Ten Minutes for the Family

Systemic Interventions in Primary Care

Eia Asen, Dave Tomson, Venetia Young, Peter Tomson

• Publisher: Routledge
• Year: 2004
• ISBN:
  9781134416608
• Edition: 1
• Topic: Medicina
• Subtopic: Atención sanitaria

The systematic approach provides a coherent framework for all members of multidisciplinary primary care teams, whatever their individual theraputic orientation Case histories, boxed information and vignettes are used extensively throughout the book to illustrate the techniques and highlight the key points

1
Systemic practice in a changing world

This chapter covers:

• Organising contexts for the team as well as for patients
• Split bodies and minds
• Differences between linear and circular causality
• The changing nature of primary care

We have already explained that each individual is part of, and influenced by, a variety of organising contexts – physical, historical, financial, spiritual, cultural, family and relational. This not only applies to patients but also to the clinicians working in primary care settings. There is the context of the team which is affected by ever-changing political and economic priorities. New – or old – ideologies shape these priorities. Then there are the professional and personal beliefs that we all bring to our workplace. The systemic approach lends itself to helping clinicians and primary care teams to view their beliefs and actions in context. In reality, many primary care teams do not feel that they work very well together. Just like families, they may work better at some times than others, they contain members with quite different ideas about how to proceed. They have often grown in size over the years but may still be using rules that worked better for families of the 1950s!

We would love to explore the richness of each and every one of these contexts – but you are busy and practical people who want to ‘do things’! So we have picked out a few of the cultural and ideological contexts which seem most important to us. By offering systemic perspectives on these ‘organising contexts’ we hope to offer some liberation from ossified ways of working. But first a word about a word – context. This term is much used and means so many different things, depending on the contexts within which it is used! The GP may see a patient in the context of general practice. The 10-minute consultation is a common time context used in general practice. There is also a person context: the individual, the couple, the family. Families – and individuals – exist in ‘living contexts’, whether neighbourhoods, countries or indeed cultures. The word context is derived from a Latin verb meaning ‘weaving together’, thus implying a dynamic phenomenon rather than the static notion the noun conjures up. In the systemic field we look at actions or interactions, at a word or a phrase, in specific contexts, each of which might give these actions or words new meanings. These different contexts are like temporary frames within which we view what people do or say. Generating new frames is an activity many clinicians see as the meat of their work. It is also known as reframing, namely placing the ‘facts’ of the ‘same’ interactions in another frame which also fits them, thereby changing its conceptual and emotional meaning completely (Watzlawick et al. 1974).

Contexts overlap and intermingle. Like threads in shot silk, each one is different and at different times and from different angles they become more or less visible. They weave together to create the backdrop for our everyday practice.

The culture of the individual

In Western culture the supremacy of the individual over the group, the family or the collective has been a fact of intellectual, organisational and cultural life since long before the infamous remark of a recent British Prime Minister that there was no such thing as ‘society’ but only ‘individuals’. Never has this been more evident than in the development of ‘Western’ medicine, whose whole approach is based on an examination of the individual as object of positivist scientific scrutiny. Where the gaze of this science and practice has risen above the intracellular, it has rarely risen beyond the individual. Disease and, by default, illness are seen as being individual matters, located in individuals or their body parts. Consulting behaviours within most health care settings have demonstrated that, despite current rhetoric to the contrary, most patients are still seen alone, even if other family members may also be present. And if illnesses are seen to reside in the individual, they also need to be ‘fixed’ by and in the individual. Individuals are seen as having a specific personality independent of their relationships with others.

Coordinated management of meaning (CMM)

CMM (Pearce and Cronen 1980) views communication and interaction within a hierarchy of contexts. It suggests that communication is a social process of coordinating action and managing structure. Social meanings are hierarchically organised so that one level is the context for the interpretation of others. When looking at families, it is generally possible to distinguish five levels of information exchange. At the ‘lowest’ level we have (1) speech acts, verbal and non-verbal messages such as ‘undermining my self-esteem’, ‘compliment’ or ‘promise’. These turn into (2) episodes when they become reciprocal: ‘Our usual fight about who has a shower first’. A (3) relationship emerges once two or more persons refer to the terms on how they engage: ‘She is the leader, I am the follower’. At a ‘higher’ level there are (4) life scripts, the person’s concept of self: ‘I am a pessimist, but I am also a realist’. At yet a higher level we have (5) family myths or cultural patterns that locate human experience in a broader frame, legitimising ways of acting and knowing. They refer to general conceptions of how society, family relationships and individual roles work.

This theoretical model is useful when attempting to make sense or create meaning out of seemingly inexplicable or contradictory communications and interactions. Social meanings are hierarchically organised so that one level is the context for the interpretation of others. Different levels of context can be organised in such a way that each is equally the context for and within the other, with changes in each level affecting the meaning of the other. If one context is regarded as ‘higher’, then the meaning attributed to a speech act or episode will be ‘framed’ accordingly. For example, if an individual’s highest context is his life script (e.g. ‘pessimist and realist’), then all speech acts, episodes and relationships may be guided by this view. Yet, if the highest context is cultural patterns (e.g. ‘Allah watches over my life’), then the very same speech acts or episodes assume very different meanings. For clinicians it is therefore important to become curious about the highest context in any given communication.

