Figure 7.1 Change in Seating in a Family Session
Within a discussion of the structure of family sessions I include their timing, location and content. In timing family sessions flexibility is required. Although I would prefer monthly family or marital sessions lasting one and a half hours, or monthly hourly sessions for individual family members, the length of a session must depend on the needs of family members and the tasks ahead of them. Some sessions may last for thirty minutes while others extend for two hours. The first sessions may occur weekly with later sessions spaced bimonthly; sessions may occur at regular fortnightly or monthly intervals. Flexibility of timing in sessions accentuates the importance of work done outside the sessions. Regularly timed and spaced sessions provide a routine practice which creates dependence upon the therapy sessions rather than encouraging the development of the family's resources outside the sessions.
Family therapy sessions are usually located in my office, a ten foot by twelve foot room. There is enough room for individuals, couples or small family groups. A blackboard, videotape and audiotape facilities are readily available. Larger family groups are seen in a room which is thirty feet by ten feet and has similar facilities. The larger room is used when activities requiring more space are planned during the sessions, such as sculpting or other experiential exercises. Home visits may be done at any time during the therapy.
In my practice of family therapy using a transgenerational model, work may begin with an individual, a marital couple, or any conjoint combination of family members. During the course of therapy there are often changes in the combination of family members who attend. The patient originally referred may be seen once and excused from further attendance while other family members become the focus of family therapy sessions. Nuclear families may be seen occasionally while intensive work is done with one individual or married couple. Extended family members may be invited to attend the sessions and may become the primary focus of therapy. Marital couples may be split and seen on
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their own before bringing them together again. The choice of participants in a family session is dictated by the needs of the family in resolving their quandary.
The presence of a family member in a session or his calculated absence from sessions is linked to an understanding of those areas of family dysfunction in which the family member is involved. If a family member was being blamed or labelled as ill in the presenting crisis, excusing him from the sessions removes the stigma and dissociates the presenting crisis from the family quandary. Later that family member can attend sessions as an ordinary family member, able to help his relatives and be helped in return. Following clues about the transgenerational influence of the extended family brings decisions about which family members should be invited to attend later sessions. A family containing a teenage enuretic son revealed belatedly that the paternal grandparents lived next door. The father had had a similar problem which had resolved without professional help. Since the grandparents were living so close and had solved the problem one generation previously it made sense to ask them to attend the next session. Family members may wish to be seen on their own; some must be seen alone before they will agree to reveal material which they feel is too destructive, embarrassing or painful to be shared in conjoint sessions. I use these individual sessions to gain a clearer understanding of the gravity of these communications while aiding family members to judge the potential for harm of secrets if they were revealed in a conjoint session. For the above reasons I respond flexibly to the needs of the family when deciding which family members attend the sessions.
The structure of the sessions may also be classified by their content. In general terms, I would divide the emphasis of content into investigative, planning, activity or reflective sessions.
Investigative sessions are planned when new family members are introduced in a session, when added information is required by family members or therapist, or when therapy is foundering for no obvious reason. These sessions are often explorations of transgenerational influence. Time is spent delving into the ways in which the activities and interactions of family members relate to the bonds, collisions, replacements and patterns which have been previously discovered and traced. Areas of secrecy are further examined to discover information which may be hampering change in the family system. In investigative sessions nothing should be assumed, nothing taken for granted. Documentary evidence of births, deaths, marriages and other relationships are sought whenever suspicion exists. For example, in a family session an alcoholic
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woman, the identified patient, swore that her father had died of a heart attack. Her mother instantly confirmed this story while the woman's ten-year-old daughter seemed bored and uninterested. In an investigative session, the woman and her daughter returned with a newspaper clipping which claimed that the father had committed suicide. The clipping brought a new shared relationship between grandmother, mother and child which was previously lacking. Grandmother no longer needed to keep this secret from the other members of the family.
Planning sessions are used when investigation has turned up enough information to plan for change. These sessions often require complex negotiations between family members and therapist over what is a necessary, desirable or possible task to induce change. Explanation, persuasion and practice through role-playing may occur before the task is accepted and accomplished. Mrs Blue and her husband were advised to set aside one hour each week in which they would discuss their differences. At first they resisted by claiming the task was an artificial way of achieving better communication. I left them in my office for half an hour to discuss their differences and when I returned they were arguing fiercely over their son's education. The experience broke down their resistance to the task and they went on to achieve their goal.
Planning tasks for family members can leave each family member with separate assignments, some of which may interlock. In a family of six, the four children were to pick the location to which their father would take them on a Sunday morning while their mother was cooking the Sunday lunch. Mother was to spend the afternoon with the children while father listened to his stereo headphones. Father had to plan a weekly evening out with his wife. These tasks were negotiated by the family members with each other and were generated from the needs of the family in a planning session.
Some sessions are devoted to activities such as role-playing, sculpting, videotape recording and feedback, gestalt games, or sexual instruction. These activities address the family quandary by providing instruction, corrective emotional experiences or diagnostic projective tests of the family dynamics. Sharing of common experiences such as a family pillow fight or sharing of common emotions as in forced mourning provides family members with new experiences within the session which generalise in the family home. The diagnostic use of activities can lead to insights and unblock therapy, enabling further progress to occur. For example, a sculpting session revealed the annoyance of the father towards his wife for 'wearing the pants' in the family. He placed his wife centrally but revolved around her bumping her out of position. He be-
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came consciously aware of his role in disturbing his wife.
Reflective sessions coincide with the occurrence of a significant change in family structure. Structural changes in families may be comparable to the allomorphic changes in chemical structure such as the change from lampblack to graphite to diamond. The changes leave the family to view its new and unfamiliar self with anxiety as well as pleasure. Reflective sessions consolidate and explain changes prior to continuing work towards further change.
Most sessions are spent between investigation, planning, activity and reflection in combination rather than devoting entire sessions to each particular emphasis. At times a planned session may have to be abandoned in response to the family need in order to explore events outside the session.
