Milan Systemic Family Therapy
Until the late 1960s, the mainstream of psychoanalysis was an asymmetric process in which the psychoanalyst guides the patient out of his/her “neurosis” via the infinite and intense “talking cure” process. During the end of the 1960s, things were going to change. In this presentation I will try to outline the main positions of a team, comprising Luigi Boscolo and Gianfranco Cecchin that broke with the psychoanalytical mainstream in Milan. This team became eventually, after the separation from Mara Selvini, the Milan Approach. The therapist who founded the Milan Approach developed their practices in Milan, with reference to Gregory Bateson (1904–1980). This break with psychoanalysis and the implementation of family therapy, under the influence of Bateson’s anthropology (Bateson, G., Toward a theory of schizophrenia. In G. Bateson (Ed.), Step to an ecology of mind. Chicago: University of Chicago Press, 1972.), changed completely the setting and the therapeutic practice.
What is the future of the school? How the new generation of therapists is dealing with therapy, research, training, and theory? In this essay I’ll try to answer these questions.
The Milan Systemic Family Therapy Origins
The first team of family therapy in Milan was composed of four psychoanalysts: Luigi Boscolo, Gianfranco Cecchin, Giuliana Prata, and Mara Selvini.
Mara Selvini (1916–1999) was trained under the Italian/Swiss psychoanalyst Gaetano Benedetti (1920–2013). During the late 1950s and 1960s, Selvini developed a new and original psychoanalytical theory of anorexia.
At the start of the 1960s, Silvano Arieti (1914–1981) invited Selvini to New York and sponsored the publication of her book on anorexia in English (Selvini Palazzoli 1977). To give an idea of how anorexia was considered until the 1960s, the proposal for publication was rejected. The publishers believed there would be no readership. Anorexia was a rare disease. Just a couple of years later, in 1963, the publishers changed their mind; the explosion of interest in anorexia was prodigious.
Arieti was one of the most important Italian Jewish psychiatrists and psychoanalysts. He was forced to migrate to the USA after the introduction of Italian Fascist Race Laws in 1938.
Luigi Boscolo (1932–2015) and Gianfranco Cecchin (1932–2004) went to New York in 1961. In the USA, Selvini met a younger Italian psychoanalyst who was undertaking psychoanalytical training in New York under Silvano Arieti and Nathan Ackerman (1908–1971). His name was Luigi Boscolo. Boscolo came back to Milan in 1967. He and Selvini began to work together in the same studio at Milan, joined by Gianfranco Cecchin, Giuliana Prata, and some other psychoanalysts as Sergio Erba and Severino Rusconi. At the very beginning, they simply shared an office for psychoanalytical work.
In just a few years, the four colleagues began to experience the boredom of never-ending and routine analytical treatment, growing increasingly dissatisfied with a job that had become alienating and was exclusively dedicated to neurotic members of the middle and upper classes.
The group, influenced by the senior member, Selvini, was intrigued by a particular type of pathology that was to become typical of the daughters of Western middle- and upper-class families, i.e., anorexia.
Anorexia was “the new epidemic” of young middle-class women. Although, as a pathology, it had existed before – and had been interpreted in different ways by psychiatrists, endocrinologists, and other medical and nonmedical scholars, specifically “expert men” – anorexia, until the 1960s, had always been considered a rare disease. The explosion of anorexia during the 1970s in Western middle-class families became one of the principal interests of the group that came to be known as the “Milan Team” all over the world.
Modern Middle Class Family Alienation
For the Milan team, alienation became the emotional focus of Western middle-class families through a new form of silent protest and rebellion inside the family and toward the affluent society (Barbetta 2004). Starving was the way in which young women were silently expressing the social disorder of the bourgeoisie; it was its discrete charm, as in Louis Buñuel’s film The Discreet Charm of the Bourgeoisie (1972), in which the protagonists never manage to eat, and eating becomes an obscene practice, to be carried out in a separated room, while defecating is an important moment during the party.
Nevertheless, an authentic view of what was going on in the Milanese bourgeoisie is portrayed in Pier Paolo Pasolini’s Teorema (1968). The movie concerns a bourgeois Milanese family devastated by the temporary presence, as a guest, of a handsome young North American man (the visitor), with whom everybody, including the maid, falls in love and has sexual intercourse. When the visitor decides to leave the house, all the members of the family descend into madness: the father gets undressed at Milan Central Station; the son, who was spying on the naked body of the visitor under the blankets – since they used to sleep in the same room – leaves the house as well; the mother starts to have sex with other men; the maid returns home to the countryside and becomes a kind of mystical hysteric; the daughter has catatonic and anorexic reactions.
