Psychological approaches II: beyond the individual couple, family, and group work

Question 1

What engaged the development of systemic approaches?

What are the origins of structural (systemic) family therapy?

Answer 1

> Satisfaction with individual therapies

> Systemic family therapy was developed in mid-1950s from system theory and cybernetic theories on communication in complex systems

=> Argument: problems and “pathology” fundamentally interpersonal as opposed to individual

Question 2

What was the argument of cybernetics?

Answer 2

Causation is best understood as a circular continuous process that relies on feedback mechanisms

E.g.
Person becomes anxious and depressed -> partner becomes worried -> children notice adult’s distress -> children become disruptive or upset -> friction between adults -> anxiety and depression…

Question 3

Who are the pioneers of systemic therapy?

What is their school called and what did they start?

Answer 3

The Palo Alto Mental Research Institute (California)

• Bateson
• Jackson
• Weakland
• Haley
• > shared interest in the nature of the communication process

> Collaborated at the Palo Alto Mental Research Institute (MRI)
- applied anthropological observation + social system theory to families of individuals with schizophrenia

Question 4

What are the three systemic approaches?

Answer 4

1. The Palo Alto Group
2. Double-bind theory (1965)
3. Theodore Lidz

Question 5

What did the Palo Alto Group propose?

Answer 5

> Symptoms of schizophrenia function to maintain homeostatic balance in families
- they are the result of interactions amongst family members

> All behaviour is communication

> Communication happens at surface (content) level AND the meta-communication (intent) level (extra-meaning)

=> Contradictions between communication levels lead to confusion (“double-bind” communication)
- e.g. exasperated parent saying “do what you want” with a frowned look and crossed arms

Question 6

What does the Double-bind theory (1965) propose?

Answer 6

> Double-bind communication = paradoxical communication in which contradictory and logically-inconsistent messages are communicated

> Double-bind communication is used to describe how schizophrenia can be explained in context of families

> Once the receiver perceived the world in contradictory messages, he is confused
Trying to make sense of contradictory messages leads to schizophrenic symptoms

Question 7

What did Theodore Lidz (1910-2001) propose?

Answer 7

> Investigation of family dynamics in schizophrenia
-> large number of individuals with schizophrenia reported unhealthy relationships with their families, particularly with their fathers

> Fathers have a profound influence on the development of schizophrenic symptoms in their children

=> Attention shifting to the role of the familial nucleus in the development and maintenance of psychological distress

Question 8

What are the tenets (principles) of systemic therapy?

Answer 8

> Microsystem (home, immediate family, school) ; Mesosystem, Exosystem and Macrosystem (widely shared cultural values, beliefs, customs, and laws) all interact with the individual
-> individuals exist in relation to significant others and social networks

> Systemic therapists argue that:
- difficulties need to be explored in context of individual’s social environment
- psychotherapy should be seen as a way to help people strengthen their relationships - making disturbing symptoms less necessary or problematic
(not seen as a cure to mental illness)

Question 9

What is the cultural background to systemic therapy?

Answer 9

> Social constructionist and postmodernist beliefs:

• reality is socially constructed by individuals in dialectical interactions
• meanings and connotations attached to objects/concepts are the result of socially-agreed conventions

> The same behaviour can have different meaning across societies and time

> Subjectivity can be investigated by studying language and communication
Regulations and interactions are negotiated and change through verbal and non-verbal communication

Question 10

In systemic social theory, what characterised the family?

Answer 10

Family = “maker of meaning”

• communication/storytelling within families organise experiences and shape lives
• families can be dependent on these collective recollections as they are passed down from generations, limiting perceived options
• these stories are not objective accounts of reality, nut beliefs and ideas created through language and interactions

Question 11

What is the argument of structural (systemic) family therapy (SFT)?

Answer 11

> It doesn’t matter where/what started the problem, what matters is all units of the system are interconnected
-> change in one sphere precipitates change in another sphere

> Systemic family therapists reject linear cause-and-effect as potentially carrying blame
Efforts to identify reciprocal influences / interconnectedness

> Researchers concentrate on larger family units
Family is viewed as a system or an interacting unit, with its own characteristics and rules

> Addressing symptoms and the interpersonal helped to liberate individuals from oppressive and pathologising cultures

=> This approach was revolutionary, in direct contrast to psychotherapeutic approaches which focus on the individual and assume an intrapsychic model of mental distress

Question 12

What is the goal of structural (systemic) family therapy (SFT)?

Answer 12

Developed as a psychotherapeutic endeavour explicitly focused on:

• Altering interactions between family members
• Improve the functioning of the family as a unit

=> the locus of the problem is between people rather than within the individual

Question 13

What is the evolution of systemic family therapy (SFT) as characterised by Dallos and Draper in ‘An introduction to family therapy’ (2010)?

