This chapter introduces a section of five chapters which contain the clinical account of transgenerational practice. My clinical experience has been obtained primarily in the adult psychiatric services. My clinical background includes experience in conjoint marital or family therapy with over one hundred families in a number of settings over the past eight years. In addition I have treated individual family members using a transgenerational approach and supervised a number of cases treated by professional colleagues. Most of the designated patients were late adolescents or adults. The geographic location has included inpatient and out-patient units located in both American and British teaching hospitals. I have also seen families while working in mental hospital settings. This range of venues has allowed me to work with a very wide range of families of differing ethnic and social backgrounds. Most of the families were treated without a co-therapist. The length of treatment has ranged from one session to eighteen sessions over a period of as many months. Sessions were usually spaced on a fortnightly or monthly schedule and lasted between one and two hours.
The psychiatric diagnoses of designated patients have included the psychotic disorders, such as schizophrenia and manic-depressive psychosis; personality disorders; the addictive states such as drug and alcohol addiction; and the entire range of neuroses. Not uncommonly, some of the family members who were not designated patients also presented with diagnosable psychiatric illnesses. Their illnesses included the same wide range of diagnostic categories. Where drugs were required for the well-being of any of the family members they were prescribed.
The use of the family approach has had to take into account the constraints of the adult psychiatric services. Each new referral required evaluation in order to establish that the family transgenerational approach was suited to the needs of the referred family member(s). The
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referral procedures are important in a general adult psychiatric unit. Family therapy cannot automatically begin in the first session. Some child psychiatry units have established the routine of seeing the nuclear family conjointly in each referral. This practice serves to emphasis the importance of the family system but increases the danger that those families not yet educated into a family approach will never be seen. Some embarrassment may also occur in sessions in which individual organic diseases are first explored in a family setting as if they were psychological.
I begin family therapy formally after the initial assessment has determined which of the organisational levels of intervention (social, family, whole person, organ, tissue, etc.) would be most economical and effective. HatfieldNote 1 addresses this issue of hierarchical levels while engaged in a family-oriented general practice. For example, a patient referred with symptoms and signs of acute appendicitis would hardly require a family intervention. The level of intervention would be the diseased organ, a subsystem of the individual, namely the appendix, by removing it surgically. Similarly, the referral note and the initial interview are used to determine which subsystem of the family (or the individual) requires intervention for the resolution of the presenting problem.
More recently most of my referrals have been made by professionals who are aware of my area of expertise and interest. Family and marital problems are now referred to me in such a way that the referral note alone informs me of the nature of the family quandary.
Referrals for treatment can be sparse, inaccurate or misleading. I no longer assume that referrals made to a family therapist must necessarily be family quandaries. In order to illustrate the need for caution in forming unwarranted conclusions, I would like to present a pastiche of referral letters which I have received and whose family members have been seen.
Dear Doctor,
Can you please see A. Horn re: his sexual problem?
Yours etc.
The preceding referral note is an example of an impoverished communication and is not atypical of some of the tersely worded letters I have received prior to my initial assessment interview. Mr. Horn was seen
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alone but a short chat convinced me that his wife was directly involved and required in the interview. Luckily she was in the waiting room and she agreed to take part in the remainder of the interview. This referral gave no information as to the true nature of the problem, whether family quandary or individual pathology. He could have been a man seeking help for impotence caused by a spinal tumour, a man seeking help for his wife in an unconsummated marriage, or a man with any number of marital or family problems. The first interview soon fixed the problem within the family. Mr. Horn had been having affairs since his marriage twenty-two years previously, at the rate of at least one per year. Three years before referral he began having sexual relations with his thirteen-year-old daughter. Six months before referral he left his home to live with a younger woman who had been a baby-sitter for his children. One month prior to referral he returned home. His daughter, frightened at his return, informed her mother of their sexual relationships. Mrs Horn had put up with her husband's previous affairs with resignation but now she threatened him with divorce and prosecution unless he saw a doctor about his 'problem'. After receiving this information I was able to frame the therapy sessions around the marital subsystem.
