III - Family Psychology & Family Psychiatry - Psychotherapy
The term “family psychotherapy” means treatment of the family by any procedure that helps to restore health to the family. The term “family therapy” has sometimes been misused and employed in a wider sense to cover a family approach, or in a narrow usage to cover one treatment technique, family group therapy.
Psychonosis is a preventable disorder; severe states of psychonosis are difficult to cure; moderate states of psychonosis can be modified.
Thus, the greatest hope for the eradication of psychonosis and the improvement in the standard of emotional health lies in the promotion of emotional health rather than in direct procedures of cure. However, the two roads to health are parallel and complementary. From the curative field comes knowledge that can be applied on a wider scale in health promotion; curative measures offer a research area. At the same time, curative procedures make a small, but useful, contribution to improving the standard of emotional health.
The greatest bar to progress in therapy is not lack of personnel, or services, or efforts, small though these are; the main bar to progress is ignorance. The emotional and mental health services should not be judged by their therapeutic success; this is small. Their importance is that they exist. Because they exist they are a rallying point for the afflicted and the problem is exposed. Furthermore, they are a rallying point for a large number of dedicated and interested workers, who some day will collectively find the answer to psychonosis. Unfortunately, they are also the rallying point for an even greater number of workers who seek palliation of their own problems through working with others in a similar state; to select healthy workers, the product of healthy families, is one of the greatest organisational problems facing all the professions in this field.
Ignorance is the true bar to progress. The field is complex. Research is difficult because of the many variables. The work is highly emotive and lends itself to misconception and wishful thinking. Many workers are dedicated, but their grasp of scientific principles is rudimentary. Thus, vague notions of a quality that can be termed mystical offer great appeal; the appraiser, aware of his own ignorance, assumes that the mystic has greater knowledge and that his own lack of ability prevents him seeing the truth. Thus, he assumes the truth to be there, when in fact he is faced with intellectualised wishful thinking.
Ignorance is prominent in psychopathology, a vital but most difficult area. Only understanding of the pathological process can lead to rational therapy. But, here, ignorance is at its greatest. Explanation has been invented rather than sought in carefully planned investigation. Invention has relied heavily upon thinking by analogy. Analogous phenomena are assumed to have all the same characteristics of the phenomena with which they are compared. Thus, picturesque illustrations are assumed to have causal links; links made so readily in the illustrations are assumed to apply in the life situations with which they are compared. That such obvious misinformation is allowed to go uncorrected soon makes it clear that heavy personal emotional bias is at work. For example, it is stated that children are brought up by mothers, when simple observation shows that they are brought up in a group – and yet uni-object relation therapy is sacrosanct. Psychopathologies do not tally with reality, or with experience. Such is the ignorance of psychopathology that it is not surprising that therapy is largely ineffective. With irrationality dominating the principles on which it is based, therapy must be ineffective. Cults have replaced responsible investigation. The way into the cult has often been through sickness. The patient becomes the therapist. Later still the therapist becomes the teacher. The blind and weak lead the weak and blind. The cult wards off attack by defences built on a dogma that cannot be understood, and thus cannot be attacked, by the uninitiated.
Emphasis has been given above to the understanding of psychopathology. It is important also to emphasise the importance of diagnosis. One must understand before one can treat effectively. Similarly, if one does not differentiate between diagnosis and therapy much of what happens in the process of diagnosis is assumed to be therapy. Almost all the films on “family therapy” (ie family group therapy) are, on careful evaluation, nothing more than diagnostic exercises. The family and the “therapist” (in truth a diagnostician ) learn a great deal about the history and psychic tribulations of the family. But nothing changes. Revelation is not therapy. Insight is not enough. Let me illustrate: An account is given in one publication of about 50 “therapeutic” sessions involving a mother and son. In the last session, the mother is able to reveal that the pregnancy which resulted in the birth of her son was the cause of her unhappy marriage. She hates the husband and his son and rejects both. The cause of the son’s vivid adolescent misdemeanours is now clear. The therapy is now assumed to have come to an end; revelation has been made. But the mother does not thereby stop hating. Nor does the damage done to her son over the last 15 years urgently repair itself. All that we witnessed was an encounter which allowed rapport to develop very slowly (a sympathetic friend would have reached this stage as quickly) to the point when the woman could reveal to a therapist something she already knew. The sharing of knowledge is a prelude to therapy, but it is not itself therapy.
One of the major lessons of diagnosis is to reveal the way in which somatic pathology runs parallel with psychic pathology. It is rare for psychonosis in an individual or in a family not to show itself in some somatic pathology. Only global examination exposes how common is this link between somatic and psychic pathology, and often the severe, and life threatening, nature of the somatic pathology. Diagnosis establishes the case for somatic and psychic therapy to run together.
Diagnosis must be accepted as a separate, if sometimes parallel, exercise from therapy, otherwise we shall not appreciate what little therapy takes place. It is matters such as this which lie behind the comment of an honest and particularly experienced therapist, both as psychoanalyst and family therapist. He was told by a prominent family sociologist, “I feel the need for the therapist to explain himself, what he did, how, when, and why, with a particular family”. Nathan Ackerman comments, “Again and again, I try to do this but I am never sure that I succeed”.
Would the populace be worse off if there were no psychotherapy? A protagonist might say that surely effort must stand for something. But the massive blood-letting perpetrated in the past in somatic medicine was also effort; it was based on wrong ideas of pathology and did much harm to those it was trying to help. We cannot contemplate the therapeutic scene in psychiatry today with equanimity. More harm than good in therapy may easily be the order of things. Psychotherapy is practised on a wide scale, with great enthusiasm, in many guises, by almost anyone. It is often insufficiently realised that bad practice is worse than no practice. No surgery is infinitely to be preferred to bad surgery. No one, least of all the patient would accept a situation where an enthusiastic first aid worker was allowed to practice major surgery. But surery of the psyche based on bizarre rationale is everyone’s practice. Inactivity at least allows the organism’s natural defence mechanisms to have their sway. Intervention may prevent this, eg loss in divorce, like loss by death, goes through a number of natural stags ending in resolution, helped by forgetting, which is the main defence mechanism; but misplaced “psychotherapy”, by analysing the breakdown in detail over many months, merely succeeds in preventing the natural process of forgetting from playing its therapeutic part.
To prove that a procedure is therapeutic, it has to be established: (i) that a change has taken place; and (ii) that the change is for the better (it could be for the worse).
To often we are content to delve to the point of understanding events and then we hope that “something will happen”. The change must be shown to be constructive and fashioned to this end.
But not all is lost. Some practitioners of psychotherapy, the better trained, proceeding with caution, recognise the limits of knowledge, and practice within these limits. Furthermore, some practitioners have the precious gift of a harmonious personality; this exercises itself to the patient’s benefit, whatever the dogma held.
Psychotherapy is in a parlous state. The road to retrenchment is clear. We must return to the data of life, the facts of reality, to life experience as it is. If we can study, dissect, understand the life experience, we can learn how to reverse the psychopathological process. Therapy can then have a proven rationale and a predictable course. Already much progress has been made, data are available and, fortunately, the way to ameliorate through health promotion is already open.