Tasks in transgenerational practice aim towards the separation of past influences which haunt the family from the present reality of existing relationships. The work outside the session will accomplish desired relationship changes through task setting.
One common task assigned is that of gathering information about past and present relationships with and between relatives. For example, George Graham was a family member who was asked to describe his parents' relationship with each other. He was unable to do so because his mother had died giving birth to him and he had been raised by his stepmother. My interest in his mother was that he had chosen his wife as a replacement for the mother he had lost when he was born. The evidence for this included a similarity in names and physical resemblance with a photo of his mother. His wife failed to match the idealised image George had of his mother, so that his marital bond was based consciously on an idealised image while unconsciously determined by the model of his stepmother. A task was set for him to discover as much as possible about his mother.
The task could have been accomplished in several different ways. A direct approach would involve him in discussing his mother with his father. This task might prove a difficult or impossible one involving a confrontation with his father. It might be accomplished by asking him to set up a structured interview with his father with specific questions set by the therapist conveyed to the father. A less direct approach might involve the task of finding any existing documents relating to his mother. Newspaper articles, birth, marriage and death certificates, old photographs, diaries, or her letters might still exist. Another indirect approach
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might involve the task of seeking out his mother's relatives and speaking with them; or discussing his mother with other relatives who had known her, such as his father's siblings or grandparents.
Information gathering is a task which may reduce the fantasies upon which many family quandaries are constructed. The conflicting details of these fantasies can be investigated by family members while filling gaps in the transgenerational information gathered by geneogram.
By seeking out information from relatives outside the session, significant family patterns, family losses and replacements, moulding, transgenerational passage and the derivations of marital choice may all be investigated and clarified. Information gathering breaks down secrecy and boundaries between family members. When one member seeks previously withheld information there is a general lowering of the continued classification of painful material as secret among family members attending sessions. Gathering information involves each family member in the therapy process. They are engaged outside the sessions by devising methods of obtaining information as well as actively seeking it from relatives and other sources. Family members can communicate through telephone calls, letters and visits to informants, whether relatives, friends or strangers.
Gathering information about important family facts and relationships is the easiest of tasks to explain to family members; the tasks are also the least difficult to accomplish. The use of the geneogram increases the ease of setting this type of task since many questions normally arise out of the diagramming of family structure.
During the process of gathering information from relatives, new ways of interacting, discussing, asking and approaching relatives must occur. Long-abandoned or disused lines of communication with relatives must be reopened; old relationships are reopened and new links made with other relatives. In this way relationship bonds are altered. The very act of gathering information for clarification leads to this alteration of relationships between two family members.
Relationship bonds may be altered by direct task setting. The task may be a simple one, asking one family member to share new emotions with another outside the session. This differs from setting an information gathering task which results serendipitously in sharing of new emotions. The intent of bond-altering tasks is either to increase bonding, decrease bonding, or reorient the bonding into a new framework. Minuchin's concept of helping enmeshed families disengage describes the situation in which overly intrusive bonds have become a family patternNote 1 which must be altered. But family quandaries may result from weak
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bonds, distorted bonds, or lack of bonding, as well as enmeshment.
An example of a task set to affect directly the bonds between family members is that of John Village, a 29-year-old single bus conductor. He used to phone his mother every day and shared all of his emotional problems with her including his sexual fear and fantasies. The task set him was uncomplicated; he was to reduce his phone contact with his mother to one call each week. He realised that he had had an over-close relationship with his mother which had excluded his father. Through the task he established closer ties with his father and lost one of his major symptoms, an obsessive fear that he might be homosexual. This change in relationship with his father was generated from the first task of decreasing contact with his mother.
In another example of bond-related task setting, Martha Brown was asked to write and express her feelings of anger to her geographically distant father. Their previous relationship had been one of distant admiration punctuated by incestuous fantasies. Mr Brown responded to the letter by visiting his daughter. Both families were invited to attend a therapy session. Their relationship altered to a more realistic one through thorough exploration of their incestuous fantasies. Sharing the incestuous feelings reduced their boundary functions which had prevented the two family members from forming close relationship.
Quandaries involving bonding may become apparent through use of the geneogram or through direct observation of interactions within the session. One couple who were endlessly discussing decisions without reaching conclusions displayed these interactions in the offices. Their vacillation had paralysed them into inaction and was a symptom of the over-close bonding between them. They were asked not to talk to each other unless they had individually made a decision. This task provided one month's peace at home in which their marital bond seemed to have little substance beyond their chronic indecision. The original marital bond had been forced from sibling rivalries within their families of origin. Removal of that rivalry through task setting revealed a relationship only weakly bonded by love and mutual sharing.
Some bonding tasks aim to establish new relationship with distant relatives or relatives with whom relationships had been severed. Parents, grandparents, uncles, aunts, cousins and other relatives may be made the object of an information quest aimed at establishing a new bond. The quest for information is used to overcome resistance generated by fantasies existing between relatives. New bond formation can result in the weakening of other bonds and a disengagement in other relationships. This natural consequence provides the rationale for a task
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designed to decrease pathological-engaged relationships The resulting emotional distance allows individual family members greater freedom. Setting the task of forming new relationships with a relative serves as a method of diffusing the intensity of existing ones. This task is especially attractive in family quandaries where family members have put all of their emotional eggs in one basket. This type of task must be set after close study of the existing relationships in a family. Mr McTavish was asked to contact his father's oldest brother who was living in Dubai in order to establish certain details about his father's upbringing. Mr McTavish was the oldest son in his family but was over-involved with both his father and mother to the detriment of his marital relationship. His uncle and he had much in common except that his uncle had managed to escape over-involvement in his own family of origin. I felt the task would provide Mr McTavish with a new relationship, model a new relationship with his parents, and allow him to separate by forming the new relationship. His uncle wrote a warm reply to his initial letter and suggested that they meet when he returned to England for a visit. When they met they found that they enjoyed each other's company and conversation. The relationship between them grew while his relationship with his parents became less intrusive.