Dear Doctor,
Mr.Saroyan is a 55 y/o West Indian Porter who has been to the surgery every day during the past two weeks. He has complained of many physical aches and pains, none of which have any basis in fact. Our health visitor has attended your family therapy seminar and would like us to refer him and his family to you for your assistance. Thank you for your help.
Yours etc.
The preceding referral letter illustrates a case in which a patient and his family were incorrectly referred for family therapy. Mr. Saroyan and his nuclear family were seen several times. They were interviewed in front of a one-way screen, videotaped, and several home visits were done. But when I eventually untangled the emotional issues from the facts, Mr. Saroyan's physical health remained the one shared concern of the family. His health had deteriorated over a three-year period since his mother died, but no amount of explanation, discussion, revelation of secrets, task setting, or sharing of feelings about loss altered the family's primary concern nor convinced them that Mr. Saroyan's physical symptoms were due to emotional causes. In desperation I assumed
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my doctor's role, accumulated all of Mr. Saroyan's hospital notes, did a thorough physical exam and ordered laboratory studies. I found that the family quandary was a very different one to that which I had been presented. Mr. Saroyan had been suffering for years with temporal lobe epilepsy and essential hypertension. A recent heart attack and arterial disease in his legs, which caused him great pain on walking, had prevented him from working. The family, far from being over-concerned, were rightly concerned with his health which was poor. The quandary was at the cultural boundary between their West Indian background and the middle-class English helpers who had not understood the real nature of their concern. Family therapy for their relationship problems was the wrong level of intervention. This was clear when Mr. Saroyan's physical illnesses were treated.
Dear Doctor,
John Harrow is a 17 y/o schoolboy, just about to study for his 'A' levels. His father is a consultant physician. Over the past year or so he has been tearful for no apparent reason. The core of all this is that he feels, in theory, stupid - that everyone is better than he is. He has totally lost confidence in himself and his work. Also he feels that people are always going to reject him so he withdraws. The background is that his parents are very caring although his father tends to be stern, and their expectations of him academically are very high and he feels he cannot cope. About a year ago he was rejected by a girlfriend. This was not a very advanced relationship but it made a big impact on him. In spite of his view of himself, he is a very capable and intelligent boy - no one else shares his views of himself. He is taking low doses of antidepressants, first prescribed by his father, with little or no effect. Could you please see him? Thank you for your help.
Yours etc.
The preceding letter has been included to illustrate the plight of an adolescent who was inaccurately labelled as mentally ill while actually experiencing normal adolescent adjustment problems. The referral was for individual therapy, and the father's profession was a key element in the family quandary. After an individual session with John I could make no individual diagnosis of depression. The individual symptoms had intensified when his father had started to treat him with antidepressants.
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The family quandary involved the inability of John's father to separate form his professional role as a doctor and assume his family role as a father. Labelling John as ill escalated his problems for he began to be treated differently at home, at school, and even by himself. His referral to a psychiatrist confirmed his deepest fears about himself.
This referral illustrates the 'self-fulfilling prophecy' phenomenon in which an adolescent or child, not having been ill in the medical sense, is labelled as such through misdiagnosis, and then begins a long career in search of neurotic 'mental illness' or personality disorder' as doctors, family members, neighbours and other community helpers reinforce the belief that he is ill. The individual comes to believe in his illness until his identity as a mental patient solidifies. Family therapy was indicated because of father's crucial role in defining John as a mentally ill person, rather than a normal adolescent. When the family was seen, a geneogram was constructed and explained. The transgenerational influences all pointed to a family quandary: father's avoidance of his parental responsibility and discipline by incorrectly diagnosing his child rather than interacting with him. One family session was all that was necessary to remove John's label and return his adolescent strife to its proper arena.