In the Milan team’s experience, anorexia and schizophrenia became two ways of revealing the obscene truth hidden beneath the conformist life of a bourgeois family. The family unconscious was blatantly showing (it)self during the conversation in therapy.
One of the main characteristics of anorexia was the firm proposal (or “stubbornness,” as some old-fashioned psychoanalyst would say) of anorexic women with regard to starvation, an obsession with doing physical exercise, and generally keeping their bodies under strict control. During that period several anorexic women died in hospital as a result of starvation, including instances in which they were force-fed. It is a point of fact that the usual “talking cure,” as envisaged by traditional psychoanalysis, was totally ineffective in such cases, at least at the very beginning of treatment.
During the 1960s, Selvini – as well as other psychoanalysts, such as Gisela Pankow (1914–1998) – tried to organize a setting similar to the Kleinian one for children, where an object plays the role of facilitating the analyst’s access to the client’s world (Pankow 1977). In 1971, Selvini wrote the Introduction to the Italian version of the Sceno Test Handbook (Selvini Palazzoli 1971), in which she presents the clinical case of Mina, a young anorexic woman who was successfully treated through the use of the Sceno Test, which is a psychological tool that was created for diagnostic purposes but revealed immediate therapeutic uses.
Milanese Magnetophons: Alienation Becomes the Videotaped Family Theater
After those individual session experiences, Selvini proposed that Luigi Boscolo, Gianfranco Cecchin, and Giuliana Prata should join her, creating a team for family sessions. Collective therapy was considered a kind of mind-expanding experience. During the same period, the antipsychiatry revolution began to spread throughout the Western world, and schizophrenia came under discussion, together with psychiatric practices for treating schizophrenia and other so-called mental illnesses, with particular reference to electroconvulsive therapy. Thomas Szasz’s The Myth of Mental Illness was published in 1961 and translated into Italian in 1966, but the Milan group was apparently unsatisfied by Szasz position, they were looking for a way for health, instead of an antagonist protest.
In the USA, two main experiences inspired the Milan team: New York family psychoanalysis at the Ackerman Institute – particularly influencing Luigi Boscolo’s thought and practice – and strategic family therapy at the San Francisco (Palo Alto) Mental Research Institute, which mostly influenced Mara Selvini.
By far, the biggest influence on the group was Gregory Bateson’s ideas and anthropological studies. Bateson (1904–1980) wrote, in 1968, with Jurgen Ruesch (1910–1995), one of the founders of social psychiatry, Communication: The Social Matrix of Psychiatry. While Gregory Bateson was working as an ethnologist in Palo Alto Veteran Hospital, psychotherapy with schizophrenic patients was transformed into family therapy. After the coauthorship with Ruesch, Bateson wrote – together with Jackson, Haley, and Weakland – the most important article influencing the Milan team: Toward a Theory of Schizophrenia (Bateson 1972), in which the authors explain the double bind theory. Bateson’s double bind theory became the benchmark for therapeutic practice in systemic family therapy.
All the family members would meet together with the therapist. The Milan team decided to experiment with this practice in a private setting, outside the hospital. In an apartment totally unconnected to the medical context, they undertook a wholesale conversion of psychotherapy from being a medical experience to a social intervention, to be guided by social sciences instead of medical principles.
The new setting for family therapy was suggestive of a theater stage. One of the four members of the team would talk to the group of family members, while the other three observed and listened to the conversation from behind the one-way mirror. It is quite clear that the psychoanalytical setting was completely deconstructed. The transformation from a more private and secret enclave to a kind of open and public space and from a monological style to a conversational and theatrical one was blatant or, in keeping with the style of change, dramatic.
The Milan team was developing a new family treatment for schizophrenia, called the “prescription of the symptom.” In 1975, they published Paradox and Counterparadox (Selvini et al. 2002) translated into English in 1978. The subtitle of the book is A New Model in the Therapy of the Family in Schizophrenic Transaction.
The Milan team splits into two parts at the end of the 1970s. Mara Selvini follows the influence of strategic perspectives and Jay Haley’s point of view. Luigi Boscolo and Gianfranco Cecchin were more interested in nonauthoritarian practices, as in Gregory Bateson’s critique of Palo Alto’s approach to therapy (Cecchin et al. 2005).