Bonding tasks accomplished outside of the therapy sessions through decreasing, increasing, establishing or re-establishing new relationships are natural outgrowths of a transgenerational practice. This technique of changing family relationships through tasks set outside the session uses present and past relationship patterns in the planning and achievement of future alterations in relationships.
Outside tasks may also be assigned to follow on behaviours newly learned within the session. Sexual instruction is an example of this use of outside tasks. A range of techniques taught within sessions which are then practised at home have been developed to deal with specific problemsNote 2. Outside practice sessions can also be assigned when using forced mourning procedures, or when argument skills have been taught. For example, after having shared feelings about a dead relative in the office, a family member will be assigned the task of sharing those feelings at home with the same or different family members. Couples may be given the task of planning a one-hour argument session at home after having practised in the office using role-playing and simulated situations. The tasks are necessary because they directly oppose transgenerational influences, which are evident as resistances to the tasks. In order to survive, marriages require argumentative skills of great sophistication. These skills may be inhibited in the spouses whose moulded experience
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with their parents was never to argue. Alternatively, when parents, presented a model of constant argument and bickering, their children may have determined never to do the same. The choice of a task to be practised outside of the session is tailored to the needs of family members through exploration of the family quandary and its transgenerational background.
There has been a creative explosion of new techniques for use in the family therapy session. These techniques have been developed in response to the redefinition of the goal of therapy in family-oriented treatment. They are aimed at producing changes in the constitutive properties of families as well as generating new insights for the family members. Most of the techniques assume active and directive participation by the therapist. Specifically, they are used to increase the sharing of emotions or information, for developing interpersonal skills among the family members or for increasing motivation for change.
The use of the geneogram has already been described in Chapter Four. It is a major technique used in the transgenerational practice of family therapy but there are many other techniques which I have found useful. A few have developed out of the theoretical postulates of family therapists but most have developed pragmatically in response to the changed clinical goals in family therapy.
A paradoxical intention is an instruction given by the therapist to one or more family members which proscribes the very result, reaction, behaviour, or resistance which the therapist wishes to occur. For example, if a family member is known to resist the therapist's instructions he might be told to argue forcefully with his mother at home with the intention that he ceases his destructive arguments. This technique must be used judiciously and accurately or the intention may be taken at face value by a co-operative family member, thereby causing greater suffering and pain.
Prescribing the symptom is a special form of paradoxical intention in which the therapist focuses on the original, identified symptom, either individual or interactional, and asks that the family member continue the symptom behaviour with even greater intensity. The result of this paradox is that the symptom, which was previously seen by the family member as outside control, becomes controllable. The family member or members gain control of the offending behaviour either by carrying out
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the prescription or by resisting it and decreasing the symptoms. An amusing and instructive case using this type of technique describes the treatment of a marital couple, each of whom suffered from lifelong enuresisNote 4.
Both members of the couple were instructed at bedtime to kneel side by side on the bed and 'deliberately, intentionally and jointly wet the bed'. They were then told to go to sleep and repeat this behaviour every night for two weeks. If after one night's respite the bed was spontaneously wet the following morning, they were to continue the prescribed behaviour for a further three weeks. The couple obeyed the prescription with increasing discomfort and dread for two weeks and following their one night's respite they never wet the bed again.
In transgenerational practice, the paradoxical intention is a useful way of instructing resistant family members to recontact estranged relatives. A thirty-year-old actor had been out of contact with his parents for three years. His wife and daughter had been unable to tolerate his increasingly aggressive behaviour. The behaviour arose at the time of his daughter's birth. His wife had become more involved with her daughter, shifting some of her interest from the husband. Since she constituted his only strong emotional bond he responded with anger and frustration. He was estranged from his family of origin and would not initially consider contacting them despite my explanations. Finally, I stated that I had reconsidered the objections to contacting his parents or siblings. Since he clearly felt that they were not interested in him he must know his family better than I did. His feelings that his parents had never loved him or cared for his welfare must be true. I asked him to formally address the issue that to him his parents were as good as dead, and that no further contact should or would every be necessary in the future. We were to begin working on his position of being alone and isolated in the world. The following session he returned to proclaim defiantly that he had spoken to his parents on the telephone and arranged to visit them. He recanted his previous negative feelings towards them and expressed instead his anger at me for having attempted to permanently sever his relationship with his family. A sense of bewilderment and relief was present in him throughout the session. His aggressive behaviour at home disappeared.
Prescribing the symptom may also be used to good effect in transgenerational practice in the attempt to loosen, strengthen, or alter bonds. In marital couples who have been referred because of their constant quarrels, increased arguments at home are prescribed. Families complaining of an over-closeness are asked to do more together. One
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particular example of prescribing the symptom is the 'divorce session'. In some couples one partner uses threats to leave the other as a way of maintaining dominance. These couples are involved in a session in which all possible routes to the achievement of a divorce are explored in great detail. The effect of this procedure (if correctly chosen) is that objection after objection is raised to each aspect of divorce until both partners are fully aware that neither of them really wishes to carry out the threat. The resulting relief is often considerable and sometimes provides a singular resolution of the family quandary.
The reversal is a technique used to alter family patterns by asking that one family member reverses the way in which he deals with another family member. It differs from the paradoxical intention in that the underlying goal of the reversal is to accomplish the task which the therapist has devised rather than its opposite. The family member is asked directly to reverse their behavioural interaction in order to express the silent and disregarded aspects of their relationship. Since most family members in a quandary try harder and harder by using their familiar patterns of response, they create a spiralling feedback of every-increasing problems. For example, a husband responded to his wife's quarrelling by withdrawing from the argument and physically leaving the house. She interpreted this withdrawal as a lack of love and quarrelled increasingly with him because of it. He was normally a solicitous, kindly, passive man and these traits had originally led his wife to choose him as her husband. Her increased quarrelling increased his solicitude and kindness as he desperately tried to use his every trait to help his wife. When I proposed a reversal of his behaviour so that he began to argue rather than retreat, to be 'cruel instead of kind', the balance in their relationship changed and became less tense.
