Philadelphia Child Guidance Clinic
The Philadelphia Child Guidance Clinic (PCGC) was founded in 1926, the third clinic devoted to care of children, following IJR in Chicago, in 1909, and the Judge Baker Guidance Clinic in Boston. PCGC was initially psychoanalytically oriented, and as late as 1967, there were still couches in all the offices!
The Child Guidance Clinic was located in South Philadelphia next door to Children’s Hospital of Philadelphia (CHOP), both moved to a fancy new building in the University of Pennsylvania Medical complex in 1974. The 7 years between Minuchin’s arrival in Philadelphia and the Clinic’s move to its new location were the most fruitful in developing the theories, practice, and research of Structural Family Therapy. The next 7 years after the move allowed for some elaboration, but more importantly were the years of disseminating these ideas and practices through practica, workshops, and internships.
The major figures at the clinic during the Minuchin era were Salvador Minuchin, himself, Jay Haley, Braulio Montalvo, and Bernice Rosman. But the activity at the Clinic attracted many others: prominent visitors and presenters included: Nathan Ackerman, Virginia Satir, Carl Whittaker, and Murray Bowen, while Peggy Papp visited regularly for several years, Rachel Hare-Mustin worked at the clinic before branching off on her own, and Lynne Hoffman, too, seemed to be honing her skills there before branching off. For some time, Chloe Madanes and Marianne Walters were associated with an important program to support indigenous workers in the community; Harry Aponte worked with the clinic school connection and eventually became Director of the Clinic; Avner Barcai, visiting from Israel, spent a year working with Minuchin on the psychosomatic work; Lester Baker, a pediatrician from CHOP, collaborated in the psychosomatic work.
The Philadelphia Child Guidance Clinic became the site of the significant development of probably the most comprehensible system of Family Therapy – Structural Family Therapy, which was a visible, mappable, and understandable system, even though it is not systematic, in the sense that there are discrete steps to follow. Essentially, the model articulated the significant concepts of Joining and Enactment, and a framework that described “boundaries” between individuals, the recognition of subsystems in families, and the differentiation of subsystems according to hierarchies. Although these concepts underlie the practice of Structural Family Therapy, there were no rigid rules of process.
There were a number of observation rooms and one-way mirrors in the old clinic on Bainbridge Street in South Philadelphia. When the Clinic moved, in 1974 to the brand new building, there were many more. Supervision and training occurred with observation and the opportunity to review video tapes. The underlying concept of family work, which is working with what you can see rather than what you guess about what is going on in people’s heads, was embodied in the teaching and supervision. The work was about what one could see. And the supervision and teaching furthered this kind of engagement and participation with what was happening. In live supervision, it was common for the supervisor to call in to the therapist or even ask to speak with a family member. It was also common for the supervisor to actually join the session for an intervention. And it was also common to invite a family member or two to join the group behind the mirror to observe what was going on. Observing was the source of understanding, then offering an intervention and observing the response, these were the hallmarks of family therapy as developed, practiced, and taught at the Philadelphia Child Guidance Clinic under the direction of Salvador Minuchin.
History of PCGC
The arrival of Salvador Minuchin in (1967) fresh from his experience at the Wiltwyck School for Boys and the publication of Families of the Slums ushered in the era of family Therapy at PCGC. Minuchin brought his colleagues and co-authors with him – Braulio Montalvo and Bernice Rosman. Montalvo studied Minuchin’s work on video tape, and through this, identified interventions which became the foundations of Structural Family Therapy. In the early days, he would go over a tape and say to Minuchin, “did you see what you did there?” And in one famous instance Minuchin placed a standing ashtray between an anxious man and his wife, and Montalvo froze that moment as a concrete illustration of a structural intervention. This became identified as a “boundary.” Boundaries are basic to Structural Family Therapy. In another famous tape Minuchin made a boundary in the family of a girl with eating peculiarities, by turning her chair to face him, bringing his closer to her, and leaving her parents farther away. The tape was called, “Between you and me” meaning between the child and Minuchin, thus helping the girl to disembroil herself from her attention-gathering mother.
