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THERAPIST-* INDIVIDUAL
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DYAD
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GROUP
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MULTIPLE
CONTEXTS 7
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Figure 1. This emphasizes the shift by the therapist from the individual to
his wider contexts. What it can only partly show is the interplay between:
one dyadic relationship and another; the individual and the family; different
dyads and triads; widersocialcontexts.Each of these permutations may
occur in relation to the past, present, or future.
Asking questions
A major tool of systemic therapistsis the askingof questions which are
intended to lead the client to question the beliefs, expectations and
roles, for himself and for those around him (Penn,1985; Tomm, 1987a
and b, 1988). Systemic therapists might start by asking how the client
decided it should be just him who should attend for the interview.
Whom did he discuss it with? If he had brought his spouselpartnerl
parent, what might that person saynow? Would the client agree with
that response? If the client disagreed, what might the other person say
at this point? How would they settle this disagreement? Carpenter
and Treacher (1983) have addressed these questions as part of the
process of engaging the family in treatment.The particular emphasis
in this current paper is that it is just as importantto elicit the client’s
beliefs about others and his beliefs about their position in relation to
him, as it is to use this as an active focus for convening either the
family andlor the wider social or agency systems.
Case example l
T h e case of Amy P illustrates how a therapist, working systemically
withonepersonfromthestart,bringsthewidercontextintothe
interview.
Twelve-year-old Amy was referred toa child guidance clinic by her
G P because of a n ‘eating disorder’. T h e G Pmentioned in his referral
letter that Amy’s mother had come to see him on her own to voice her
concernabout Amy’s deliberate dietingand weight loss. She
apparently told her doctor that she was the ‘main worrier’ in the
family as her husband was often abroad on business trips. Amy is one
of three children. The therapist (male) sent an appointment letter,
addressed to the parents, inviting thewhole family to attend, ‘so that
we can get everyone’s views and ideas of the problem, and how to
help’. In the event only Mrs P came.
MRSP: I’m sorry it’sjust me, but my husband is very busy, andhe has a very
important meeting today.
TH.:I see . . . does he know you have come here today?
6 Hugh Jenkins and Knrl Asen
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If mother and daughter had come together, the therapist would see
what the daughter could do to get her father involved:
‘What would you have to do to get your father to come to these meetings?
How much more weight would you have to lose before he would agree to
come?’
Discussion
This approach is significantlydifferentfromaone-to-onepsycho-
dynamic relationship where therapists relate the patient’s responses
to themselves. Instead, systemic therapists ask the client to consider
his dilemmas in relation to the people who are naturally involved in
his lifc. This could include asking:
‘Why might you not be able to say certain things if X or Y were present?’
‘What would happen if your wifelmotherletc. heard you say this?’
‘What might be the implication of feeling this way but of X not knowing
about it?’
‘How would the client behave if X knew?’
‘How could he tell X?’ and, ‘What might be Y’s response?’
‘How would that alter their relationships with each other?’
Case example 2
M r D’s wife participated only in the final three meetings, although
had she not, it is likely that therapeutic work would still have been
effective. The important point is thatthedoorwas left ‘open’ for
others to join at any point during therapy.
M r D, aged 53, was referred to a psychiatric out-patient depart-
ment by his GP, who stated in her letter: ‘Mr D has suffered from
depression for many years and this has created considerable tensions
in the marriage. I have discussed the possibility of marital or family
therapy with him and also separately, with his wife. She is adamant
that she does not w.ant to be involved in his treatment.’ T h e therapist
(male) decided to offer an appointment to M r D and the following is
an excerpt from the first meeting, some ten minutes into the session.
TH.: . . . and when you get really low, who is the first to notice?
M R D: Probably my daughter, . . . she is very sensitive.
TH.:What is it that she observes, you think, that makes her realize you are
low?
M R D: I don’t know . . .
TH.:I would really like you to imagine very hard, what it might be that she
observes that leads her to conclude that you are feeling low?
M R D: I suppose she notices the expressions on my face.
TH.:W h a t d o you think is it actually that she observes?
M R D: I probably look dejected, as if I am going to burst into tears. . . pace
up and down . . . I probably sigh a lot . . .
TH.:And then what happens? What does she do? What does anyone else do?
M R D: She tries to cheer me up. Sometimes she puts her arm around me . . .
TH.: And what happens then?
M R D: I feel awful.
TH.:More or less awful than before?
M R D: I don’t know . . .
TH.:When you feel awful in this sort of way, what is it that you do next?
Family theraFy without the f a m i b 9
MR D: I try to leave the room. I go to my bedroom.