Similarly a woman who complained that her husband never took her out in the evenings was asked to take him out instead. The result was a closer bond between them, followed by an equitable sharing of the task between them. The reversal is a difficult technique to employ without through explanation to the family members involved. They must first begin to realise the destructiveness that trying harder in the same familiar ingrained way entails.
Because of the serious nature of the quandaries which family members bring to therapy sessions it is all too easy to allow sessions to become
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unbalanced in the direction of serious, sombre discussions with an over-emphasis on the gravity of the situation. This over-emphasis towards the darker side of the problem serves to detract from the valuable use of humour, lightheartedness and play in placing problems into a more balanced perspective. A humourless relationship or family is an unhappy one and the introduction of humour into sessions may serve a valuable function. Most family therapists whom I have watched at work have used humour to ease tension within a session, sidestep resistance to their suggestions, point out absurdities in family situations or simply model a less sombre approach to relationships. AckermanNote 6 cites the use of humour on eight separate occasions either to ease tension, soften a blunt interpretation, provide support or as an ironical comment. For example he asks a man about his father's penis size and when he denies having seen it, Ackerman wonders aloud at the man's short-sightedness, a reference to his thick glasses. The man and his wife laugh and the point is made.
I feel that humour should be an integral part of the therapeutic process, not only permitted but encouraged as a part of the full interplay of human emotions. An example in the exploration of the geneogram of a married couple occurred when I came across a clue to the possible replacement connection between the husband and his grandfather. The husband was a drummer in a pop band, and after he had described his grandfather in words similar to his description of himself I smiled and raised the connection by asking him if his grandfather also played drums. Similarly while exploring the past history of the mother and father of an anorexic girl (see Chapter Four) the following dialogue took place:
(Father and mother both laugh).
The final laughter was in response to the realisation that a point of great importance had been made about the passage of time and its ravages upon a romantic relationship.
At another point in the interview the following exchange occurred:
Roars of laughter from the entire family followed and the daughter relaxed considerably. The laughter acknowledged the importance of the connection as well as its absurdity, while the tension which had been building in the session was released.
WhitakerNote 7 formulated several tongue-in-cheek rules which apply equally to therapists as well as the families we treat. Among them are injunctions to 'develop the benign absurdity of life, develop your own craziness, learn to love by flirting with any infant available, and be childish with your mate'. The judicious use of humour will keep both therapist and family from going stale and maintain within them a greater spark of enthusiasm and life.
Forced mourning is a technique first described by PaulNote 9 as operational mourning. Operational mourning was a procedure designed to provide a belated mourning experience in those families which have developed a pervasive defence against losses and disappointments as a result of incompleted mourning. This defence is passed from generation to generation unwittingly and promotes a fixated family pattern and equilibrium. Operational mourning was developed to weaken the fixed equilibrium allowing family members to develop. Forced mourning is a similar procedure designed to unblock the pathological bond which one or more family members may maintain with a deceased member of the family. Forced mourning is based on the application of recent ethologic and
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behavioural concepts as well as specific work on aspects of morbid grief. The procedure may be used individually or conjointly depending on the needs of the family members involved.
During the use of the geneogram to explore family losses and replacements the family's reaction to loss is explored. The need for a forced mourning procedure to be undertaken arises out of this exploration.
Table 7.1: Principles of Bereavement Counselling in Normal Grief
1. Initial comfort during the stage of numbness allowing the bereaved time to take in what has occurred.In normal bereavement counselling various precepts have been developed in order to help prevent morbid grief reactions from occurring (See Table 7.1). Individuals receiving this type of assistance are aware of their loss and its impact on their lives. Morbid grief and forced mourning are distinct from bereavement counselling in two main areas. First, there is a need to justify and explain the connection between the family quandary or individual symptoms and the loss. Family members with morbid grief reactions often present with symptoms which have been isolated from the loss that stimulated their reaction. The connection of the loss and its resultant production of symptoms often requires persistent and patient
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explanation of events which may have occurred many years before the family member has been seen in a session. The second area lies in the primary goal of forced mourning, the conversion of a morbid grief reaction into a normal mourning which is then followed to completion. The therapist must actively stimulate and direct the family members to explore and experience the avoided and painful feelings and remain tolerant of the strong expressions of those feelings when they come.
In forced mourning, grief becomes a conjoint experience in the office and at home as photographs, letters, and other memorabilia are used to provoke feelings and memories about the deceased. Visits to the grave are encouraged and letters written to the deceased may be an assigned task designed to uncover hidden feelings. Any strategem which will aid the exploration of buried emotions is encouraged. The feelings which are shared between family members are both negative and positive. Resolution occurs when family members have reviewed their relationships with the deceased, acknowledge both positive and negative aspects, put aside all avoidance behaviour, and have readjusted existing relationships while placing the deceased into a realistic perspective.