When I first arrived at PCGC, several programs were in place. There was an intervention in a local school, and there was an anthropological study of the relatively poor, mostly Black, community/neighborhood around the Clinic’s South Philadelphia location. These programs were in tune with the heyday of the Community Mental Health Movement and provided experience and background for a program for training community based “indigenous” family therapists who were HS graduates. Led by Gerald Ford, the trainers, all of whom are important figures in family therapy, were Jay Haley, who had come from CA to be with Minuchin, Chloe Madanes, who married Jay Haley, and subsequently moved with him to Washington, D.C. to found a center for Strategic Family Therapy, Harry Aponte, and Maryanne Walters.
With an emerging language and associated practice of Structural Family Therapy, Minuchin began his famous research on “Psychosomatic Families.” As the Clinic was next door to the Children’s hospital of Philadelphia (CHOP), there was the opportunity to collaborate closely with the pediatricians around children quite sick with diabetes, asthma, and anorexia. To elaborate models that proposed dysfunctional parent child triads, there were interviews featuring getting parents to disagree while being observed by their child, then bringing the child into the room, and see what happened. Though the research claims have been challenged by others looking at data, those who observed through the one-way mirror never had a doubt that when a diabetic child watched her parents arguing, all three having continuous measurements of free fatty acids showed increases. But when the child went into the room with her parents, their FFAs dropped while hers continued to rise, so much that she needed to be taken to CHOP because of ketoacidosis. And the physiological changes mirrored the interactional changes – that is, the parents stopped arguing/fighting and focused on the child, illustrating one of the hypothetical triads – the Detouring Protective Triad that seemed to be common in psychosomatic families. Though the physiological parameters of this relationship pattern were not easily identified in asthma or anorexia, the interpersonal patterns were the same.
Minuchin’s work was in collaboration with a visiting child psychiatrist from Israel, Avner Barcai, and, of course, continued to use the research skills of Bernice Rosman.
Through this time there were visits from distinguished family therapists: Nathan Ackerman, Virginia Satir, Carl Whittaker, Don Block, Murray Bowen, Olga Silverstein, and Betty Carter, and a more regular presence of Peggy Papp. There were workshops and practica and conferences. It was a center where people came to study and learn. Several, such as Celia Falicov, studied and then moved on to be influential in Chicago and then San Diego. Fred Gottlieb, a Child Psychiatrist, studied and took family models to the Child Psychiatry Department at UCLA.
Kalman Flomenhaft came to develop the Teachers of Family Therapy program where folks with home base at PCGC would go to CMHCs around Pennsylvania and teach family therapy practice.
In 1975, PCGC moved into a new building which had been built cheek by jowl with the new CHOP and both located on the campus of the University of Pennsylvania Medical School. The new PCGC now had an inpatient unit, a large space with classrooms for a “school,” and another space for a therapeutic preschool. Both Minuchin and Haley were concerned about what an inpatient unit might do to the PCGC identity, both concerned about the conflict between the medical model represented by hospital, and the interpersonal, family-oriented model that had been thriving since Minuchin’s arrival in the late 1960s.
Minuchin hired Lee Combrinck-Graham to be the Inpatient Director, and she immediately joined forces with the newly hired Principal of the School, Wayne Higley, and together they reconceived and renamed their programs, now called The Intramural Program with inpatient, and an intensive outpatient program usually preceded and succeeded with outpatient family work. The day program for both inpatients and intensive outpatients was the same in a psychoeducation program designed by Higley. There were observation rooms for each of the classrooms, a space used for parents to observe their children or children to observe their class when they couldn’t be in it, and the educational piece was connected closely with problems presented by the child and family – so that, for example, a behavior disturbance in a young adolescent who couldn’t read was addressed by his working with a reading specialist and learning the delight of reading.
