a therapist might think, “You’re bringing five people? I’ll bring more!”
The unintended consequence of idealizing and training fearlessness is the small irony that the same professionals who help families negotiate less injurious ways of treating one another are not immune to “ordinary violence” themselves, those subtle ways people can unknowingly inflict hurt with small gestures, paradoxical communication, the withholding of recognition and of forgiveness… the list could go on depending on the situation. I suspect this is hardly lost on even the most powerful of masters, who would not exempt their own social existence from what systemic theory predicts. In having relationships with others, in forming relational “systems,” certain patterns develop as a matter of course, becoming something bigger than the sum of its parts. Some systems work out a healthy equilibrium; others may not. The hope lies in the ever-present possibility of unsettling stasis, of doing the work of working through.
Precisely because the basic precondition of this profession is hope—an audacious hope that works against human/interpersonal/systemic inertia as well as the hegemony of psychiatric individualization, and precisely because this hope is enacted through risky experimentation, structural family therapy is good to think with. It is simultaneously a real and a metaphorical laboratory, physically lab-like yet moral in the way it puts the possibility, if not responsibility, for situational change in the hands of human actors. Historically unique as a profession and practice, family therapy simultaneously points to a universal human capacity for creating socio-moral technologies for acting on the given, in search of an otherwise.
Mattingly’s paradigmatic case concerns a mother named Tanya, who disagreed with her husband over which activities were appropriate for their son Andy—one of three children, a boy born with cerebral palsy. Her husband Frank proposed signing him up for a local “special needs” soccer team, for children with cognitive disabilities. Tanya had refused, worried her medically fragile son, who would be the only child in a wheelchair on the field, would be hurt. Frank prevailed, Andy played, and sure enough, he was knocked over in a game. To Tanya’s surprise, Andy was just fine, and she realized that “despite all her determination that others see her son as capable, she herself underestimated him” (2014:4).
This case is just one of many illustrations of how families with very sick children work to “step up to the plate,” having been “propelled into a new, often unexpected and unwanted project of [moral] becoming” (5). The families who have inspired the “moral laboratories” trope found themselves having to reevaluate their own commitments, create new communities, and transform the social and material spaces in which they lived in facing their challenges. Tanya’s story involves much more than a mother learning to “let go.” Only by seeing the concrete results of an experiment with an activity she had feared would Tanya learn something new. In another case, a family matriarch and her adult daughter “build a whole repertoire of experiences that give evidence to support their improbable hope” (79). Marcy, a former crack cocaine addict of 18 years, experiments with the mother she could be in the context of mundane but concrete routines such as accompanying her own mother and son to his physical therapy sessions. Ten years later, we learn in the last chapter, this very boy is murdered senselessly. In an angry and agonized lament to a gathered crowd of family and friends, a grieving brother pleads for change during a candlelight vigil, transforming a dodgy neighborhood park into an experimental space for social critique.
With this in mind, the soccer ball that appears in the previous footnote, as well as the Narcotics Anonymous book Marcy was reading during her son’s physical therapy sessions, take on a new significance.
Minuchin intended for these stories to “illuminate for the reader the values, biases, and constraints that he or she brought to the therapeutic encounter and how they affected both the supervisee’s preferred therapeutic style and my work to expand that style” (2006:99). That he did so is interesting given family therapy’s emphasis on the observable rather than the past—a specialty left to psychoanalysis.
Lee’s childhood story is full of irony and beauty. A short passage will have to convey its tone: “I once saw a woman running after her husband with a chopper; when she caught up with him, she chopped the umbrella that he was carrying, rather than the man himself. There was another woman who told her husband that if he left the house she would strip herself naked on the street, and she did. My father once took a beggar from the street and offered him a job to help me with my homework. On his second night, he tried to take one of the servant girls, who punched him flat on his nose. He was back to the street in no time, but whenever I got stuck with my homework, I would still shout my questions at him from the balcony, and he was always happy to provide me with an answer” (217–218).
By depersonalization, I believe Minuchin had meant that Bill’s family did not treat him like a person, a full human being. Earlier Minuchin is quoted as advising Lee to invite the brother to observe how their parents talk to Bill: with him, at him, or over him (228). While “depersonalizing” is the term Minuchin happened to use, I will in the next section interpret this family’s dynamics in terms of “ordinary violence.”
The relationship between family therapy and social engagement is rather complicated, and not a history I can get into here. Keeping social factors at bay is not the same thing as being ignorant of social inequality and the broader contexts in which family troubles develop.
On its surface level, the theory of the double bind is problematic for all sorts of reasons. But I would argue that the mother and the child in Bateson’s theory ought to be taken as metaphors—with the mother standing in for a person with power, and the child standing in as a vulnerable individual who depends on the powerful person for resources and recognition. The mother–child relationship, meanwhile, is a stand-in for any kind of relationship characterized by a significant length of duration. The entrenchment of patterns of hostility, denial, and paradoxical communication can be quite painful for the person who occupies the lower social position. The Azande in Evans-Pritchard’s classic study of witchcraft had a means for addressing interpersonal hostilities without directly accusing one another of negative feelings, although it is worth noting that accusations only traveled down the social hierarchy. It seems to me that family therapy may offer something similar, though the “accusations”—if you will—travel upward.
The big man imposes his will on others, and his willfulness is reflected in his capacity for anger.
See Imber-Black (2014) for a recent assessment of the state of family therapy in the United States. Imber-Black expresses the same disappointment about family therapy’s failure to make systemic change in the field of mental health services, but adds that family therapy’s marginal “step-child” status has its benefits, including room for staying committed to its point of view.
I am grateful to Lone Grøn for her support and encouragement, and for thinking of organizing the AAA double panel on moral (and other) laboratories in the first place, which led to this special issue. Many thanks to Tanya Luhrmann and Cheryl Mattingly, who served as discussants, and to the anonymous reviewers, who gave the manuscript a meticulous read and lent their expertise on family therapy and anthropological theory. All shortcomings are my own.
This study is part of a larger project funded by the Research Grants Council, University Grants Committee, Hong Kong (14610115).
Compliance with Ethical Standards
Conflict of interest
Teresa Kuan declares that she has no conflict of interest.
This article does not contain any studies with human participants or animals performed by the author.
For this type of text-based study formal consent is not required.
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