The following clinical description presents an example of the use of forced mourning in a transgenerational family therapy. Mr and Mrs Chislehurst were referred for marital therapy following complaints by Mr Chislehurst of marital problems related to his wife's anxiety at home. During the first three sessions Mrs Chislehurst appeared alone. At the fourth session both husband and wife were present and during the course of that session a geneogram was constructed which revealed that their firstborn child had died at the age of nine months while being treated for a severe congenital abnormality. Mr Chislehurst became deeply withdrawn and tearful for two years afterward while his wife had accepted the child's death with remarkable composure. She was advised to have another child immediately. The resulting second child was born both physically and mentally handicapped. Both parents felt guilty, upset, but were unable to communicate these feelings to each other. Two further children were born and were normal in every way. The initial therapeutic work involved the exploration of their constant quarrels, his brooding depression and her over-reactive anxieties. This work moved on after a directed investigation of their firstborn child's death. Throughout the two years of the husband's gloom and depression, neither spouse had been able to share feelings about their daughter's death. They had never since allowed any discussion about her or the impact of her loss on their relationship. At this time I introduced a force mourning procedure. The first phase involved a detailed history
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which continued into all major losses sustained by each of the members of the Chislehurst family and their reactions to them. A thorough explanation of normal reactions to loss was followed by an explanation linking the symptoms which they had suffered together following the death of their daughter to the morbid grief process. The second phase of forced mourning required the exertion of an implacable pressure to initiate normal mourning. I verbally recreated the scene of the last moments of their daughter's life and death until Mrs Chislehurst began to cry. Mr Chislehurst showed his annoyance at her until he was directed to examine his own feelings. He began weeping and the couple were able for the first time to share and expose their feelings about their daughter's death. They were instructed to share their more negative feelings as well as their positive ones both in the office and at home. Their remaining children were included in some of the following sessions. During the course of the forced mourning they were asked to visit their daughter's grave, view her photographs, relive her final illness, share with each other their shameful feelings of anger and discuss openly their hostility towards their daughter for having subjected them to these painful feelings. Throughout, my job as therapist was to stay with the painful feelings and tolerate their expression. The resolution phase was heralded by a change in relationship patterns in the family. The parents became less protective of their children. Mrs Chislehurst began learning to drive; and a photograph of their dead daughter was hung in their living room along with that of their other children. At the end of the forced mourning their marital relationship had improved although further work remained.
The use of forced mourning in family therapy is reserved for those families whose quandary involves a transgenerational pattern of grieving which is morbid and has stifled the growth and development of the family members. The forced mourning procedure should convert a morbid reaction into normal grief which is followed to its resolution phase. The conversion is stimulated by the therapist actively. By sharing the strong feelings which are generated a new family communication pattern is modelled while revealing replacements in the family, altering bonds, and providing a greater tolerance for the minor losses and tragedies of life.
I often use videotape recording in my sessions with families. I value its unique ability to electronically capture verbal and non-verbal communications which can be studied at leisure after the session. The playback of a session provides me with feedback of my own errors, reveals
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missed, unheard or covert communications and provides a record of associations in the session. As a therapeutic tool for the family members the gift to see themselves as others do is a powerful one. The first objective look at themselves in action enables the discrepancies between their own internal perception and external reality to starkly contrast. In this way a model is provided to develop a family member's objectivity about himself as well as other family members about whom perceptions are distorted. The videotaped session also provides a record of the progress (or lack of progress) which has occurred since the initial session.
Alger has written most extensively on the use of videotape recording in family therapyNote 10. He describes its use in the session in three different ways. An entire session may be recorded and then played back, either immediately afterwards or at the beginning of the next session. Alternatively, a small period during a session is recorded and the remainder of the session is used to examine the tape in detail. Lastly, during the course of a recorded session any of the participants may call for an instant replay and it is played back and discussed. Alger has also described the use of the video image in self-confrontation. The family member talks to his television image and other family members are allowed to join in talking to the real person or the image. But like any tool, videotape recording and playback is limited by the technical limitations of the equipment and the creativity of the therapist. Many other uses may be found in the future.
In my use of videotape, I rely on simplicity of equipment, needing neither technician or cameraman. I use a one camera, half-inch reel-to-reel recording system with a wide-angle lens, which enables me to carry out the entire recording session myself. The camera is placed in such a way that the entire family and the therapist are captured on the tape. I have also mounted the camera on a tripod with a zoom lens sitting next to me and operated it during the session. I only record occasional sessions and delay playback for at least one week in order for the immediacy of the experience to fade. Since objectivity is the goal of my use of videotape feedback, the same tape may have to be viewed by family members on several different occasions before they can feel sufficiently detached from their screen images to gain objective understanding about their behaviour. Videotape provides an opportunity to reveal to family members the pathological nature of the bonds forced between them, some of which are based on the replacement phenomenon in the family. Conventional explanation which provokes fierce resistance will be accepted if the replacement phenomenon can be shown. Videotape may capture those moulded traits which have passed from one
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generation to another and show the way in which a member of the junior generation in a family has taken on characteristics of a senior member.
An illustration of the use of videotape to generate objectivity in family therapy is provided by the following case. A 32-year-old nurse had been treated for depression for four years following the death of her maternal grandmother. Treatment with various drugs, group therapy and marital therapy had little effect. She maintained an over-close relationship with her husband who received the brunt of her anger and helplessness. After an initial session with her I became aware that her marital choice and her feelings about her maternal grandmother were inextricably involved with the relationship maintained between herself and her parents. She was asked to invite her parents to a session which would be videotaped, because they lived so far away and could only attend sessions rarely. During the session she appeared hostile, angry and bitter at the way her parents had treated her grandmother and herself, but denied any feelings of anger towards them, nor did her parents acknowledge the non-verbal communication of anger which was present. Her fear of her parents remained unspoken despite its obvious manifestation in her inability to tell them of her depression or her marital problems until the session had been arranged. After the session her parents were asked to return in several months' time and she was asked to view the session on videotape. It required four viewings before she could accept that the angry feelings she saw on the playback were her own. When the next conjoint session occurred she was able to reveal directly her bitterness and anger towards her parents. They reacted with apologies at first, then with matching anger of their own. The session ended in some confusion but her parents agreed to return for further sessions. She viewed the videotape of the second session and quickly realised that the expectations she had of her parents would never be fulfilled. She felt isolated and abandoned by them, feelings she connected to her anger about their treatment of her grandmother. But her relationship with her husband and parents improved subsequently to these two sessions. The videotape had allowed her to gain an objective look at herself, her parents, and their relationship.
The husband of a marital couple were set the task of arguing in a session which was videotaped. When the session was played back, the husband was able to perceive the intense competition between himself and his wife which he had denied for so long. He immediately connected it to the rivalry he had established with his elder brother. This insight led to his enthusiastic participation in further sessions. Previously he had
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been stubbornly certain that his wife was the problem in their family. The videotape had provided an objective learning experience for him and had helped him to trace the transgenerational origins of his behaviour.
