Almost all psychological approaches to emotional and behavioural difficulties (e.g. cognitive-analytical psychotherapy CAT, cognitive-behavioural therapy CBT, interpersonal therapy IPT, functional family therapy FFT, and emotionally-focused family therapy FFT) owe some debt to psychoanalysis, with the possible exception of solution-focused therapy. The debt may not still be visible, but all share the aim of uncovering underlying processes, or schemas, that seem to unite outwardly disparate thoughts, symptoms or behaviours.
The most immediate influence upon family therapy was brief psychodynamic therapy, since it offered a distillation of psychoanalytical ideas and methods, implemented over a time-scale that was far more practical for family work. A fuller account of psychoanalytical thinking, its rigour and its salience to the systemic work introduced on this website, is described elsewhere.
What all effective therapy has in common is an implementation carried out with a respectful attitude, the general attributes of good counseling present (genuineness, non-possessive warmth, accurate empathy), remaining open-minded, curious, with a wish to be helpful and a capacity to be supportive. That’s where the similarities end: there are decisive differences between a psychodynamic approach and the remainder, which to a varying degree also separates the psychodynamic approach to systemic work we describe from other systemic family therapy models.
Three characteristics that psychodynamic psychotherapy does not share with other approaches
We note any major difference in implementation between individual work and the psychodynamic approach to systemic work we describe.
1. Emphasis upon the unconscious: as expressed in dreams, recurrent relationship difficulties, avoidant behaviours, and deeply-held anxieties – rather than family members talking directly. Unconscious issues that deeply preoccupy an individual are generally considered to be masked rather than transparent, and an understanding of the issues much increased by a gradual understanding of the masks – as their defensive function is considered to paradoxically reveal much of what might lie behind.
Since shared unconscious concerns within families are usually far more accessible (see Triangulation), a systemic application of psychodynamic concepts rarely necessitates any deep ongoing exploration of a family’s defensive organization.
2. Role of the psychotherapist: as a participant-observer in the psychodynamics of the consultation; in the hands of an experienced psychotherapist, this constitutes an important tool for understanding their patient’s unconscious mental functioning.
For the same reasons (i.e. under Triangulation), unlike individual work a systemic application of psychodynamic concepts often need not include continuous self-appraisal of the unconscious thoughts and feelings of the family therapist.
3. The absence of a stepped approach: in psychodynamic approaches assessment is an ongoing process throughout treatment, not an initial step; there is an absence of any over-arching aim to explain the problems that presented at referral; the therapeutic process is relatively unstructured and therefore unamenable to the type of manualisation other therapy models have developed.
This again differs from the psychodynamic approach to systemic work we describe, which is modelled on brief therapy concepts and is most often carried out within a public sector culture that requires formal assessment. The psychodynamic approach described on this website is embedded within a structured approach, where the initial steps involve orientation, assessment, and developing a shared and agreed formulation, all completed before any formal introduction of activity directed toward therapeutic aims.
The problem/s for which a patient or family had been referred remain firmly at the centre of work, quite different to what may happen in individual psychotherapy where an ongoing concern about the unconscious sometimes ‘trumps’ a psychodynamic therapist’s focus on the problem/s for which their patient had been referred.
Both psychodynamic psychotherapy and this systemic approach share an interest in multiple perspectives, but it is pursued in very different directions
In the former, any possible psychodynamic interpretation of a perceived issue is usually examined from multiple perspectives before anything is said to the patient. Analytical curiosity would go from ‘how might this relate to the problem/s for which my patient was referred?’ to include, for example, ‘why is the issue presenting now?’ ‘how does it relate to what has gone before?’, ‘what spontaneous thought and feelings does it prompt in the patient themselves?’ ‘how might this relate to their current stage in psychodynamic therapy?’, and ‘how might this also be salient to their relationship with me at this time?’.
For reasons that will become clear, curiosity about the patient’s unconscious attitudes to treatment, and to their therapist, is not a routinely part of most psychodynamic family therapy practice.
In the model described on this website, whenever individual member’s and composite family beliefs and relationships seem to be strongly influenced by issues beyond their immediate awareness (e.g. unresolved bereavement issues, emotionally untrusting, or intimacy fears), it is unarguably always important to bring these out and make sense of them. Because without their inclusion any systemic formulation cannot be complete, and family members’ endorsement of it accordingly partial. This would then breach two of its most important principles (formulation-driven therapy, undertaken in a transparent and collaborative way).
Implementing this model requires
- a far more structured approach to therapy, including the early introduction of procedures to establish a collaborative approach to enquiry and meaning-making
- the therapist’s questions invariably turned toward family members, rather than often inwardly directed as silent self-talk; examples of these are provided below.
Multiple perspectives arising from and facilitated by family conversation
Conjoint family sessions offer a very different opportunity to address the balancing act between challenge and support, because the presence in the room of other family members (who at-the-end-of-the day matter to each-other far, far, more than the family therapist does to any of them). Their presence provides the means for a family therapist to act boldly without the therapist themselves having always to be their principle source of support, or being the only source of reiterating salient issues as these emerge.
However, families also widely vary in how freely they are able to talk in a consultation room. A frequent task for a family therapist is to keep the family-conversation going, in play as it were: as if standing at the side of a ping-pong table, where each time the ball falters between family bats, stops or falls off the table, the therapist flicks it back into play – toward or onto the bat of a participant, from which it flies onto another’s.
The excerpt below taken from a family session includes many of the alternative ways of doing this. These may seem rather like Peter Fonagy’s ‘mentalisation-based’ family therapy in action, but these were first described by two McMaster family therapists forty years ago, then labelled as ‘micro-executive’ skills (Cleghorn and Levin 1973). These were further described in the 1st edition of Integrated Family Therapy and since by Karl Tomm and the Milan group, each developing a strong theory of change based on these actions.