TH.:And what happens then?
MR D: I think someone elsein the family comes and checks whether I’m
OK.
TH.: When all this happens, what is your wife doing?
MR D: I think she has given up on me. . . I guess that’s why the children are
so involved.
TH.:What is it that she does or says that makes you think that she has given
up on you?
MR D: She makes an angry face, or makes some cutting remarks, or she just
walks out.
TH.:Letmeaskyousomethingthatmaysound a bitstrange.Ifyou
deliberately wanted to upset her, what would you have to do?
MR D: . . . j u s t be bloody depressed and morose . . .
TH.:C a n you tell me about situations when you think she is more likely to
give up on you?
MR D: The more depressed I get, the more she withdraws. O r if I want her
to ring my employer to say that I am not feeling well . . .
TII.:And what about times when youfeel she is not withdrawing, when you
feel she might try and get closer to you?
MR D: When I take an interest in her work or her family or her silly friends
. . , but I’m too depressed to do that!
In this example the therapist accepts that, at least for the time being,
the patient is not the family but M r D, who is asked to look at himself
fromdifferentperspectives, andtoscrutinize family interactions
which involve him. A diary homework task requested him to observe
fluctuations in his mood over a week and note the circumstances and
peoplepresent. I n addition, by askinghimtosee his depression
through other people’s eyes he was gradually able to appreciate the
effect his depressive behaviour was having on those around him, as
well as seeing the effects that various family members’ responses were
having on his depressive symptoms. Identifying specific patterns of
interaction helped him to experiment withnew ways of behaving. For
example (Session 4):
M r D then considers how else he could surprise his wife and begins to
predict her responses. After seven sessions M r D said that his wife had
expressed an interest in attending the meetings. Discussing the pros
and cons of acceding to this request resulted in M r D deciding to
involve her. Three further joint meetings took place, with both M r
and Mrs D stating that hc had ‘recovered from the depression’.
Therapists can continue to think and practise systemically as long
as they keep open the possibility of a ‘relevant other’ from the client’s
life comingtothe nextsession, as in theexample of M r D. The
moment this option is abandoned in the therapist’s mind, there is a
greater risk of therapist and client becoming trapped in a twosome
that will push the therapist to consider using herself as an agent of
change, and of assuming a pre-eminent role for the client.
Clients will, whether they wish toornot,attributeor‘transfer’
certaincharacteristicsontosystemictherapists. But whilst our
psychodynamicallyorientedcolleagueswould use thedeveloping
client-therapist relationship as the metaphor for addressing ‘outside’
relationships,systemictherapistsdeliberately refrainfrommaking
overt references to this, or from interpreting the transference. Even
whenworkingwithcouplesorfamiliespresent in theroom,there
always exists the danger of over-identification by one member with
the therapist (Carpenter and Treacher,1989; pp. 215-2 16), and while
i t is important to be aware of theseprocesses, it is notthedirect
material of therapy. It is the specific way of asking questions that
defines the stance of systemic therapists, and i t is the specific stance
systemic therapists assumein relation to their clients that allows them
to generate these questions.
Types of questions
T h e ways in which questions are constructed can be flexible, both in
terms of content, and in terms of time frame, ranging from the past
through the present to the future (see Figure 1): for example, ‘when
the problem began’, ‘the problem now’, or ‘when i t changes in the
future’. These three time frames can be placed within a hypothetical
perspective, as in: ‘If such and such had beendifferent in the past’, or
‘now’, or ‘in the future’, ‘how then might that affect . . .?’ In this way
Family therapy without the famil_y 11
relatedness is experienced anew and the client frequently states that
he had already thought about these issues, ‘but not like that’.
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Conclusion
Systemic work with individuals is fundamentally different from other
individualpsychotherapies,aboveall in that it emphasizesthe
openness of the therapeutic system. Within such a framework there is
little room for working with the transference which emphasizes the
crucial importance of a reference person inside the session and outside
the client’s natural social system. h‘hilst there are constant moves to
‘bridge’thevarioustherapies, often in thc name of somekind of
pragmatic eclecticism, there is a danger that in doing so the systemic
perspective is abandoned.
Family therapy without the family 13
The therapist who chooses to work systemically with individuals
must first be at ease in work with family groups, both at a conceptual
level, and in terms of interviewingskills.Systemicworkwith
individuals should not be viewed as the easier option. I t challenges
the therapist to hold a systemic framework, while working with the
intensity of only one other person in the room. The therapist must
constantly hold thctension between theindividualand his wider
social context if comfort and cosiness are to be avoided.
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