Videotape playback can capture an emotional moment which provides the family with a permanent record of their warmth and involvement. A family living in fear of fragmentation attended a conjoint session in which they were asked to play a game which they had invented when their children had been younger and much smaller. It involved a song, 'familamilamilies', sung while jumping up and down and holding on to each other. This warm and moving display of togetherness, captured on tape, was played back and broke the feelings of fragmentation that threatened to engulf the family.
The previous examples illustrate the contribution this new technology can bring to family therapy. When emotions are running high and long-standing family patterns require exposure and alteration, an objective view of themselves may now be provided to family members and therapists. Videotape feedback captures a segment of family life and interactions for later viewing and reviewing until necessary insights into present behaviour lead to a motivation to change. Family members may dislike what they see but they cannot totally ignore or deny that they are doing or acting as their screen images reveal.
Recordings can be done in sessions attended by selected family members. These tapes are later shared by the total family at home. In this way open communication is fostered between family members and the dimension of secrecy between family members may be breached even if family members were originally reluctant to reveal secrets in full conjoint session.
For the therapist, audiotape recordings provide an inexpensive method of reviewing family therapy sessions. The recording allows a leisurely replay of the session with special attention to therapist errors, missed communications and points to raise in the next session.
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Experiential or action techniques differ from the parts of sessions in which words are used as the main therapeutic tool. The use of action teaches the family the value of experiential learning in establishing new behaviour, emphasises non-verbal communications between family members, as well as providing new experiences through doing rather than talking about doing.
Experiential learning is the earliest form of learning. Before we learn words and symbols, we learn as infants and children through watching others, through experiencing, through trial and error, and through our body movements. This earliest form of learning eventually enables us to form words with the musculature of our vocal apparatus. But the non-verbal, experiential learning model remains with us as a powerful tool in effecting changes in behaviour and relationships when words are inadequate. Action can speak louder than words provided that the action is judiciously applied and based on the needs of the family.
The importance of experiential learning may be illustrated by considering the difference between reading about sexual intercourse and experiencing it. The metaphor is appropriate; sexually there is a great deal of individual apparatus which works without the need of a relationship (masturbation). A sexual relationship may consist of two partners engaged in mutual masturbation or it may involve a great deal more of the interactive, mutually-dependent responsivity which defines a different level of practice and experience. The latter requires practice in the organisation of the sexual relationship physically and emotionally. No amount of reading or talking can replace it. The practice is experiential learning and similar practice is involved in the establishment of new behaviour in other spheres of family life.
Which experiential technique to use is dictated by the transgenerational analysis and its resultant theoretical solutions to the family quandary. The methods may involve the simple movement of seated positions in a conjoint session, elaborately planned games or family sculpting sessions.
I often use changes in position, posture or movement in family sessions. For example, in a session including five family members - Peggy, the identified patient, her parents, brother and maternal grandmother - the seating was as pictured in Figure 7.1a. Peggy was seated between her mother and father while the therapist, grandmother and her brother were more peripherally located. Both mother and father revealed that they had been dependent upon their parents with bonds which were
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only partly severed by the death of their respective parents. The strong influence grandmother exerted during the sessions confirmed the nature of the relationship. Peggy had fallen ill when she briefly left home for the first time in her life. During the session while her parents described their dependence, she became agitated. Her mother and father then attempted to parent her; this only stimulated rapid and increasingly incoherent speech in her. A 'white noise' enveloped the session with all three family members talking at once, followed by Peggy getting up and walking out. The parents then knowingly gazed at the maternal grandmother and the therapist as if to say 'She certainly is mad, isn't she?' On her return the sequence of events repeated itself several times. Finally, Peggy was asked to sit next to the therapist who placed himself between her and the door. The parents were moved to face each other in confrontation while their son and grandmother were seated together in the room as in Figure 7.1b. The move was initially intended to counteract parental dominance of Peggy by getting her to sit with the therapist. The moves actually changed the experience in the session in three different ways. First, the tension between the parents could not affect Peggy as much, due to the support of the therapist's closeness; second, the separation from her parents in the session modelled an experience that Peggy required and wanted despite her guilt. Finally, the position of the therapist near the door inhibited Peggy from leaving; she would have had to talk out in front of him and he could prevent this if necessary. The result of the change in position in the session went as expected. Mother and father responded to their confrontative position by expressing differences of opinion instead of presenting a united front. Peggy felt more relaxed with lowered anxiety. The relief in the session generalised to tall participants. The simple change in position was later used to explain the family quandary and set tasks to deal with it, while providing a simple experience of active change.
Role-play is a more complex activity than simple position change. Role-play in a session is illustrated by the following portrayal of emotional bonds which occurred in a marital session. While quarrelling the wife began to weep. Her husband, paralysed by her tears, did nothing to acknowledge or assuage her distress. He turned to me and began discussing his job. I asked him if this was his usual reaction to his wife's distress and he admitted that he was unable to console his wife. I asked them to stand up and embrace each other. His wife tolerated the embrace briefly and then pushed him away. I asked him why he had so easily let go and entreated him to hold on to his wife despite her moves to the contrary. When he accomplished this task, his wife began deeply sobbing
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in his arms and allowed him to comfort her. This sequence of behaviour was used as a model for work at home which enabled them to share their distress with each other. I knew that the husband's timidity in approaching his wife was representative of the cold relationship he had had with his parents. He needed to learn to comfort and be comforted through touching. When his wife pushed him away he felt rejected and was helpless to deal with her distress. By holding to her long enough his persistence was rewarded.
A more elaborate activity was the dominant-submissive game in which a family of three were involved. Two parents and their eight-year-old son were seen together. They were each asked to take a turn standing on a table looking down on the other family members. The person on the table was dominant and in charge of the other family members. The family quandary was the result of parental democracy which gave each
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member of the family an equal vote. Endless wrangling and avoided decisions resulted from split ballots until their son was born. He was given a vote and each of the parents attempted to woo him to their side. The game was designed to give each of the family members absolute dominance over the others. When the son was ordering the parents around the room the natural order in the family was revealed. The son, and only child, was relaxed while ordering each of his parents, who were two youngest siblings in their families of origin. His parents spontaneously recalled how they had been constantly told what to do by their older siblings. The husband realised that he had abdicated his responsibility for decision making in the family. He agreed to work on that task at home. He was to make decisions over his wife from a standing position while she was in a sitting submissive posture. Their son's neurotic traits ceased after the session.