Systemic practice acknowledges both individual and contextual factors. It is particularly interested in the way individuals behave in relation to each other, it assumes that one person’s actions and feelings are connected with those of other persons. Illnesses do not just reside in organs and individuals, they are also relational and contextual. When Mrs S brings her depressed husband to see her GP and he denies that he is feeling low with a smile on his face, she is a contextual thinker when she says: ‘It’s just typical, he’s been absolutely miserable until we came in here – now he’s going to make a liar of me.’

A systemic clinician will want to make connections, without just validating one person’s view at the expense of the other. This can be done by, for example, inviting the husband’s reflections or comments: ‘Mr S, what is it that your wife has seen or experienced at home that makes her bring you here and say that you are “absolutely miserable”?’

Here the clinician is interested in how each person came to form their specific views. Inviting the husband to look at himself through the eyes of his wife is a step to joint exploration of what seems to be a problematic issue. This can be followed by: ‘Are there times when you might be more or less “miserable”, as your wife puts it? What’s your explanation for this?’

And, a bit later the systemic clinician will want to elicit Mrs S’s views about her husband’s views. In this way different and differing views become linked.

Much of what clinicians encounter is linked to multiple contexts – if one wants to find the links. ‘Pauline [Health visitor], my baby just won’t stop crying.’ Which clinician has not examined and then just held a crying baby on a night visit, only to see the baby calm down as it relaxes away from its anxious parent? The child has a temperature and is crying with pain or tiredness or misery. The parents try whatever they can and for many reasons lose confidence that crying babies are not all that abnormal. They enlist the, sometimes conflicting, help of others. New or unfamiliar things are tried with the baby who becomes more distressed. This only goes to ‘prove’ the seriousness of the problem. Finally the health visitor is consulted. She has seen many ill and unhappy babies before. The parents have some confidence that she will know what is going on and – surprise, surprise – often the ‘room temperature’ and the ‘carer temperature’ and ultimately the baby’s temperature come down. Generally it seems easier to be sure about where the disease (a cold) is located. It is much more difficult to determine the ‘site’ of the illness or problem – it tends to be ‘between’ people! Panic attacks can be located in the individual, but their emergence and manifestation are often contextual: the presence of concerned onlookers almost always makes the job of controlling a panic attack harder.

It may still be difficult to see the disease belonging to a context but it is often easy to see that the problem is far wider than the individual. For example, there is good evidence that many of us carry Streptococcus bacteria in the oral cavity, but we do not all have tonsillitis all the time. Stressors of various kinds often seem to precipitate the disease of tonsillitis in the individual. But where is the problem – in the tonsils, in the individual, in the context that generates the stress, in the learned responses to that stress in that particular individual or in the family in which they learned these responses? Systemic clinicians tend to broaden the context and ask the patient, at some stage: ‘What would be most useful to talk about today – that your throat is tense or that your life is tense?’ Clearly such a challenge requires a bit of preparation, but it can be very effective in shifting the focus and can come as a relief to the patient.

Split bodies and minds

A central feature of Western thought has been to split the Mind from the Body. This split is so embedded culturally that it organises most of our perceptions and many of our practices. The split is manifested in disciplines: we have the field of psychiatry versus the specialty of ‘internal’ medicine. It is also reflected in service structures: we have national standards for delivering mental health services that are quite separate from those for diabetes or heart disease, despite the fact that feeling sad is a better predictor of death after a heart attack than taking aspirin (Mumford et al. 1982)! Is a headache in your mind or in your head or in your skull? Where does the head end and the skull start? It can be heart-breaking just thinking about the knots this intellectual schism has caused! No wonder we sometimes have headaches, as our language, our training and the services we work in all coerce us into sorting people and their symptoms into categories: ‘You to a heart specialist; you to a psychiatrist.’ But which expert is best placed to look after a broken heart? Much of modern medicine seems to encourage our patients to ‘dis-integrate’ and present different body and mind parts to different specialists, so that we can apply our ‘bitsy’ remedies.

Systemic practice goes some way towards the aspiration of integrated practice. Integrated practice takes as its core value the inextricable and indivisible link of mind and body, the intrinsic relatedness of the physical and the psychological. The playing out of this core value occurs at the level of thinking, of language, of communication, of structure and of organisation. Recipients and providers of care, patients and clinicians, are partners in the construction of integrated practice. More simply put, a systemic clinician will invite the patient presenting with ‘heartache’ to look at the symptom from a variety of stances (broken heart, heavy heart, divided heart, cupid’s dart). It is not only (trained) experts that are expected to sort out the broken hearts, but it is for the patient – the ‘expert by experience’ – and relevant others to join forces with clinicians. This process of jointly questioning the symptom is central to systemic practice. Of course many patients (and professionals) are closely wedded to the idea that only through a thorough ana...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Introduction
• 1. Systemic Practice In a Changing World
• 2. Ingredients of the Systemic Approach
• 3. The Evolution of Systemic Work
• 4. Questioning and Reflecting On the Agenda
• 5. The Family Within Us – Genograms
• 6. Not Going Round In Circles
• 7. Family Transitions
• 8. Assessing, Reflecting and Connecting
• 9. Working With Couples
• 10. Dancing With the Family
• 11. The Family In Crisis
• 12. Roots, Trunk, Shoots, Fruits and Seeds
• References