Dear Doctor,
Mr. and Mrs Sturdy are the Welsh couple about whom we spoke in the corridor. At present their problems are centred on their mutually exclusive academic aims and pursuits, but I feel the conflicts are more fundamental than that, arising partly from their different expectations from the marriage, based on their very different backgrounds, and also from sexual difficulties. They are very interested in the welfare of their five-year-old daughter although Mrs Sturdy resents the effects her presence has had on her career. They are both meticulous and ambitious and rather competitive with each other in the academic field, as well as with regard to their daughter. I do hope you will be able to help them.
Yours etc.
The preceding letter illustrates an appropriate referral whose accuracy was tested in the initial interview. The initial interview was also used to begin the therapeutic process. The referral indicates that the quandary is a constitutive one, a relationship problem. The family quandary exists in the marital valency-conflict of the marital bond between husband and wife. There is a hint of the transgenerational influences and family collisions in the reference to 'their very different backgrounds'. This family
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was engaged and treated in family therapy based on the analysis of their transgenerational influences.
The referral letter in an adult psychiatric service brings many types of problems, only one of which is the referral of families for treatment. Family influences must be weighed against other biological, social and cultural influences before a decision is made to treat a problem as a family quandary. A flexible approach helps to avoid the engagement of the wrong subsystem in therapy, while encouraging family members who require prolonged education and explanation to continue in treatment until their relatives can be engaged and involved.
In many referrals to me it would have been inappropriate to use family therapy although family sessions and the exploration of family dynamics have been helpful in clarifying the nature of the problem being presented. Contraindications to family therapy sessions are few, but there are circumstances in which the family therapy is not possible. For example, an individual who is isolated through death and distance from all other family members cannot begin family therapy. Families hoping to cure an organic condition by the use of family therapy are unlikely to benefit. The family members must have some motivation for therapy, however strongly the therapist feels that the family is the correct unit of treatment. Unmotivated and unengaged family members may attend sessions but will resist efforts by the therapist to change them.
The following referral is one which recently arrived on my desk. I leave it to your imagination and fantasy to determine the appropriateness of the referral and the need for further information before offering a family-oriented treatment.
Dear Doctor,
Thank you for seeing this man and his second wife. I have already asked Dr. Peters to see them in February. We agree that conventional psychiatry might not help much with their problems and he did suggest a referral to you if matters don't improve. Mr. Brennan at least has asked for help. Basically I feel that he is not solely responsible for their quarrelling and has been seeking ways of changing. I do appreciate your help.
Yours etc.
Family therapy does not yet enjoy instant acceptance and recognition as
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a valid method of approaching problems amongst the helping professions. The medical model remains as the traditional doctor-patient relationship which assumes that pathology is encapsulated within the individual. Although the helping professions have become more aware of family-based theories and treatment, the traditional treatment still remains individually centred.
It is no surprise that family members often require reorientation and education into the basic concepts of family therapy before treatment can begin. Since most referrals come through the helping professions, the referred patient or patients have already had their pain and unhappiness explained in traditional language several times before reaching my office. They may already have used and exhausted conventional methods of individual somatic and psychological therapy. To such patients, family organisms, transgenerational influences, family collisions and conflictual bonding will cause confusion if introduced without explanation. They must first undergo a basic re-educative process. The following example will serve to illustrate this.
Mrs Rifle had been treated by various psychiatrists for six years before her referral to me. She had originally suffered a severe attack of influenza followed by apathy and depression. She had been admitted to hospital and her subsequent history was a dismal progression of admissions in which the entire range of antidepressant medication and electroconvulsive therapies were used in an attempt to cure her depression. After several serious suicide attempts she was referred to me by a bewildered and uncomfortable junior doctor. The following dialogue is a telescoped version of the re-educative process used to engage her in a family-oriented therapy.
(There follows a lengthy explanation of the ways in which her husband never makes a decision at home and leaves all the decisions to her).
