III - Family Psychology & Family Psychiatry - Psychotherapy
The blacksmith had this to say in Ronal Blythe’s Akenfield(1) – “I always look at the parents before I take an apprentice. If you know the home, you already know the son.” Family meets family – this is the essence of the encounter in benexperiential psychotherapy, not an individual therapist meeting the family. The therapist is the epitome of his own family. Thus, the meeting is between his family and the family under treatment. Selection of therapist then means selection of the therapist’s family.
The therapist’s preceding family is the area for exploration when consideration is being given to choosing a trainee therapist. Success in his own family will go a long way to guaranteeing success with families in treatment. Great care must be given to this task. A therapist requires an exceptionally harmonious personality; it is this which is going to make it possible to stand up to the strain of contact with very disturbed people, coping with persons with varying problems, giving security when it is required, withstanding hostility, offering toleration, charity and affection. All these qualities can be provided only by the product of an exceptionally harmonious family.
It is sometimes thought that training will overcome deficiencies of personality. It never does. Even new methods of therapy will not guarantee success by a therapist with severe personal deficiencies; the old therapies have been markedly unsuccessful both in training and in clinical work. Furthermore, it is far better for available training resources to be concerned with inculcating expertise in those of sound basic personality. It is sometimes argued that to have undergone a number of breakdowns adds insight into the process. This notion does not stand up to examination. Persons predisposed to breakdowns have suffered through the trying home situation that have denied them those qualities essential to help others. Of these qualities one of the most essential is the capacity to give emotionally; this is the very quality lacking in the emotionally ill.
Selection of therapists should turn around careful evaluation of preceding family climate followed by an apprenticeship to a master in psychotherapy. These in turn should be married to experience – experience of the world as it is. Therapists should ideally have been cast in many economic roles, roughed it around the world, had class, education, religion, cultural and other biases rubbed off in the hard school of life.
Success in psychotherapy depends upon: (i) the experience of a harmonious family; (ii) on having been exposed to a broad life experience; (iii) training under a master craftsman in psychotherapy.
In this chapter it is better to aspire to describing the ideal therapist; in practice we may have to settle for less.
In the therapist one looks for qualities such as toleration, with the capacity to understand and be charitable to a wide range of human failings; the ability to be unbiased and unprovoked by the less beautiful aspects of life; a capacity not to blame or moralise. The therapist must be friendly, kindly, understanding. He must be able to make warm relationships with a great variety of people. Indeed, the greater his adjustment, the wider his spectrum of affectivity.
Chairman and convenor
The therapist has the task not only of convening the meeting, but also in general terms of directing his efforts. After all, the family has come for therapy, not for a pleasant afternoon’s discussion of contemporary social events. Thus, his presence or his words must continually remind the family group of the task on hand. He must be sensitive to the topics that the family needs to discuss and, furthermore, can discuss at that moment. Sometimes, the family has not as yet the capacity to tolerate a topic. He must give everyone in the family the right to speak and to do so in security.
Catalyst and releaser
Expectation, and sometimes silence, provokes the family towards a discussion of events which are embarrassing, hurtful or painful to them, matters which they would wish to avoid. He instigates an exchange where necessary. On the other hand, he teaches the family members that an interchange can take place without aggression, hostility and fury. He himself indicates and teaches that rational discussion can bring the resolution of problems. Above everything, he is expectant; his non-verbal behaviour conveys a deep and sustained interest in his patients.
The healthy therapist brings with him the values and the opinions of the community; a man of the world, he sees life as it is and accepts the best of it. The family may not conform to the attitudes and principles in the community outside, but can acquire these from the therapist. Explanation may sometimes be called for. The therapist inculcates an attitude by example rather than by direct teaching. It behoves the therapist to have adequate community values of his own and be secure enough to recognise and discard outdated values.
The attitude of the therapist is always that of conciliator, when faced with hostility or aggression of one family member to another. His aim is to create a climate where constructive work can proceed. He is not a judge, but a conciliator. He should avoid taking sides. Indeed, he has loyalty to all the members of the family and this will be tested time and time again. He must truly be a benevolent, security-giving figure to every member of the family.
No one within the family group should, if possible, be hurt through the family discussion. Thus, to some extent, the therapist is a protector. This is particularly true in relation to the younger or weaker members of the family. In the eyes of the therapist, everyone is equal, everyone deserves support, everyone has equal rights. His loyalty is to the family group and thus to all.
Even if he does nothing else, the therapist, by bringing a healthy attitude into the family group, quantitatively dilutes the psychopathology of the group. The only effective argument for having more than one therapist is that the dilution process is even greater. However, as will be seen, this can have disadvantages.
Embarrassing, belittling, hurtful attitudes and experiences are exposed within the family discussion. The toleration of the therapist removes the sting from all these experiences; in particular, guilt is relieved.
The therapist reveals and clarifies. He does not interpret (translate) into other terms. The only valid term is life experience, factual and unadorned. Revelation must not occur too soon or be used to hurt. It must never be more than can be endured – and the capacity for this depends on the degree of security. Benevolence creates increasing security and increasing endurance. Naturally, revelation itself does not produce change, but is a prelude to change.
