Working Systemically with Families

Formulation, Intervention and Evaluation

Rudi Dallos, Arlene Vetere

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429924248
• Edition: 1
• Topic: Psychology
• Subtopic: Psychoanalysis
• Index: Psychology

Systemic theory offers a valuable framework for integrating the diverse ideas found throughout the mental health arena in both theory and clinical practice. With this accessible book, the authors take you on an enjoyable and coherent journey through systemic theory. They then review the body of research into family therapy and conclude with a critical review of major recent developments in theory and application. At the end of several chapters are reflexive notes containing exercises that relate to the ideas and processes found within the chapter to further develop the reader's understanding. The conclusion draws together the ideas found throughout the book, with particular emphasis on the interlocking triangle of formulation, intervention and evaluation and how this will impact on systemic practice in the future. While this book will be an invaluable introduction to family systems theory and practice for clinical psychology training courses, plugging a gap that the authors have identified as one of their motives for writing it, its remit runs much wider. It will prove an essential companion for any professional working in the public services, whether systemically trained or not.

Chapter One
What is family therapy and systemic practice?

From the intra-psychic to the trans-personal

The central organizing thesis of the systemic paradigm is the focus on interpersonal relationships and the move to thinking about relationships as the cradle and web of human experience and development. For us, the excitement of this paradigm shift lies in understanding and explaining individual experiences in relational terms and in understanding individual processes in the context of emotionally significant relationships. Thus, individual distress can no longer be seen only as the product of the individual’s psychology, but rather as a complex iterative process that is understood in terms of relational dynamics at many levels of contextual understanding. Applied psychologists’ preference for (ongoing) formulation maps well on to systemic thinking, so that the particular circumstances of the people seeking our help will dictate how much relative importance is attached to individual, relational, group, cultural, and societal levels of explanation. Making the connections between these levels of explanation and their relationship over time, connecting past to present to future, is the powerful contribution that systemic thinking can make to psychotherapy formulation and ensuing practice. Thus, when we use the term “systemic”, we are using it in the wider sense of its meaning as rooted in developments in family systems theories (Dallos & Urry, 1999; Vetere & Gale, 1987), rather than in the narrower definition adopted by practitioners of a particular approach in family therapy, based on the developments in the Milan school of family systemic psychotherapy (e.g., Campbell, 1999).

Clinical practice

This shift to relational thinking has given rise to two powerful developments within the clinical professional field: (a) practice as a qualified family therapist; (b) and/or systemic practice while qualified in another mental health discipline. Both choices are open to mental health professionals who work with individuals, couples, family and extended kin groups, professional teams, agencies, and networks. The systemic paradigm has given rise to a body of well-researched theories and techniques that are helpful to us when offering direct therapy, consultation, training to others and, in our team, working and networking across inter-agency relationships (Boscolo & Bertrando, 1996; Campbell, 1995; Carr, 1997). In this book, we shall consider both professional paths interchangeably when looking at the contribution systemic thinking and practice has made and can make to clinical psychology and the practice of psychotherapy.

Although family therapy had its roots in thinking and working with families, the systemic tradition evolved rapidly as the ideas were seen to have application across a number of different human groupings or systems where the interest lay in thinking about connection and relationships. So, applications with work groups, such as multi-disciplinary teams in major public agencies (Reder, 1986), residential homes (Dimmock & Dungworth, 1985), the educational sector (Dowling & Osborne, 1994), project teams in commerce and industry, management practice (Campbell et al., 1991), inter-agency relationships and working with complex systems (Hardwick, 1991), all led to creative and innovative applications beyond the emotional connections of family relationships. Arguably, this drove the change of description from family therapy to systemic psychotherapy and systemic practice to reflect the diversity, evolution, and range of application of these ideas. In this book, we shall not attempt to try and capture the full flavour of the field as it is today, but rather to concentrate on those developments, ideas, and practices that will be most helpful to applied psychologists, psychotherapists, and mental health practitioners in their day to day practice.

Enduring ideas in systemic family therapy: a conceptual map of the evolution of ideas

Psychology, including clinical psychology, has arguably been fundamentally concerned with the individual and intra-psychic states. This has included the study of cognitive as well as emotional states. Underlying this has been the view that people can be regarded in terms of a relatively stable self, for example, a personality composed of enduring behavioural, cognitive and emotional characteristics. In contrast, one of the most enduring ideas of Systemic Theory is that individual experience, including problems and pathology, is fundamentally interpersonal rather than individual. Philosophically we might question how it is possible to both have individual experience and to say it is not personal and individual but interpersonal. We might suggest a partial answer to this by pointing to the young infant without language who appears to be inextricably connected to, and synchronized to his mother’s behaviours and states (Schaffer, 1977; Stern, 1985). Rather than being an immutable fundamental we might argue that the notion of an individual identity and self is learned or socially constructed (Berger & Luckman, 1973; Gergen, 1985). To quote one of our colleagues, babies are born systemic. Arguably, even in our most private moments, for example, when engaged in writing, thoughts ricochet from thinking about the content of what we are trying to write to the potential reactions of the reader.