In other forms of role-playing I have asked family members to replace each other or play the role of a dead or absent relative. For example, in a marital session Mr Blair was asked to play the role of his wife's dead father. She was asked to talk to her father as naturally as possible. The discrepancy between his acting and her memory of her father was so great that she was able to distinguish her husband from the replacement role for which she had been using him since she married him. In other role-play sessions I have asked family members present to exchange roles. The over-exaggeration which often results creates freedom and novel experiences for each of the family.
In family sculptingNote 11, relationships are pictured without the use of words by placing family members in various positions and using their expressions and postures in order to represent the bonds and constitutive properties in the family. A scene from the past or present may be represented as well as hypothetical scenes or relationships based on emotional states. A tableau of distance, responsibility, or domination might be constructed for example. Transgenerational input may be depicted or the sibling position portrayed.
I used one sculpting session to enable each of the family members to portray their feelings of closeness. The family, consisting of father, mother, son and daughter, were each asked in turn to do a sculpture of their feelings of closeness. The mother's sculpture (see Figure 7.2a) shows an alliance between her and her daughter with some distance between her and her husband and son. The next sculpture was done by her husband (Figure 7.2b) who portrayed his family in a planetary model, measuring closeness by the distance from the centre of the model where he placed his wife. He represented himself as the closest
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planet followed by his daughter and finally his son in a distant orbit. The son placed his father and mother in opposite corners of the room facing the wall while he and his sister occupied the middle of the room facing each other. (Figure 7.2c). The last sculpture was done by the daughter who placed her parents together while her brother stood next to her. All four were placed in a line (Figure 7.2d). The four tableaux revealed the differing attitude of each of the family members and enabled each to experience themselves from a different point of view. The tableaux were later used in an experiential exercise. The family members were asked to change what they were unhappy with and the changes were acted out. The sculpting session provided them with insight, new experience, change and eventual growth as they were finally able to compromise and allow each family member the space they needed in the family.
Family sculpting is an example of the creative formal activities devised for use in family therapy sessions. But all experiential techniques, whether spontaneous, structured or formal, can provide experiences which are informative, cathartic, or confrontative to the family members, increasing the repertoire of response to life. Their successful use depends on matching the experience required to the family needs. Creative use of experiential techniques provides a powerful tool for family therapists if they are rooted in care and concern for the family members.
Within the ambit of specialised techniques, sexual instruction is one limited to the marital subsystem. Many marital problems contain within them an element of sexual dysfunction so that the family therapist must have some ability in this field. Instruction in sexuality follows the model of the pioneering work done by Masters and JohnsonNote 12. Often couples referred specifically for sexual dysfunction treatment have major relationship problems concomitantly which are affecting their lives. Even such sexual dysfunctions as vaginismus or premature ejaculation may have roots in transgenerational influences which will require analysis. The use of sexual techniques in family therapy is illustrated by the following case. Mrs Edwards, a thirty-year-old social worker, was referred for marital therapy with her husband. She had previously been admitted on many occasions suffering from phobic anxiety, chronic depression, and had made multiple suicide attempts and abused psychotropic drugs. The ward staff and her psychiatrist had reached the limits of their skill and patience. Her referral was in the hope that a family approach might help.
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It was noted in her medical history that she had three surgical vaginal dilations for vaginal constriction. The couple had a poor sex life due to painful intercourse according to the history. The marital therapy was undertaken and her symptoms were traced to their transgenerational source. Geneograms were used in several conjoint marital sessions in which Mr Edward's contribution to her symptoms was explored. One family session with Mrs Edwards and her mother was also undertaken. Both she and her husband were so naive about sexual matters that they had assumed the marriage was consummated. In fact they had not actually experienced penetration during their four years of marriage. The transgenerational influence from both sides was one of intense naivety and secrecy regarding sexual matters.
Both Mr and Mrs Edwards felt that their sexual education was inadequate from family, friends and school sources. They had attempted to read books but found the words difficult to connect with their anatomy. Sexual work seemed necessary and was undertaken at this point in the therapy. The treatment involved six sessions. Sensate focus, a technique in which the couple explore and massage each other's bodies, was taught to them. Mutual exploration and verbal feedback sessions were prescribed to be carried out at home. Attempts at sexual intercourse were prohibited to relieve stress caused by pressure to perform the sexual act.
The nature of the sexual problem was her vaginal tightening (vaginismus) combined with his inexperience and fear of female genitals which prevented him from consummating the marriage. These factors were explained and anatomy lessons were given using diagrams and photographs. The entire course of therapy for vaginismus was explained. Mrs Edwards was given a vaginal dilator and instructed in its use. She was asked to insert it within her vagina. While leaving it there she was to imagine that it was her husband's penis. Following the completion of the sensate focus and dilator tasks an instruction session was planned. During the session Mrs Edwards explored her genitals. Her genitals were explored by her husband while I showed them the correspondence between the diagrams and the actual anatomy and feelings of the body. Her husband was encouraged to penetrate her vagina with his fingers. He was fearful of hurting her at first, but eventually was able to insert three fingers and was convinced that his penis would be able to fit. Following that session penetration was successfully achieved. Much of the marital disharmony disappeared as it became clear that they both felt cheated of a normal married life and the possibility of having children which had not materialised. Mrs Edwards was able to continue working for her
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qualifications and required no further treatment. She and her husband now have one child with a second one on the way. No further psychiatric or therapeutic interventions have been necessary.