The therapist’s main task is to reveal to the family its collective group psyche based on the family imprints from the past. This is analysis only. Reconstruction must follow. Thus, as will be discussed later, he then has to mobilise the assets within and without the family to overcome its liabilities. He needs to build new healthy coping devices and he needs to find ways to circumvent deficiencies produced by the preceding families. Handicapped family members have usually experienced unhappy family relationships in the past. Now they are in touch with a benevolent family figure. This figure, however, exercises no power. Indeed, one of the lessons he has to teach the family is not to use force, power or authority. He aims to create a situation of security wherein the family can reveal itself, work towards resolution and thus change.
A therapist is a craftsman, a trained expert. A therapist should not appear to be a god, it is said, and should therefore admit weaknesses – it makes him human. Patients do not expect their therapists to be gods, but they do expect them to be craftsmen. To admit having weaknesses, of any considerable degree, is a negation of expertise. Affection can be expressed without the admission of weaknesses. This attitude of apparent honesty relieves the therapist of feelings of guilt at inadequate performance; an even more honest attitude would be to admit the need to change vocation. The therapist is fundamentally an expert and a craftsman, who uses the warmth given him by his family as an affective and effective tool in his task.
A figure in his own right
Therapists are not necessarily parent figures. Though in child development literature prime place is given to mother, in therapeutic literature father often comes into his own as an all-powerful, supportive father figure. But this is a distortion of events. Father, mother, uncles, aunts, brokers, butchers, jockeys p all can have personal qualities of the highest emotional quality. Indeed many jockeys are also fathers. What people crave for at all times from others is an affectionate relationship. This is more important than its sources, even if the latter are the parents. Love is more important than parenting. Parenting may or may not supply it. Others may or may not. Thus a therapist is not just a parent figure – he can be a figure in his own right. A therapist is not a good mother or father figure, but a good therapist.
A number of therapists fail because they are constantly at war with the family under therapy; there is a need to outwit, manipulate, score off, feel omnipotent towards, or crush with hostility. At best this is bad technique, at worst this reflects the therapist’s experience in his preceding family. Consider the following extract from the literature:
As D. X suddenly flipped from his mimicking involvement with the family to being sarcastic, you had the feeling that the family was suddenly being cut apart. I think it is necessary at times to hurt in order to get at the pathology, in the same way that you can’t get at the appendix unless you go through the skin and belly. And then he got sneaky, as a master manipulator, and the rest of the film, to me, could be lumped in this area. (Author’s italics.)
Here, we have mimicking, sarcasm, to cut apart, hurt, being sneaky, manipulation. This is not therapy but war – and of a dirty variety. The analogy with surgery is unfortunate; great surgeons are renowned for the minimum of trauma, effortless technique and absence of drama. The above is not analogous to surgery but to butchery. Confrontation is at its height in films and public performances of therapy. The insecure therapist needs to exert himself, there is much blood about, the drama is great – but the family bleeds. And the audience, all would-be therapists, identify with the powerful therapist and soon the family has ceased to be as it is. It is a thing apart, responding to different roles, with different feelings, a savage dangerous thing. But it is not really different. Its members are as we are. They are us.
Hostility brings insecurity and the need to defend – even by force. Thus it maintains the unhealthy coping devices. Security is an essential precursor of change.
The essential confrontation is between the family of the therapist and the family under treatment (and their preceding families) or preceding family of the individual patient. Both father and mother in their preceding families and children in the present family have undergone a holistic experience – an interaction between child and father or child and mother. (In the literature on child psychiatry, because mother comes to clinics with the child, there is an emphasis on the mother/child relationship. In literature on what is termed “transference”, as the therapist is often a male, there is emphasis on the father/child relationship. Both are artefacts.)
The therapist also represents a family, complex and multidimensional, a family of the best kind. He is the amalgam of a superb G factor plus special skills. He is himself. Patients are not in touch with a phantom of their own making, but with a real person. They react to the therapist as the life experience to date, especially in their families, has taught them.
The way they interact with the therapist is personal to them and their experience and speaks of it. Thus it is helpful in diagnosis. But this is diagnosis and not therapy. It is not correct to interpret (ie translate); one should reveal. Any knowledge from the interaction reveals the preceding family; no interpretation is required, but simply the revelation of facts about the preceding family.
The best therapist will be aware of some weaknesses in himself – real ones from his family – and will make allowances on this account. The patient is not interested in this. To expect help from a patient is ridiculous. The therapist must go elsewhere for any help, or in the event of marked weaknesses, seek other work than therapy. In the past, the analysis of “counter transference” has been a substitute for a sound therapist.
“Transference” and “counter transference” are a part of the interaction between patients and therapist. To claim that they are the whole, the major part, the more important part, of the interaction gravely limits the interaction and its potential.
Diagnosis is not therapy. The therapeutic element depends not on the analysis of the communication, but the capacity through the communication to give a new constructive experience, ie a benexperiential therapy. This is not achieved through an interaction with a projected image imposed by the therapist. The ideal therapist has an easy time – much of the time he automatically does and says the right thing.
The greater part of the communication between therapist and patient occurs at a non-verbal level – an intensely affective level. Eyes, face, posture, gesture and movement convey interest, encouragement, praise confidence, security, toleration and the expectation of change. It has the added advantage of being time-saving. Time consuming verbal communication alone is almost exclusive to the insecure family group.
Effective therapy takes place in tranquillity, peace and orderliness. Drama is for the ineffective.