Boscolo and Cecchin gave their own new practices the name of “Milan Approach.” They were influenced by constructivist epistemology, such as Heinz von Foerster’s Observing Systems (von Foerster 1981) or Humberto Maturana’s and Francisco Varela’s Autopoiesis Theory (Maturana and Varela 1980) and, more generally, by the constructivist theories.
During most of the 1970s, the group acted as a therapeutic team that met for two days a week and saw an average of two families a day. The interview format was divided into five parts: the pre-session, the session, the intersession, the intervention, and the post-session discussion. During the pre-session, the team came up with an initial hypothesis about the family presenting the problem. Only two members would meet with the family. During the session itself, the team members would validate, modify, or change the hypothesis. After about forty minutes, the entire team would meet alone to discuss the hypothesis and arrive at an intervention. The treating therapists then would go back to deliver the intervention to the family, either by positively connoting the problem situation or by a ritual to be done by the family that commented on the problem situation and was designed to introduce a change. A positive connotation is a message to the family from the therapist[s] that the problem is logical and meaningful in its context. A ritual is an ordering or behaviour in the family either on certain days [odd days, even days] or at certain times [after dinner, in the morning]. Finally, the team would meet for a post-session discussion to analyse the family’s reactions and to plan for the next session. (Boscolo et al. 1987, p. 4)
As you can observe from these descriptions, the change of setting from psychoanalysis to family therapy was definitive. We can consider any phase of the session as part of a theatrical performance: the prologue, the parodos, the episodes, the stasima, and the exodus.
The prologos corresponds to the presession, the parodos to the intersession, the episodes to the session[s], the stasima to the interventions, and the post-session discussion to the exodus.
Each part of therapy was recorded on videotape; this innovation arose in the USA and introduced a taste of North American democracy into therapy, which was anathema to the classic European psychoanalyst.
At the end of the century, Cecchin developed strong relationships with new therapy teams in the USA, influenced by Lyotard’s ideas concerning the impossibility of theorizing or making meta-narratives; the so-called postmodernist approach. Cecchin’s position was ironic, the concepts he used – “irreverence, not that much as to be reverent to your irreverence,” “cybernetics of prejudices,” “perfect ideas,” etc. – highlight his own approach to practicing therapy.
Boscolo (2009), instead, was more attracted by the narrative therapy of Australians Michael White and David Epston’s, and their inclusion of Michel Foucault in the dominion of systemic thought – in point of fact Foucault was teaching the History of Systems of Thought at the Collège de France, in Paris. One of the main tendencies Luigi Boscolo evidenced during the 1990s, following an important book about Time, written together with Paolo Bertrando (Boscolo and Bertrando 1993, Boscolo 2009), was the use of temporality in the therapeutic sessions.
The Future of Milan Systemic Family Therapy
In more recent years, the Milan Approach has changed. This is not surprising since an approach is not a model. The approach, to be considered such, must be embedded in ongoing change. The change of the Milan Approach is linked to the new worldwide social and cultural contexts.
The social perspective endorsed by Boscolo and Cecchin has always been different from any form of reductionism. Unfortunately, the psy world has focused attention increasingly on the brain and nervous system, neglecting society and family relationships.
The new neurosciences are not the same as they were during the 1970s and 1980s. Throughout the 1970s and 1980s, approaches to the nervous system were influenced by the “theory of complexity.” It was the era in which, with complete honesty, neuroscientists said: “We know almost nothing about the brain and nervous system. The brain is not alone, it is inside a body which has a connection with the world, and with other bodies.”
Now the basic formula, which appears to be a must, is a kind of reductionism: “if we control the brain, we control society.” “Marketing-oriented” neuroscientists say: “We know almost everything about the brain,” simply because they need funds to deal with filling the “almost” gap.
The Milan Approach, of course, maintains a distance from this mainstream, in which financing is obtained to create a technocratic society, promoting life as a “clinical disorder” and transforming the world into a gigantic health care system.
However, this period of obscurantism in the mental health field is going to decline slowly, and, in the future, anyone who remembers this historical nightmare will call it “the Decade of Brain Worship.” During this obscurantist period, the therapists at the Milan School have started to research new ways of continuing the school and renewing the Milan Approach.
After Bateson, we drew inspiration from Michel Foucault, Gilles Deleuze, Felix Guattari, and the French Thought (Viveiros De Castro 2014). Michael White was one of the first family therapists to be inspired by Foucault. Other systemic therapists have developed new links with the ideas of Deleuze and Guattari, such as Maria Nichterlein, with whom I have coauthored two essays (Barbetta and Nichterlein 2010, 2012), and who has published a new book on Gilles Deleuze and psychology (Nichterlein and Morss 2016).
