This is a recurring question in the plays of Arthur Miller. In Death of a Salesman, the suicidal despair of an exhausted Willy Loman facing the loss of his job prompts his frightened wife to round on their two young-adult sons to try to stop their challenging behaviour towards him:
I don’t say he’s a great man. Willy Loman never made a lot of money. His name was never in the paper. He’s not the finest character that ever lived, but he’s a human being, and a terrible thing is happening to him. So attention must be paid.
Linda’s ‘cri de coeur’ illustrates one of the most important maxims of family therapy: the whole is greater than the sum of the parts. By working together as a family, something can be put right, or at least lived with better, or in a more kindly way.
What’s happened?: In the US, there is now a growing movement that Trauma should be mainstreamed and services should now ask the patient early on not “how are you feeling?” but “what’s happened to you?”. This is more easily answered than the first question, not least because of how frequently feelings change, get confused, get repressed or dealt with by dissociation.
Family therapy attempts that over generations. One of its most powerful tools is the ‘genogram’, summarising key individual and family issues and events over several generations. This is usually developed by the family therapist together with the family with one of the children perhaps helping to write it on a flipchart. Originally intended to serve the purpose of making sense of complexity, genograms are now also used to help recognise where strengths lay and how despite terrible odds at times, resilience was found. This was self-evidently useful to families working out how to move forward again. (The genogram example we provide elsewhere was developed from the abused woman’s neighbour in Tracy Chapman’s song who, to emphasise the universality of these issues, we’ve relocated to a Scottish island and called Dorothy.)
The socio-cultural context of events: any genogram of Willy Loman’s family would have been inadequate without including the social context of the play: an old-World immigrant salesman in the US, clinging to idyllic new-World myths of advancement even as he, and others of his generation, were breaking under them. Underlying this, was the question of how to overcome poverty.
Applying a cognitive behavioural therapy interpretation to the US (from where CBT had originated) Arthur Miller was engaged in portraying a clash between two utterly different schema – Willy Loman’s self-other and world. The disparity of power is illustrated in this exchange:
His boss declares that there is no opening for him without continued travelling:
You’re a road man Willy, and we do a road business …
I put thirty four years into this firm Howard, and now I can’t pay my insurance. You can’t eat the orange and throw the peel away – a man is not a piece of fruit …
Power and disempowerment as portrayed in Miller’s play is an important issue in family therapy. It can never be ignored. Therapists’ ‘expert’ position in therapy – who has power? – and the increasing criticism of directive styles has become, through the work of feminist writers like Hoffman, a dominant theme in the family therapy literature. Talk about ethics, bias, and confirmatory bias comes up time and time again in therapists’ discussion and during training.
Applying a four-level assessment framework: this was introduced in the first edition of Integrated Family Therapy to describe and make sense of what is happening in families facing difficulties. Applying it to the Loman family’s difficulties as portrayed in the play results in the following:
- ‘surface action’: the frequent arguments in the Loman household, the father’s exhausted provider role, Willy’s declamatory talk that repeatedly misses the mark, his sons’ dismissive and challenging behaviour, Linda’s bypassed attempts at caring and peace-making
- ‘dysfunctional transactional patterns’: the family are enmeshed in a conflict-ridden pattern with avoidant or ineffective problem-solving which reflects a ‘manic’ defence against despair. Unresolved feelings and beliefs are projected onto other family members, who, vulnerable because of their own issues, act these out as if they were their own
- ‘links with the past’: The Lomans are a second-generation immigrant family in the new World, where cultural myths about social advancement haven’t changed but the means to achieving this have since Willy’s early employment successes
- ‘why now?: economic recession and the conjunction between Willy’s exhausted provider role with the failing emancipation into full adulthood of his two sons
The original framework did not encourage a focus on resilience but the text offered a structured approach to assessment where strengths as well as difficulties could be recognised and understood. We will develop this further elsewhere.
Acting out, rather than remembering and talking openly: just as the act of bringing a play to the stage brings life to a script, the open talking of a family at an assessment meeting with a therapist facilitates a deeper understanding of the issues members are concerned about.