When an individual is referred with a label marked 'illness' the initial session must determine the validity of that label. If it is not valid or only partially so, I redefine the problem, introduce doubt about the 'illness' and connect what is happening within the patient to what is happening outside of them in their interlinking relationships within the family. The geneogram may be used to facilitate explanations of relatedness and transgenerational influences. My redefinition of the problem to myself is insufficient; it must be explained to the patient. This education process is crucial to the success of future work. Once a person understands that their 'illness' is linked to their relationships with others, new
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solutions based on transgenerational analysis will be more acceptable to them.
The referral of an individual family member makes the educational process more difficult because of the immediate lack of evidence about relationships which exists in a conjoint interview. Use of the geneogram provides the educational focus. The individual family member is first given a professional opinion which refutes their previous diagnosis. The orientation of a family therapist is explained; the family is an organism linked by relationships and the disorder which seemed to be in one person is a reflection of a family quandary. The geneogram shows the relationships, patterns, and bonds which make up the quandary. The family member is encouraged to question this redefinition. Patients treated for many years with drugs and individual therapy may be angered by the shame and guilt which they have had to bear, by the stigma attached to them, by their loss of self-esteem, and by the waste of time in their lives. Conversely, some patients cling to their illness like a well-worn and familiar coat rather than accept a family reorientation. More usually the reformulation of their problem is welcomed and eagerness to involve other family members in their therapy is evident.
When the first session is a conjoint marital session, the educational needs may differ. Marital couples may accept that the difficulty has grown from their relationship, but blame each other as individuals for the responsibility of causing the referred problem. An acrimonious exchange may break out in the initial session. For example, one working-class couple was seen after the husband had had an affair. As soon as they entered the office they began hurling abuse at each other which culminated in the following exchange:
The couple had seen therapy as an opportunity to air their grievances, entrenched in their own positions, filled with anger and resentment. My role was to be that of judge, jury and executioner. The educational focus is on their own responsibility in bringing about the current crisis rather
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than focusing on their spouse. A blaming session is not a useful way to begin a marital therapy.
The educative process into a transgenerational model starts each of the marital pair at the origin of their relationship. They are asked to explore their reasons for choosing each other. The discussion shifts to that time in the past when the bonding began between the pair. The transgenerational influences brought to bear on them, the moulding of their own personality, and the family collision are all explored. Geneograms may be used as an educational and explanatory tool to bring out the various family influences. The marriage of the couple can be the last detail drawn into the geneogram, graphically depicting the collision of the family cultures involved. In this way, the marital problem is no longer depicted as isolated between two individuals. It is connected to their families of origin, reorienting them in the process to a broader view of their quandary.
For example, a couple who had married after living together for some time had been referred for marital therapy after the wife had been treated for depression which began shortly after marriage.
At this point in the interview a geneogram was built up in front of the couple of the husband's family of origin. We eventually came to his description of his maternal grandmother.
hard time all her life. It's a shame.
At this point a parallel between the husband's grandmother and his wife is apparent to me. He continues by revealing that he often amused his grandmother in an attempt to cheer her up. He used similar descriptions of his relationship with his wife. I called his attention to the parallel as it became more and more obvious. He was moulded in his relationship with his grandmother and his wife was replacing aspects of that relationship.
In the preceding examples of engaging and educating the marital couple, attention was diverted from their present marital strife while the couple were required to reconnect to their family of origin. Exploring their marital bond as a collision of family cultures removes the sense of isolation which occurs in a couple who feel the marital subsystem is the sole source of the quandary. Their bonds with other family members become equally important and their awareness is expanded to include a transgenerational view of the quandary.
In a conjoint family referral the interlinking role of the family members in creating and maintaining a quandary may be as difficult to point out as in an individual session. Family quandaries usually exist and are maintained by all of the members of the family including the poorly functioning member, the identified patient. The anxiety and pain of all other family members will be increased if the therapist removes the burden from the identified family member through an explanation of the family approach. Families are tenacious in their need to sustain their view of their identified family member as ill. For this reason I usually begin a conjoint interview with the identified problem and work through it towards a family view.