The point I wish to make is that sexual instruction does fall within the province of the family therapist although it requires additional specialised skill and knowledge. Sexual anatomy, physiology, awareness of physical pathology, and the interaction between hormonal regulation and emotions must be studied. Frank, informed and open discussions of sexual relationships must be part of the armamentarium of the family therapist even if the couple are to be seen by a specialist sexual therapist. Since sexual feelings ply such an important part in the establishment of marital bonds and serve as a unique distinguishing feature between the marital subsystem and the other family subsystems, it is a vital area for the family therapist to master.
Family home visits may be time-consuming and wasteful of resources, but they are equally essential as Bloch has describedNote 13. I use home visits when I am puzzled by the discrepancy between reported behaviour and behaviour which I experience in the session. Home visits are also valuable in assessing the environmental influence on the interactions between family members. Finally, home visits have enabled me to meet family members who were unwilling or unable to attend sessions at the office. Home visits increase understanding of the difficulties which clients feel when they attend the familiar territory of the therapist's office. The therapist unaccustomed to visiting in the homes of his families may feel de-skilled and de-roled as the family envelops him. An increase in therapist anxiety and puzzlement may result. The visit may turn into a social occasion rather than a working session. An ability to work while in the territory of the family will increase the therapist's ability to work in his office.
A home visit done to the Bond home was undertaken to discover why there were discrepancies between the family stories about the state of the home. The family arguments centred on the wife's inability to cope with her housework or her two children. Mrs Bond had a long history of suicide attempts and had been treated for endogenous depression. Her husband denied that things at home were as bad as she believed and the children's description of their home life was at variance with hers. I offered to visit the house to see for myself. I arrived to find a home immaculately kept, well decorated and maintained. The other family members were very uncomfortable as I confronted Mrs Bond with her
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misrepresentations. She broke down and wept as she turned to the emotional difficulties which had bothered her. Mr Bond had withdrawn from her five years ago after his father died. Their sexual life had stopped then. The youngest son was in trouble with the police for truanting and theft and their oldest son was heavily overeating. The other family members admitted the truth of these facts although they had denied that there were other problems in the family during the sessions. The home visit had led to a confrontation which opened the family members to new issues in therapy.
In another family the discrepancy between the living conditions of a family as reported by the family doctor versus reports by the family members led me to visit the home. The home environment was substantially as the family had reported; the damp which had come through the ceiling had indeed caused the paper to peel off the wall. Otherwise the house was neat and tidy. The parents were rightly concerned about the health of their children and the family quandary involved the provision of basic needs for the family rather than a relationship problem.
Some of the home visits which I have done were required in order to engage family members who would not otherwise be included in the sessions. The children of a couple were of primary importance in the marital disharmony. The youngest child was autistic and brain-damaged. The parents had refused to allow their children to be seen at the hospital and had objected to their eldest son being involved. By planning a home visit I was able to gain their agreement and trust. The home environment was one of 'treading on eggshells' and emotional strain which was infectious and stifling. The over-control which was a feature of the family setting at home was an important factor in the marital dilemma.
Similarly a home visit was made to the home of the mother of the wife of a marital couple in treatment. The mother had refused to set foot in the hospital but agreed to a home visit. She was very bitter about the way in which she had been treated by previous doctors over her daughter's illness. The visit allowed reparative work to be done between the two which would otherwise have been impossible.
Before leaving the home visit I would like to call attention to the work of ScottNote 14. He has organised and developed a community psychiatric service in which family-oriented home visits form the bulwark of the primary intervention to the request for psychiatric help.
1. S. Minuchin, Families and Family Therapy (Harvard University Press,
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2. W. Masters and V. Johnson, Human Sexual Inadequacy (Little , Brown, Boston, 1970)
3. P. Watzlawick, A. Beavin, and D. Jackson. The Pragmatics of Human Communication (Norton, New York, 1967).
4. M. Erickson, 'Indirect Hypnotherapy of a Bedwetting Couple', in J. Haley (ed)., Changing Families (Grune and Stratton, New York, 1971), pp.65-9
5. E. Carter and M. Orfandis, 'Family Therapy with One Person and the Family Therapist's Own Family', in P. Guerin (ed), Family Therapy (Gardner Press, New York, 1976), p.200.
6. N. Ackerman, Treating the Troubled Family (Basic Books, New York, 1966). pp.6, 15, 29, 118, 123, 145, 146, 271.
7. C. Whitaker, 'The Hindrance of Theory in Clinical Work', in P. Guerin (ed), Family Therapy (Gardner Press, New York, 1976) pp. 154-164.
8. S. Lieberman 'Nineteen Cases of Morbid Grief', British Journal of Psychiatry, vol. 132 (February, 1978) pp. 159-173.
9. N. Paul and G. Grosser, 'Operational Mourning and Its Role in Conjoint Family Therapy', Community Mental Health Journal, vol.1 (1965), p.339.
10. I. Alger, 'Audiovisual Techniques in Family Therapy', in D. Bloch (ed), Techniques of Family Psychotherapy (Grune and Stratton, New York, 1973), pp. 65-75.
11. F. Duhl, D. Kantor, and B. Duhl, 'Learning Space and Action in Family Therapy: A Primer of Sculpture', in D. Bloch (ed) Techniques of Family Psychotherapy (Grune and Stratton, New York 1973), pp. 47-65.
12. Masters and Johnson, Human Sexual Inadequacy. Books which can be assigned to clients to be read at home include the following:
(a) P. Brown and C. Faulder, Treat Yourself to Sex (J.M. Dent & Sons, London, 1977). A self-help manual which provides simple explanations and 'sexpiece' exercises.
(b) A Comfort (ed), The Joy of Sex (Quartet Books, London, 1974). A book which describes lovemaking in detail, readable and easily understood.
13. D. Bloch, 'The Clinical Home Visit', Techniques of Family Psychotherapy (Grune and Stratton, New York, 1973), pp. 39-47.
14. R.D. Scott, 'Cultural Frontiers in the Mental Health Service', Schizophrenia Bulletin, issue 10 (Autumn, 1974), pp. 58-73.