The excerpt demonstrates that this is more than the Milan group’s ‘circular questioning’, and more than the questions used in narrative therapy, since the task concerns working with emotion to provide the support necessary to ‘stay with’ painful feelings as these begin to emerge.
Curiosity-based family questioning: the chosen example, of 11-year-old Graham’s family, illustrates how this can occur even where little is openly talked about. Graham was referred because of emotional problems, and the family were often reticent in the session, slow to warm up. A long uncomfortable silence had followed his father’s talking, so the therapist – responding to some non-verbal attunement with his mother – decides to ask: what’s Mum feeling, what‘s she feeling just now?
The question could have been directly addressed to her i.e. the person her husband had seemed to indirectly address even as he seemed to be talking about one of the kids: how does hearing that make you feel? But the therapist, sensing distress or some disapproval, guessed she would not welcome any direct question to her at that moment, which would alarm her further by putting her in ‘on the spot’.
Instead, the choice seemed to lie between somebody more ready to talk (e.g. the person who had last spoken before her husband), or to ask her husband directly. That, to the therapist, seemed a less favourable choice, since the therapist guessed he might deflect the question in just the same way as his talk that had silenced the family (if it had been a defensive response to his attunement about how his wife was feeling).
The question could be asked to an obviously-involved observer, Graham – the referred member of the family – who the therapists saw had also been watching her: Graham, what was your Mum feeling as she was listening to your Dad talk to you?
If Graham stays silent, to another of the children: what do you think Graham was thinking, when Mum was listening to what your Dad said?
After another, on behalf of Graham, appears to guess correctly, a question perhaps to Mum: are they right?
If she still remains silent, to the family in general: what’s it been like, hearing what Mum’s maybe been thinking?
Still silence, so perhaps to Mum about Graham, now looking at his father: that look he’s giving his Dad (the family therapist gestures), what’s it saying?
If no response, back to Dad again: Dad? what was that look saying?
The prominence given to children’s participation in therapy is what sets systemic work completely apart from other forms of psychotherapy. A nomadic Muslim tribal chief in Fallujah described their children as ‘our best seeds and our fairest fields’. An Anglican priest talked of how parents do their best to give their children ‘roots and wings’. A family therapist’s task includes helping kids feel safe even as we also ask them to fly.
These questions involved communication, both verbal and non-verbal, prompting family members to engage with one-other, to ask or to respond to questions, and to tentatively comment on transactions between members. The types of question illustrated are drawn from three domains of ‘micro-executive skills (stimulating and clarifying communication, and stimulating and labelling family transactions), all which are described in detail elsewhere.
The unfolding family story therefore provides the main source of evidence upon which a formulation is derived, not transference and counter-transference issues involving the therapist. The difference is explored further by comparing how the evidence from individual psychodynamic psychotherapy is triangulated in comparison to that process in systemic work.
The term, as it is applied to the accumulation of evidence, should not be confused with Minuchin’s term, which describes the induction of a 3rd family member into some unresolved issue between two others. It is completely different. The concept evolved from qualitative research. It describe the convergence of different sources of information, which may indicate something previously unrecognised – but fairly robust – is present in the data.
Triangulation as applied as a scientific method employs converging lines of relatively independent data; in the above example, family members were being invited to take part in such an iterative process. The process is very different in analytical psychotherapy, because the gradual accumulation of information about the unconscious life of a patient (however rich and detailed, and painstakingly gathered) derives from uncorroborated data.
That constitutes a very different form of triangulation: the working alliance between the analyst and an observing part of the patient to examine the ‘ghosts in the room’ brought into the session as memories by the patient and by transference. This requires a splitting in the patient, between an observing-ego and an unguarded voice increasingly able to talk to the analyst about feelings and thoughts (however infantile or shameful), a form of triangulation upon which progression of the whole work depends.
A psychoanalytical perspective would be skeptical that family sessions can relatively quickly provide what individual psychodynamic therapy might take many sessions to arrive at. However, the presence during a family consultation of multiple relationships, talking together and responding to one-another, provides a density of material. This often bewilders inexperienced trainees, perhaps overwhelming them as participant-observers, but it constitutes vivid material for the more experienced, for whom any question about how the family is relating to them remains subordinate to their curiosity about what is happening in the family.
In short, ideas about what’s happening (in the patient’s mind, or in the family) are arrived at by two very different processes of triangulation.
The possible misuse of psychoanalytical concepts
From a psychoanalytic purist’s position, there are two important concerns which, unaddressed, would constitute possible misuse of psychoanalytical concepts:
- that some important aspects of a family’s relationship with their systemic therapist are, and remain, unconscious and risk being ignored by this model. To which the principle response might be a combination of – is what is being presented as a problem, on the surface, congruent? If it is, is it proportionate (in affect-size) to the main problem for which the referral had been made? If not, then unconscious, out of awareness, processes require attention.
- that a therapist can never really knows what actually happened in the past; that all recollections are subjective, provisional rather than ‘true’; so any formulation that allows “narrative to masquerade as explanation” is unsafe in that one can never truly know.
To which, our response would be that making the best possible sense of the problems for which a family was referred is deeply wished for by most families, most of whom apply common sense to the ultimately provisional nature of what ‘makes sense’ that should drive therapy. However remaining transparently aware of and curious about potential out of awareness family experience that has not yet reached conscious understanding is crucial.
Cleghorn, J. M., & Levin, S. (1973). Training Family Therapists by Setting learning objectives. American Journal of Orthopsychiatry, 43(3): 439-446.