Mr. and Mrs Bloch requested an appointment for their eleven-year-old son whose behaviour was becoming increasingly disturbed. He was rebellious at home and they believed that he was being victimised at school and not performing to his capacity. The initial interview was arranged so that the nuclear family would attend in a conjoint session. It included Mr. and Mrs Bloch, Sandy, the identified patient, and his thirteen-year-old sister Amelia, who was partially blind with mild congenital heart
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disease.
Mrs Bloch explained at the beginning of the interview that they were very concerned about their son. He had been aggressive towards his sister, rebellious towards his parents and disobedient as well. He would not do as he was told, kept his room in a dreadful state and had been banned from playing sports for one school term. Mr. Bloch and Amelia concurred in all of these accusations. I wondered why these behaviours were seen as symptoms of some illness which warranted psychiatric treatment. I mentioned to the family that my own children had done similar things but perhaps the situation in their family was different in that they hadn't encountered this type of behaviour before. His parents were irate when I pointed to the essential normality of their son's behaviour (he was rebellious but not ill). They admitted that his behaviour was alien to them and their own upbringing. The re-education process began when I refused to accept that their son was ill and required the family to re-evaluate the entire situation. The vacuum which occurred in the family session became filled with a history of the many problems that had befallen the family in the past few years including family deaths and serious physical illnesses which had caused the parents to withdraw from each other. Mrs Bloch began to weep and Mr. Bloch withdrew into himself. These behaviours were identified as they happened and their meanings explored. The entire session became one in which the original symptoms of the family quandary were redefined. By the end of the session the parents accepted their role in the family quandary and had agreed that Sandy needed to be given more responsibility for himself. They had been holding him back because of the deaths which had occurred in their families of origin and their need to strengthen the remaining family bonds. Amelia remained dependent due to her illnesses and had not provided a model for differentiation of the children. The family accepted the view that Sandy was only one element in the family problem and agreed to return to explore their other problems.
To summarise, the process of engaging a family or its members in family therapy must begin with an education process. The family members must understand and accept the family orientation of the treatment. Usually, the first step in this process is a professional pronouncement on the lack of signs and symptoms related to an individual mental illness. This task is easiest for the therapist when no mental illness exists. But in families with schizophrenic family members or any other diagnosable mental illness the redefinition can still be accomplished if the quandary is caused by the relationship difficulties in the family which exacerbate the individual illness. The next step in the edu-
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cation process is the provision of a new model based on the family relationships through the use of explanation using examples from the family life or a geneogram. A new framework is constructed and taught to the family so that they can work with family and transgenerational concepts. The initial educative process ends with a return to the presenting problem which has now been redefined in family relationship terms.
The willingness of family members to participate in family therapy sessions would not be accepted at face value. I have had the experience in which family members attend out of politeness or loyalty to their general practitioner, with little investment in the therapy sessions. Without an agreement or contract in therapy, family members may nod acceptance while month after month goes by with little work done. An elusive non-verbal shroud will hang over the entire process of therapy. An example was a teenage girl who was referred by her psychiatrist for family sessions. She arrived at the first session with her mother and father. Her medication had relieved the symptoms of schizophrenia for which she had been treated, but she was not working as her parents wished and she spent much of her time alone with no hobbies or other outside interests. The family attended for four sessions, listening politely and answering questions about their background. Tasks of the simplest type were not performed and at last I asked the family why they continued to attend their sessions if they were not going to use them. I was informed that they had only come because the psychiatrist had referred them and they were awaiting my pronouncement of their daughter's cure and discharge. The daughter revealed that she had a boy-friend who occupied much of her time and whom she was hoping to marry soon. No verbal contract or therapeutic alliance had been forged between myself and this family.
Family therapy requires the active participation of the family members in order to succeed. The doctor cannot merely prescribe while the patient passively accepts. Family members must agree at some level to the active role required in their treatment. I recommend thorough exploration of the initial resistance and motivations regarding family therapy before asking family members to return and work in further sessions.