Answer 13

1. First order SFT:
   - mid 1950s to mid 1970s
   - modernist: attempted to take empirical approach to psychology (as scientific)
   - structural and strategic family therapies
   - attempt to classify families according to number of variables
2. Second order SFT:
   - it became evident that such “objective” descriptions were inaccurate as different observers viewed the families’ problems in different ways
   - shift in SFT, and more broadly in psychology and the social sciences -> postmodern view
   - e.g. the Milan School
3. Third order SFT:
   - emerged from social constructivist theory
   - emphasised the role of language in shaping meaning
4. Fourth order SFT
   - proposed by Dallos an Draper
   - concerned with the integration of SFT and of the intrapsychic and the interpersonal

Question 14

What did the Structural Family Therapy (SFT) consist of in the first order?

Answer 14

> Hierarchical structure of families

> Emphasised boundaries and structure (who’s in charge, how are decisions made)

> Decision-making processes and boundaries are crucial to healthy functioning of the family

> The family is a system that operates through transactional patterns, which regulate behaviours

> Individuals within a family are part of subsystems

• each belongs to multiple subsystems simultaneously
• > determines individuals’ power

Question 15

In Structural (systemic) Family Therapy (SFT), what are boundaries?

Answer 15

> Used to protect the differentiation of the systems
Should be clear yet permeable to allow balance between autonomy and interdependencies

> Patterns of enmeshment or detachment were deemed incapacitating of family structure

> Problems result from developmental and environmental challenges that may lead to conflict avoidance through either disengagement or enmeshment

• > Boundaries become too porous, too enmeshed, too rigid, too disengaged
• > System’s failure to realign
• > Power imbalances

=> Systemic family therapists try to determine how close are family members, how flexible are the rules

• subsystem negotiation,
• dynamics between family clusters - who aligns who, who gets left out?

Question 16

What is the process involved in Structural (systemic) Family Therapy (SFT)?
(therapist’s view)

Answer 16

Process of assessment, mapping and altering the family structure through

• escalating stress,
• creating crisis,
• enacting and balancing

Question 17

What does Strategic family therapy (first order) consist of?
Who was one of the main proponents of this therapy and what did he/she propose?
What is the functionalist view point, core of this approach?

Answer 17

> Similar to SFT but emphasises interactional dynamics and power struggles
- resulting from a family’s need to change and reorganise at transitional stages

> Haley (1923-2007) (first order cybernetic):
- difficulties in families arise when there are incongruent and confused hierarchies
- symptomatic members get triangulated in cross-generational interactions that reinforce and contribute to the confusing hierarchies
- Functionalist view point: dysfunctional families need symptomatic behaviour as a stabilising device in order to relieve stress
<=> symptoms preserve stability

Question 18

In Strategic Family Therapy, what are conflict detouring and incongruous hierarchy?

Answer 18

> Conflict detouring:
- identified patient becomes essential to maintaining family stability and for other members of the system to avoid confronting their own problems

> Incongruous hierarchy:

• strategic family therapists recognise the possibility that the patient uses the symptom as a strategy to control other family members
• can be used for love, protection, or domination

e.g. Parents might lose their superior position in response to the helplessness of a symptomatic child, who gains power and control

Question 19

What is the position and the focus of strategic family therapists?

Answer 19

> Therapists view the problems as attempted solutions

> Focus on development strategies that can change need for the symptom and help balance power

> Therapists become experts and focus on the hierarchy and power struggles through directive and paradoxical tasks
- while emphasising family structure

Question 20

How was the Milan School (second order SFT) developed?

Answer 20

> 1970s: some criticised previous approaches as too mechanical and emphasised importance of exploration of meanings, beliefs and family stories

> Milan followers (second order cybernetics) argued it’s crucial to study communication

=> It’s through communication that family relationships are defined

Question 21

What does the Milan School model consist of?

Answer 21

> Prejudices and beliefs are located within the communicating systems

> Importance of values, background, attitudes and culture in the creation and negotiation of meaning

> Family is the maker of meaning
- tell stories which organise their experiences

> Milan School = second order cybernetics

• challenged first order cybernetics which have a functionalist view (symptoms preserve stability)
• > functional view only exists in the eye of the observer

Question 22

What characterised the Milan Group?

Answer 22

> they did not regard clients as phenomena in reality, but as a therapeutic system consisting of the family and therapists

> used therapeutic encounters to create new meanings
-> new patterns of thought and behaviour

> focused on overcoming the “tyranny of linguistics”, which according to them keeps therapists and clients thinking in a intrapsychic linear manner

> sought to create a different language allowing them to understand families in different ways

• and allowing families to find new language open to difference and alternative meanings
• > reframe difficulties and move them from individual to relational level

> Rationale: free the family and therapeutic system from entrenched meanings that lead to systems becoming stuck

> Mental phenomena = social phenomena
- ‘mental health problem’ = problem in social interaction

> Therapies should be directed at patterns and interactions (not at individual intrapsychic dynamics)

> Problems needed to be reframed in social terms (rather than rooted in individuals)

Question 23

Why can the Milan School be regarded as the most systemic family therapy?
What is the Greek Chorus?