Hopefully this can occur because an orientation has taken place i.e. talking to establish a common sense of purpose, building some trust and understanding of their forthcoming time together. The process that might include the therapist taking opportunities to ask questions when things aren’t clear, or to comment on observations made during the meeting that are not otherwise talked about directly. Any absence of these agreed conditions makes it more difficult to understand what is happening in families. A second piece of dialogue is used below to illustrate where acting out takes place rather than remembering and talking.
Acting out, rather than remembering and talking about an issue in therapy, represents a key psychoanalytic concept: the proposition that important emotional stuff doesn’t go away if it’s not talked about. Even if it is quite deeply repressed and held in the ‘unconscious’, some of it is nevertheless expressed. Rather than being remembered, it becomes recognisable from the content of dreams or enacted through behaviour (including how stuff gets talked about rather than what is talked about). This idea derived from individual case-studies, developed from the rich narratives individuals provided of their relationships with others, including how they related to their analyst in and between sessions.
Recognising the risk of therapist’s acting out: psychoanalysis has long recognised that a pre-disposition to act out isn’t always one-sided e.g. micro-acting out within a session by an analyst unable to restrain themselves from showing off to their patient by clever interpretations. The latter might reflect unresolved immaturity or loneliness on the part of the analyst, but it might also be an insufficiently considered response to having picked up something unspoken in the room from the way their patient relates.
Without recourse to psychoanalytic terminology such as introjective and projective identification, Rober has written extensively on the unspoken in families and how to address this, including feelings and thoughts elicited in the therapist during family sessions.
Applying a systemic approach to untalked-about issues: we briefly explore this in relation to families in severe difficulties who do not come to seek specific help for themselves as a family and where the question ‘what’s happening in this family?’ and their resulting contacts with services is not being actively pursued. As the Tracy Chapman example demonstrated, this is very different from the basic assumptions of many families coming to a clinic or agency which, broadly stated, might be something like ‘as a family, we have a problem, we wish to resolve it, with you, we’d like to do that now’.
The dialogue below is a brief conversation during a husband’s visit to his wife who had been admitted on a Short-Term Detention Certificate to a psychiatric ward. They were talking on the evening before a ward round when they knew a discussion would take place about whether a CTO application for compulsory treatment powers should be made. Many previous admissions had taken place, often compulsorily detentions. These were usually short-lived admissions prompted by her life-threatening behaviour, which generally settled fairly quickly.
Although the husband had never made himself available to be interviewed, both he and his wife (who was sexually and emotionally abused in childhood) understand that a diagnosis of ‘borderline personality disorder’ has been made. Ward staff understand that he has an alcohol problem. Staff had also heard from Heather, the couple’s daughter, that her parents “never communicate”.
Husband: So what do you think, will they get an Order?
Wife: Don’t know, we’ll have to wait and see
H: Are you feeling any better then?
W: I’m not sure. Maybe. I don’t know. We’ll just have to wait and see what they say
H: Do you want me to bring in more clothes?
W: I don’t know. I may not be staying. No, you better had. But not that black lacey thing you brought me last time (she briefly laughs, glancing at him, she sees him look away, they sit in silence) Are you going to your brother’s at the weekend?
H: Don’t know, depends what the bairns want – Sean’s got his football, don’t know about Heather
W: She’ll be staying at her boyfriend’s again? (put as a statement)
H: I suppose so (looks toward the door out to the corridor, silence)
W: (drawing him back): Can I have a smoke? (he leans over to light the cigarette he gave her, but she seems to have changed her mind about getting up to leave for the smoking room, they sit in silence)
H: Who’s that lady across the way? the one that’s looking at us – do you know her?
W: (shakes her head)
H: What’s she in for?
W: (shakes her head, he sees her sigh as she looks into her lap, they sit in silence)
We return to this case elsewhere, but a useful exercise just now might be to
- think about their communication, what was said and what seems unsaid
- what each were perhaps thinking or might be saying to themselves in ‘self-talk’
- consider what Heather would be wanting them to talk about
- what measures the ward team could adopt to engage them both more effectively
The case illustrates how institutional systems and families may interact where unaddressed family issues are present, particularly when long-term or frequently renewed contact has taken place. Reviewing such contacts through a systemic ‘lens’ often indicates something further about what may be happening in the family which drives the behaviour that had alternatively been concluded as evidence of a disorder, in this case by a diagnosis of ‘borderline personality disorder’.