Although I resist making a formal written agreement because I feel it would hinder a flexible approach, I insist on distinguishing the referral and exploratory sessions from the therapeutic work which requires an undertaking on the part of the family members present to become
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actively involved. With the receipt of that undertaking the therapy can begin. Thereafter, whenever resistance to the therapy process occurs I can refer back to our original agreement and the undertaking that was made.
I am aware that I have artificially divided therapy sessions from exploratory ones for purposes of discussion. The effect of redefinition and the education of the family can be therapy in themselves as I have previously indicated. Although some family quandaries may respond to history-taking redefinition as the only necessary therapy, many family quandaries require structural changes in the family relationships in order to achieve resolution of their problems.
My primary goal in family therapy is to achieve a resolution of the family quandary that will generalise outside of the therapy session. When family members return to that bastion of engulfment and defensiveness, the family home, the true test of therapeutic effectiveness begins. Families may understand their dynamics, patterns and transgenerational inputs during therapy sessions; they may change their behaviour in my presence; but upon arrival home where no therapist is present, generalisation of their insight or new behaviour is lacking. The familiar dysfunctional patterns may be reconstituted as soon as the family members take their leave of the therapist at his doorstep. For this reason alone I would de-emphasise the role of the therapy session as the primary location for changing behaviour.
As a general rule I see family members as seldom as is consistent with maintaining continuity, usually once every two to four weeks. I consistently accent the necessity of work which the family members must do outside of the session. Tasks are set which must be accomplished and reported on during the next session. Resistances to task completion are explored and family members are coached within a session so that they will be able to practise a new way of relating during the following weeks at home. Family sessions at home without the therapist are encouraged. In these home sessions, family members are encouraged to talk to each other about painful issues, make their own geneograms, recontact distant relatives or look at family albums. It is hoped that these activities will give the family members a growing sense of change while away from the therapist, and reduce their dependency upon the family therapy session.
Therapy sessions do have definite uses within the constraints outlined above. Once the family members have agreed that the family approach
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best fits their quandary, the brief time spent in sessions is planned so as to enable family members to make maximum use of them. Sessional time is spent on exploration, introduction of new behaviour, or digestion and reflection of changes which have already occurred.
Exploration in a session involves the family members in detective work. Unexplained present interactions are traced to their origin in past relationships and influences. Where did that behaviour come from? Who in your family did that? Who did you do that with when you were young? Exploration of the transgenerational influences raises further questions about the present interactions leading to investigative tasks which can be assigned for completion before the next session. In this way a rationale is provided for family members, enabling them to recontact relatives and ask questions of them which were previously unasked. These sort of tasks not only gather information, they lead to changes in long-standing relationships.
For example, Bertha Hall was a 25-year-old woman suffering from anorexia nervosa. During a family session she was assigned the task of contacting her father. She felt her father would be uninterested, distant and unwilling to supply details about his family. On her return, having completed the task, she enthusiastically chattered about her father's family for most of the next session. She noted a change in her relationship with her father and felt relaxed in his presence.
Exploration in the conjoint family session may also uncover present interactional conflicts.
Therapy sessions may be used to introduce new experiences and teach new behaviours to family members. A comprehensive and continually expanding range of techniques is available for use by the family therapist. These techniques can be used to plan emotional growth experiences for family members. Some are original to family therapy sessions, while others have been borrowed from the armamentarium of behavioural, gestalt and psychodrama techniques. Videotape and audiotape feedback have also provided valuable aids in therapy sessions. These techniques are described in detail in the next chapter. Their general aim is to facilitate change in the session as a first step towards generalising the newly established behaviour in the home. Learning new interpersonal, emotional or sexual skills, without experimentation and practice is difficult. For example, the sharing of unexpressed angry feelings can first be facilitated in a session. Once the feelings are started the family members are sent home to continue work on them using specific tasks.