Answer 23

> To maximise the systemic approach, associates work interactively in teams behind a one-way mirror

= the Greek Chorus

• offers inputs whose aims are to support, confuse, challenge and confront the family
• while remaining at a distance -> retaining an objective stance

Question 24

Why can it be argued that all family therapies are systemic?

Answer 24

> They consider the person in a larger context of which she is simultaneously a part, yet distinct
They view the symptom of an individual member as rooted int eh family as a whole

Question 25

What are the key ideas of the third phase of systemic family therapy (SFT)?

Answer 25

> Problems are shaped by culture and language, which defines power
-> a move towards social constructions theory

> Some (e.g. White and Epsom) argue this is the end of family therapy

> Understanding of identity, gender etc. shaped by social discourses and ideologies
- Social constructionists: meanings are constructed in interactions shaped by language

> Pathology is inevitable because it actually reflects the pathology of society
Families are seen as mirrors of society, reproducing rather than creating these difficulties

> Problems viewed as stretched across social context, emphasis on the power of language
- e.g. doctors, scientists, politicians may use jargon to keep power and boost status

> Our own inner dialogue is constructed of verbal dialogues and images from our culture
-> language becomes strategic and used to initiate change

> Anderson and Goolishian: problem is not in family dynamics or structure, but in the way discussions become saturated
- discussions lock families into becoming stuck in one way of seeing their actions and experiences

=> Part of the therapist’s goal is to enable families to construct ALTERNATIVE NARRATIVES

Question 26

What does Narrative therapy (third phase SFT) consist of?

Answer 26

> Looking at issues not only from an individual or family perspective, but from a community perspective

> Argument: Dominant psychobiological paradigm locates problems within individuals and ends up leaving individuals feeling helpless and unable to challenge or address problematic experiences

> Narrative approach explores and encourages multiple perspectives of a situation

> Often associated with issues such as stigma, gender, sexuality, or racism

Question 27

What does the narrative approach focus?

Why can it be problematic for people?

Answer 27

> Narrative approach focuses on overarching framework
- may be problematic because people can end up feeling little room too for agency

> If people identify with narratives that are saturated, their attention will focus and be skewed towards noticing information that reinforces their view

> The problem is not the problem itself, but the identification of the individual with a problem-saturated narrative

Question 28

What is the first step in narrative therapy?
What is the aim, why so, how?
What is crucial?
What is the desired outcome?

Answer 28

Explore the dominant story the person has about their life and problems

> Aim: develop a map of problematic descriptions without accepting it’s the client’s fault or the only study he/she has

• when stressed we face problems and struggle to see different perspectives
• often we don’t notice the exceptions where problems are less overwhelming because the problem-saturated description minimises differences

> How: begin to notice and have questions for the client about exceptions
- with conversation, enable the client to develop a different understanding of these exceptions

> Crucial: pay attention to the client’s experiences because of the danger they feel invalidated

> Outcome: through exploration of instances where the person challenged the problem, the individual may develop a sense of agency, which eventually allows them to feel and behave differently

=> Enable the client to reframe the problem from a linguistic point of view and use language as a vehicle of change

Question 29

What is the externalisation technique in narrative therapy?

Who brought this technique in narrative therapy?

Answer 29

Michael White
> Having a problem rather than being the problem
- “The person is not the problem, the problem is the problem”
- e.g. presenting with depression rather than “being depressed”

> People are encouraged to resist the problem by seeing it as external (“unwelcome visitor”)

> Both individuals and family members are encouraged and positively challenged to consider ways they can work together and resist the problem

Question 30

What does Attachment narrative therapy (ANT) consist of?

Answer 30

> Combines attachment, narrative, and systemic theories and techniques
- systemic principles + attachment dynamics, explored through family member narratives

> Example of eating disorders
- model: difficulties originate in an insecure attachment style (this idea is supported by research)
Explore:
- dysfunctional family dynamics
- disturbances in relationship between child and primary caregiver
- failure to develop autonomy from a parental figure
- boundaries and enmeshed boundaries
- nature of narratives in individuals and their family

Question 31

In attachment narrative therapy (ANT), what would a therapist observe?

Answer 31

> Difficulties discussing or expressing emotional states

> Lack of coherence in narratives (typical of insecure attachment styles)

> Difficulty adopting alternative narratives or difficulties considering the possibility others may see things differently

=> ANT therapists combines all of these in this newer approach