Though the enduring paradigm shift offered by systemic theory has been the move from an intra- to an interpersonal view of problems and difficulties, there has also been a rich variety of developments and elaborations of this paradigm. These evolutions in many ways parallel some of the changes that have also occurred in mainstream psychology. We want briefly to offer a conceptual map of the developments of family therapy and draw out some of these parallels before we go on to outline some of the core ideas. As a caution we quote the famous phrase much used in family therapy that the map is not the territory (Korzybski, 1942). By this we mean that we are not making a claim that this map objectively represents the reality of the developments but rather that it may capture some of the essence of the changes that have occurred.

Broadly, we suggest that systemic family therapy has progressed through three phases.

Phase 1: systems theory and functional analysis

In many ways the first phase of family therapy can be seen as sharing some perspectives with theory and practice in other types of clinical work. The guiding metaphor of a family as a system, though representing some fundamental changes in thinking of problems as interpersonal versus intra-personal, nevertheless can be seen as containing some of the dominant contemporary ideas. For example, a central idea was that a symptom displayed by one member of a family was serving a “function”, such as a family which might otherwise disintegrate into separations or divorce, so that it is able to assist and care for the person. This idea is shared by behavioural approaches and psychodynamic therapies. In addition, families were conceptualized in terms of behavioural sequences and patterns and in emphasizing the function of a symptom in maintaining the stability of a family system. Significantly, therapy involved a belief that family systems could be accurately described in terms of such patterns and structures and the therapist, as an expert, could initiate changes largely outside the family’s awareness. There were differences, too, in that systemic approaches emphasized communication, not just behaviour. In fact, behaviours were seen as a form of communication or exchange of information in families. However, family members’ unconscious responses to each other’s communications were given considerable emphasis, in contrast to their more explicit understandings of their own and each other’s actions.

Types of therapy

• Structural.
• Strategic.
• Brief Therapy.

Focus

• Function of symptoms in the family.

Core concepts

• Circular versus linear causality.
• Dysfunctional patterns and structures.
• Circularities (patterns of behaviour).
• Family structures.
• Power, inequalities and confusions.
• Homeostasis.
• Family rules.
• Communication.

Key therapeutic approaches

• Therapeutic tasks.
• Altering patterns.
• Disrupting circularities.
• Reframing.
• Altering structures.
• Unbalancing.
• Enactment.

Phase 2: constructivism

This represented a move, again in many ways consistent with changes outside systemic family therapy. For example, psychology saw a shift, that came to be known as the cognitive revolution, to a focus on cognition, meaning, and personal beliefs as opposed to the dominance of a behavioural approach. The notion of an observable, objectively known family was questioned in favour of a view of the therapist as only being able, like the family members themselves, to form personal, subjective views. A core metaphor in this phase of family therapy came to be of the person in a kind of “personal biosphere”. This suggested that each person essentially held a unique and personal view of the world. In turn, each family member was seen as unique and possessing a unique view of their family, expectations of each other, and so on. Therapeutically, this phase significantly entailed a move away from the therapist as expert to a more collaborative position. The therapist recognized that he or she might never really understand how members of a family saw things, partly due to the complexity of this task but, most importantly, also because this understanding would itself be coloured by his or her own assumptions and prejudices.

Types of therapy

• Milan.
• Family Construct Psychology.
• Brief Therapy/Solution-focused therapy.

Focus

• Patterns of beliefs in families.
• Levels of meanings.
• Communication.
• Observing systems.
• Hypothesizing.

Core concepts

• Punctuation.
• Reality as subjective.
• Inter-locking beliefs.
• Auto-poiesis.
• Communication.

Key therapeutic approaches

• Reframing.
• Re-storying.
• Co-construction of shared stories.
• Circular questioning.
• Positive connotation.

Phase 3: social constructionism

Again reflecting changes in sociology and psychology, especially social psychology, there was a move towards seeing families and individuals as inextricably linked to the wider cultural contexts, especially through our participation in language. This included a growing recognition of how normative assumptions about family life are embedded in the language of any given culture. It is argued that language contains a legacy of ideas, for example, assumptions relating to gender, race, and class. In some ways this third phase brought back into focus notions of commonality (as in the first phase) of family experience versus the individuality emphasized by the second phase. However, now these were seen to be shaped by the immersion of the family in the wider socio-political and socio-linguistic realities rather than being predominantly internally produced.

Types of therapy

• Feminist.
• Narrative.
• Post-Milan.

Focus

• Role of language in shaping experience and actions.

Core concepts

• Discourses.
• Narratives.
• Conversation.
• Reflection.
• Power (socially constructed).