Sessional time is also used to digest the changes which have occurred. During the course of therapy the presenting problem may have melted
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away. If the initial problem has long since disappeared, the way in which this has happened may be obscure. Time is required for reflection, discussion and sharing of the work which has been carried out. These discussions centre on successful and unsuccessful attempts at change, and the work which still remains must be explored. New personal growth of family members is placed into the context of their past, present and future lives. Feelings about the therapist are discussed. Entire sessions may be spent in an unstructured way, temporarily releasing family members from the stresses imposed by a goal-orientated approach which has emphasised the need for performance and change. In these sessions, feedback of information to the therapist by the family members is facilitated.
Family therapy need not generate the strong transference feelings and dependency upon the therapist that individual therapy necessarily entails, especially when family therapy is used in the manner described. Most family therapy treatments last for one to five sessions. The timing of the ending is determined largely by the disappearance of the presenting problem and the resolution of the underlying family quandary. The end point is reached when each family member is adjusted to the new state of balance in the family; no individual is being blamed for the daily aggravations of life together; and the family members are feeling more comfortable in their lives.
The family sessions end with a summary of where we have been in the past, how the present is altered from that past and what the future holds. I try to maintain a follow-up contact of one year or longer in order to evaluate my own work. I rarely need to wean family members away from the sessions, if they have only attended between one and ten sessions.
In family therapy which has extended over a period of one to two years, ending the sessions may require more delicate handling. Transference of feelings from the family, real dependence and countertrransference issues might need to be explored. Such families, whose adjustment may have seemed satisfactory, create a new family crisis as soon as the termination of sessions is mentioned. The new crisis, if it is designed to prevent the ending of the sessions, can be useful in illustrating that the family members have the ability to cope with such crises on their own. Emphasis throughout therapy on homework allows the family's real capabilities to be separated from whatever feelings of loss are present. I share my own feelings of loss during termination as well.
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Families which have grown as a result of successfully negotiating a difficult transgenerational obstacle course are a source of satisfaction to me.
Family therapy sessions may end without effective relief of the quandary or may even result in increased pain and distress to a family. A family therapy treatment may end without complete resolution. An impasse can be reached when the crisis which precipitated the cry for help has ended and the family members settle back into old patterns with no further stimulation for change. Families may cancel further sessions with little explanation, make excuses about missed appointments and simply disappear, neither answering letters or phone calls. For the therapist it is important to acknowledge failures of treatment as well as successes.
The sessions may end on a realistic if incomplete note. After having worked with a family of five for one year, two tasks remained which were acknowledged by the husband and wife. Neither of them had been able to approach their own parents to form new relationships. The sessions ended when neither party was able to carry out the remaining work. The truce arranged between them remained and their relationships with their own children had altered. They have been in contact again two years later and have returned for more help.
Failures of treatment are failures of the therapist as well as the family members. There are cases in which I have chosen family therapy incorrectly as the vehicle of treatment. I have had cases which illustrated my failure to discover the underlying family quandary; I have chosen some families whose motivation for therapy was lacking; and I have had some families for whom my task-setting was inept. Many of these families have taught me more than I was able to impart to them.
The family therapy process begins with the exploration of the family quandary after the initial evaluation of the appropriateness of the referral. A detailed exploration of presenting symptoms and precipitating causes precedes the decision to use family therapy as the focal intervention. The family members are engaged in an education process in which they are taught the difference between traditional individual intervention and family therapy. Transgenerational concepts are introduced, using the geneogram during history-taking and analysing the germane transgenerational material. A tentative working plan is conceived based on the analysis which includes corrective emotional and educative experiences designed to change the relationship structure of the family. The successful conclusion of therapy is heralded by the increased ability
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of each of the family members to deal with each other and the crises in their lives. Some families fail to respond to family therapy. These families are the shared responsibility of the therapist and the family members.
1. F. Hatfield. Understanding the Family and Its Illnesses. 1978, privately printed manuscript.