Marcelo Pakman, inspired by Jean-Luc Nancy, Alain Badiou, and the Jewish philosophical tradition, has written two very important books in Spanish (Pakman 2011, 2014). At present, I am collaborating with him on ongoing training for Hispanic therapists under the heading: “Pensar la clinica.”
A group of people from Santiago de Chile (Gálvez Sánchez 2010) – some of them trained at the Milan School – are also engaged in connecting Bateson’s and Deleuze’s concepts in training student of psychology and psychotherapy.
Cristobal Bonelli, from the University of Amsterdam – who was trained at the Milan School – has undertaken ethnographic work with the Mapuche people in Chile, discovering the anthropological theory of Eduardo Viveiros de Castro (2014).
The systemic school Familias y Parejas from Buenos Aires and the group close to Gerardo Resindiz and Ricardo Rosas, from Mexico – also trained at the Milan School – are now in connection with us, with the aim of inventing new ways for therapy and social intervention.
This is to mention just a few of the people we have been in contact with during recent years, in order to explore ways of giving diverse meanings to therapy.
The history and cultural matrix of diagnosis, beginning with The Social Matrix of Psychiatry (Ruesch and Bateson 1968) through to Michel Foucault’s History of Madness (Foucault 1988) and Ian Hacking (Hacking 1998) who has reconstructed the psychiatric perspective of clinical phenomena such as autism (Barbetta and Valtellina 2015) and memory disorder (Barbetta et al. 2014), with the disappearance, in just a few years, of diagnostic categories such as multiple personality or Asperger syndrome.
Gilles Deleuze and Felix Guattari (Deleuze and Guattari 1987), who shed light on a new way of envisaging schizophrenia when, in A Thousand Plateaus, they quote Gregory Bateson’s statement concerning the Balinese approach to raising children: “Gregory Bateson uses the word ‘Plateau’ to designate something very special: a continuous self-vibrating region of intensity whose development avoids any orientation toward a culmination point or external end.”
The notion of considering, as “subject,” a system of relationships involving not just humans, but even other animate or inanimate entities. Everything as a meaningful part of a system of meanings that comprise the subject.
Clinics and Research
From the clinical point of view, the Milan Approach has radically changed its way of using neutrality: we take a position. For several years now, we have involved ourselves in qualitative research, such as conversational analysis (Fele 2007), ethnography of communication (Hymes 1996), indefinite triangulation (Cicourel and Knorr Cetina 2014), and discourse practices of institutions (Bartesaghi 2009a, b).
We consider psychotherapy a psychosocial science, dealing with migration, refugees, and multiple languages. We are also dealing with issues of gender and multiple family approaches to living.
One of the major issues in Europe is violence in the street and within the family, including issues of child abuse, battered women, family violence, and bullying. However, we are also facing increasing episodes of children violently beating parents and dropping out of school, this often resulting in retirement from the social world and psychiatric hospitalization. These latter are, in our view, the new challenges of the so-called postmodern era.
Systemic family therapy, group therapy, and individual therapy are ways of preventing such disruptive outcomes, using circular and reflexive questioning, sharing hypotheses as to what may be going on in a family or in the multiple mind of violent groups. Our challenge is the social analysis of collective subjects.
We think that present capitalist ideology, as an authoritarian principle, tends to dominate the social sciences and, more generally, society. Systemic analysis believes such ideology to form part of the reproductive process of violence and destructivity.
From the top down, institutions are driving the mental health system toward a return of behaviorism, as has been codified in the Soviet Union by Pavlov, and “technologized” in European and US armies, a way of shaping obedient people. From the bottom up, this practice results in domestic violence, bullying, and an escalation in revived fundamentalisms.
From the outset, the Milan Approach has fostered antiauthoritarian and anti-oppressive practices. We believe our job is to welcome people, and to trust them, although this can be increasingly difficult inside the European context.
The key thing in clinical training is to be exposed directly to clinical work. The Milan Approach does not train therapists through abstract theories. This does not mean that we are unacquainted with the various theories; we (adopting Bateson’s or Deleuze’s position) are dissatisfied with them. There is a constitutive gap between any particular theory and clinical praxis.
In our training we try to teach therapists how to embed any cultural instance within clinical work. There is no specific meaning to framing families within any oedipical picture, family play, standard plot, Gestalt, polarity, or similar. It is more interesting to know whether we are dealing with the Mad Hatter, or some mad tea party, the Queen of Hearts, the Man without Qualities, Raskòlnikov or Antigone, just to abandon this vision throughout the stream of the therapeutic encounters.