In collaboration with Minuchin, the inpatient unit had been designed with two apartments, each with accommodations for parents and up to two children, with kitchen, bath, etc. They also had observation rooms. The parents could go out to work and take their children to school, while the IP joined the psychoeducational program during the day. But the opportunity to work intensively on daily interaction with the family was remarkably effective.
The other requirement for the Intramural Program as designed by Combrinck-Graham and Higley, and later joined by Arlene Kelly, who became director of Child Life, was the expected continuity of treatment from outpatient to inpatient. The family’s outpatient clinician was expected to work with the family while they were engaged in these more intensive levels of care – but this became impractical, because families came from all over the area. Then there were designated admissions clinicians who would go to where the children and families were, to evaluate and help plan the admission.
With evolving regulations, the flow of children from inpatient to intensive outpatient in the same program was complicated by their having to be discharged from one and admitted to the other, even though it was the same staff and treatment plan, and the regulations surrounding apartments – who were the patients, how would it be paid for, continued to plague the program and finally ended it.
While PCGC was struggling with its identity as now a child psychiatric hospital with a basic family systems orientation, with the new outpatient facility there were many therapy rooms with observation rooms and opportunities for teaching and learning and research.
The heyday of the clinic as a center of family therapy waned in the context of the tension between PCGC and the Regional Council of Child Psychiatry, as the Council questioned whether PCGC was doing child psychiatry and qualified to have a program to train fellows in child psychiatry. This tension was characterized in a famous paper “The Undeclared War between Family Therapy and Child Psychiatry.” by John McDermott and Walter Char, neither of whom had ever been to PCGC, but who worried in an important publication about the compatibility. As things developed, there was tension within PCGC between the child psychiatry training director, Charles Malone, who had come from Boston to the clinic to work with Minuchin. And as tensions grew, Minuchin tired of University politics, withdrew as Director of the Division of Child Psychiatry at the U of P, and gave the job to Malone. Malone then exercised the university backed power to try to take over the Clinic, and when this didn’t work he left, even before the move to the new building. An NIMH site visit of the child psychiatry program ended with Minuchin hiring a rather traditional “Professor” of Child Psychiatry, Marshall Schechter, and then Minuchin left Philadelphia and went to NYC. Harry Aponte became Director of the Clinic, furthering the programs with the indigenous family therapists in the community, and focusing on school consultations.
When Aponte left the Clinic, Ronald Liebman, once a protégé of Minuchin’s, became Director. Lee Combrinck-Graham left to run the MFT program at Hahnemann University. And gradually the Clinic became more closely involved with CHOP so that eventually it was taken over by CHOP and ceased to exist as a separate entity.
The Philadelphia Child Guidance Clinic has had a long and distinguished place in the world of family therapy and child psychiatry. The work conducted there by Minuchin and his colleagues has been highly instrumental in establishing family therapy as a viable treatment for children. The most recognized and perhaps most important model of family therapy, Structural Family Therapy, was developed and disseminated at PCGC. Various training programs, influential training tapes, and important books and articles were written at PCGC. Minuchin’s books are among the most widely read and recognized in the field of family therapy. Scores of professionals were trained in the post graduate program. They all left and spread the word about Structural Family Therapy. Many of them, themselves, became prominent in the field. For example, Multidimensional Family Therapy, developed by Howard Liddle, has roots in Structural Family Therapy. Minuchin, himself, towered over the field of family therapy and served as a vocal and influential leader. There can be little doubt that the field of family therapy would not have advanced as it did without the existence of The Philadelphia Child Guidance Clinic.
- McDermott, J. F., & Char, W. (1974) The Undeclared War Between Child and Family Therapy. JAACP, 13(3), 422–436.Google Scholar
- Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.Google Scholar
- Minuchin, S., Montalvo, B., Guerney, B. G., Jr., Rosman, B. L., & Schumer, B. (1967). Families of the slums: An exploration of their structure and treatment. New York: Basic Books.Google Scholar