Key therapeutic approaches

• Re-storying.
• Reflecting processes (teams).
• Externalizing problems.
• Interviewing the internalized other.
• Writing.

It is possible to see in this map close parallels with developments in psychology. The dominance of behavioural models in both clinical and academic psychology gave way in the 1970s to the “cognitive revolution”. In many ways the development of cognitive psychology in academic psychology was mirrored in clinical psychology by the ascent of cognitive therapeutic approaches, not least cognitive behavioural therapy (CBT) (Beck, 1967). Although still arguably dominant, these in turn have been followed by models and practice influenced by the ascent of social constructionism and ideas about mindfulness. Significantly, we have seen the contribution of a critical position inspired by feminist thinking and more broadly by socio-linguistic approaches, such as Foucault’s analysis of the interconnected role of language and power. Of course, these developments have not been discrete but can be seen as gaining ascendancy and influence over particular periods. For example, social constructionist ideas complement the earlier critiques of psychiatry in the anti-psychiatry movement that questioned the relevance and practices of biomedical models and their emphasis on diagnosis and attendant medical interventions.

We will argue in this volume that one of the important contributions to clinical practice is the skill of critical integration of models. Although to a lesser extent than in, for example, clinical psychology, there have also been attempts within the field of family therapy to develop integrated approaches. Importantly, this has included an attempt to reintroduce the person and personal experience as a central feature of systemic family therapy. So, as in clinical psychology, for example, family therapy has moved (first phase) from a focus on pattern and behaviour with little attention given to internal experiences to a primary concern with meaning, internal experience, and subjectivity (second phase). This also contained a shift in emphasis from positivist and nomothetic approaches that were interested in the search for commonalities and general laws to an emphasis on individuality and uniqueness. However, within clinical psychology, CBT, for example, perhaps represented a hybrid that maintained a commitment to a search for general explanations for types of depressive cognitions. In the third phase intra-psychic experience is still central, both in clinical psychology and family therapy, but there is also a recognition of commonalities of experience shaped by the language in any given culture. In return there is recognition of issues of power and inequality and their implications for regimes of practice.

More recently, practitioners have welcomed attempts to look at integrative ways of working which span different models of psychotherapy: Dallos (1991)—personal construct therapy and systemic psychotherapy; Vetere and Henley (2001)—group analytic psychotherapy and systemic psychotherapy; Wachtel and Wachtel—(1986) behaviour therapy and psychodynamic psychotherapy, and psychodynamic and systemic; Byng-Hall (1995)—systemic and attachment theory, and so on. In addition, there has been some rapprochement between models that have in the past defined different territories of thinking and practice, such as the fields of psychoanalysis and systemic psychotherapy (Larner, 2000). Arguably, a systemic framework is ideally suited to help both integrative projects and attempts at rapprochement, based as it is in general system theory (von Bertalanffy, 1968) with its potential to work as meta-theory. As a meta-theory, general system theory provides helpful guidelines and a language within which to make links between different theoretical models (Vetere & Gale, 1987).

The development of critical psychology (Fox & Prilleltensky, 1997) and the post-modern critiques of psychotherapeutic practice provide a stimulating forum within which to review the more recent contributions of systemic thinking and practice (Hayward, 1996; Pilgrim, 2000; Pocock, 1996). Contributions from those practitioners who write about their interest in working with issues of difference, such as cultural differences, gender differences, issues of disability, sexuality, age, and religion, have offered a number of critical perspectives on many “taken for granted” assumptions in all psychotherapy practices (Dallos & Dallos, 1997). In particular, we think the critiques of power relations in society, at all levels of relationship, have been the most demanding and challenging of all our practices (Burck & Speed, 1995). Thus, one of our tasks in this book is to evaluate how well we think the family and systemic psychotherapies have fared under this intense scrutiny.

Observing families

As in several social science fields, many of the fundamental ideas are developed early. Often what seems to follow are elaborations and critiques rather than substantial shifts. Arguably, this is nowhere more true than in systemic family therapy. One of the fundamental ideas was to emphasize the importance of patterns in behaviour, patterns over time, and the rules for behaviour and beliefs that might be said to underpin those patterns. The crux of a systemic analysis lies in the connections postulated between pattern, beh...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• CONTENTS
• FOREWORD
• ABOUT THE AUTHORS
• Introduction and overview
• CHAPTER ONE What is family therapy and systemic practice?
• CHAPTER TWO Enduring and helpful techniques in systemic thinking and practice
• CHAPTER THREE Systemic formulation
• CHAPTER FOUR Integrative practice: research on process and outcomes
• CHAPTER FIVE Integrative practice: developments in theory
• CHAPTER SIX Specific applications: integrative practice—context and method
• CHAPTER SEVEN Integrative practice: thinking in the future
• REFERENCES
• INDEX