For many years, different psychoanalytic schools have underestimated, or denied, the importance of the body in therapy. Some, such as Lacan, even claimed the body was the major obstacle for love, whatever that might mean in his idiosyncratic way of talking. Other therapists exalted the body, reducing all experience to body experience, with a rejection of the talking cure as a therapeutic experience, as if words would not be emitted by the oral cavity. Both are Cartesian experiences, separating the res extensa from the res cogitans.
Following Gregory Bateson, we learned to rediscover the importance of the body in relation (the Gregory-ax-tree system), and then body language, which is endowed with a cultural code. In therapy, taking the body into account is like being caught up in a dance, although such a dance is sui generis. Within this kind of dance, the client is the choreographer. At the same time, therapy is a polyphonic experience (Bakhtin 2010); any therapist, starting out from her/his own experience, can pick up – from the ongoing encounter during the session – sounds, words, facial expressions, body pose, smiles, humor, lapses, screams, or any relationship between glimpses of these, for use in clinical interaction.
A young asylum seeker contacts our systemic ethno-clinical group. For years, there has been a fierce dictatorship in his country, in Africa, with rebels fighting a guerrilla war. Part of the territory is rebel controlled. He works as a lorry/truck driver and, 1 day, receives instructions to carry goods into rebel territory. Having crossed the border, he is stopped, beaten, and tortured. Believed to be dead, he is abandoned in the forest. He awakens at dawn to find a hunter beside him. The hunter returns him to his home, where he is taken to hospital and recovers. It would seem he had died. The hunter had resuscitated him. He adds that his father had formerly been a hunter, having turned to farming when he was no longer able to support his numerous children through hunting.
Having lost his job as a lorry/truck driver, he returns to rebel territory, this time to seek work. He is taken on as a lorry/truck driver, taught to shoot, and remains with them for approximately 10 years. During that period, having become a rebel, the army hunts him. One morning, soldiers enter his house to kill him. They fire at his bed, but he is not there. At this point, he escapes to Europe.
Ben (not his real name) has a European tongue as his first language, but also speaks the mother tongue of his people, this being a language without a written form. Ben does not know how to write. On the basis of his intelligence and intuitive abilities, and his way of speaking the European language, we understand that Ben is an oralist, not an illiterate. He has been here for only a few weeks and has requested ethno-clinical help because he experiences pain all over his body and is weighed down by melancholy.
During the first of our meetings, a woman belonging to the ethno-clinical group – who had lived in Africa for several years, working with traditional healers – tells him that hunters have powers of invisibility. It is a question of how two subjects encounter each other, hunter and prey. A way of each making itself invisible to the other. Ben appears to be puzzled. He had always believed these to be two instances of luck. He then states that he had in fact been thinking like a soldier.
During the second meeting, Ben talks about invisibility. He is uncertain whether it is true that he has powers of invisibility, but he admits his father had not shifted from hunting to agriculture through economic necessity; his father had been unwilling to involve his children in the brotherhood of hunters, which possesses occult powers and is inhabited by jin.
A second version of his father’s story arises: the price paid by his father to protect his children is the brotherhood’s curse. Nobody can leave without giving something in exchange.
The hunter who had saved his life could be the reincarnation of his father, who transferred the gift of invisibility to him. He believes it is important to speak of the unconscious. I say: “We don’t know what we know, and perhaps it’s better like that. If we knew what we know, then we would put ourselves at risk.”
Remembering that all his family is dead, at this point Ben wonders what God wants from him for having saved him: “I think that God wants Ben to remember,” I say.
The motif of this section is that Ben is an oralist. His mother tongue, the one that counts here, is the language of his people and has no written form. Even if he were to learn to write in the European language used during the meetings, it would not be the same thing. Ben remembers his dead by sacrificing a cow, but, in Europe, this cannot be done. The third meeting is held in the kitchen of the ethno-clinical center. Ben brings meat that has been slaughtered according to tradition, and we eat together, remembering Africa and his childhood. Thus we shall proceed to other meetings.
As a Temporary Conclusion
During its 50 years of existence, the Centro Milanese di Terapia della Famiglia has bridged many “disjunctive syntheses” and has welcomed different ideas and clinical practices, always with an ethical eye on nonauthoritarian and anti-oppressive issues.
Well-burrowed, old mole!
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