III - Family Psychology & Family Psychiatry - Psychotherapy
Elements of Technique in Benexperiential Therapy
In the discussion that follows it is assumed that the standard interview is the family interview; most of the information would also apply to other types of interviews.
Insight. To confront is a hostile exercise. To reveal is untraumatic. Revelation is tolerable in the security of a sound relationship with a therapist. Insight implies the understanding of the significance of psychic events as they relate to that person or family. It leads to an awareness of the psychic noci-vectors that led to the damage to the “idea of self” in the past, the vulnerabilities there were produced, and the coping devices employed. It allows awareness of the psychic noci-vectors operating today on vulnerabilities produced by the past.
Insight is only a prelude to therapy
Psychic noci-vectors now. The psychic noci-vectors or vectors must be identified. They may be operating on a sound personality or on a vulnerable personality, which, on removal of the vectors, can only return to its pre-traumatic state.
The following procedures, alone or together, are employed against the noci-vectors:
- Resolve the conflict of attitudes from which the vector comes. Thus the quality of the vector can change.
- Reduce the power of the vector. Frequently, preoccupation with it allows it to dominate thought and appear more threatening than it actually is. Thus putting it in perspective will reduce its power.
- Reduce the time over which the vector works.
- Arouse assets in the individual to measure up to it. Self-confidence allows of healthy coping.
- Share the experience with the patient and allow other constructive people to do the same.
- If it is not essential to his interests to meet it, allow the patient to side-step the vector without loss of face.
- Counter the vector with opposing vectors of greater strength, repeated, and of long duration.
Damage to “idea of self” in the past. The damage is repaired by putting the self through a benevolent new experience. This is a process. A process is a “continuous series of events”, eg guilt, with its damaging feeling of unworthiness, having been exposed, is countered. The security of the relationship with the therapist or others and the reduction in damage allow maladaptive coping devices to be put aside and be replaced by new healthy devices – usually imitated from the therapist or others and the reduction in damage allow maladaptive coping devices to be put aside and be replaced by new healthy devices – usually imitated from the therapist or others. Special attention should be given to the more powerful coping devices listed previously. Insight allows identification of previous damaging vectors; to use benevolent vectors of reverse but greater power than the damaging vectors is central to success.
It is crucial to understand that a process requires time over which to operate. The greater the damage and the longer it has been operative, the longer the period of therapeutic time required. Intensity of therapeutic process can reduce this period.
The greater the damage, the greater the number of unsatisfactory elements in self, and the greater is the therapeutic effort required.
It is fundamental to understand that the therapeutic process need not take place exclusively in the interview situation. The following are possible:
- An exclusive interview process. This is necessary for very damaged people and calls for frequent interviews over a long time.
- Guidance by therapist and use of others, especially the family, as allies in therapy.
- Vector therapy, guided by the therapist. Benevolent influences in the family and outside are utilised to repair the damage to self; they can also be used to counter any psychic noci-vectors in the present.
The importance of the process and the use of extra-interview therapists can be shown by two brief illustrations, one from ethology and one from clinical practice.
Harlow (2) and his colleagues have been conducting for many years a series of intriguing experiments with monkehy. This work passed through a number of phases and has now reached the ultimate in interest. The sequence of events was as follows:
A number of young neurotic monkeys were produced by deprivation situations. Some grew up and the females were mated. They became neurotic mothers and rejected their infants. So severe was the deprivation of the infants left with their mothers, that they had to be rescued. The workers now sought some means of treating these second-generation disturbed infants. They tried behaviour therapy in vain. They tried the care of adult monkeys – but these punished the infants and there was no success. They then paired a disturbed monkey with a healthy monkey. The older monkey did not threaten the younger, nor did the younger impose rules on the older. The relationship prospered and in six months there was a marked improvement in the older monkey. The workers concluded that the young monkey was effective, even though it had never read about psychotherapy!
Here is a therapeutic process at work – and effective. To understand this process is to know the full nature of therapy. We now know a great deal and can hasten and enrich this process. But, even without full knowledge of its nature, the right process can still work.
Mr. X is an angry man. His father was an angry man. His father made him very insecure and damaged his “idea of self”. His father ignored him and he is very sensitive to being ignored. It makes him angry – this is the device he adopted from his father as a means of coping. Mr. X is quickly angry – not only with men but with women, his wife, his son, his daughter, his friends. Ignore him and he is angry, and it matters little who ignores him. He feels “little inside”, unworthy, despised. Mr. X has help. His preceding family is not available. A strong secure relationship allows him to talk without shame or fear of his early deprivations. But that alone does not make him less angry. The relationship passes into its constructive phase. In a long, intense companionship he is given attention, his assets are realistically emphasised, is self-appreciation improves, and his most sensitive vector, being ignored, is negated by attention.
Others are encouraged to enmesh him in the same pro-Mr. X experience – ie benexperiential therapy. Thus therapy was shortened by the use of the extra-interview therapists.
It may be useful to outline some of the major shortcomings of some methods of therapy used at present:
- Listening is not enough. There has been a tendency to regard the therapist’s role as being a passive one of listening. This is far from the case. In the diagnostic formal phase there must be active questioning with much participation by the interviewer. In the elucidation of psychopathology the role is less active, but direction is required to cover the whole area and active clarification of data may be required. As we have seen, the therapist has a highly active role in therapy, even if non-verbal; guidance, experiential process work and decision making are essential parts of his role.
- Decision making is an essential part of therapy. It is held that the therapist must never make decisions or even be involved in the decision-making process. This at worst is a deliberate avoidance of responsibility, at best it is bad technique. In surgery such a situation would be unacceptable. Take a moment of decision in psychiatry, eg the decision by marriage partners to seek a divorce. This requires involvement. The formula is not “I will make the decision for you”, but rather, “We will explore the situation together and my skill will clarify the issues for you better than you can do on your own. In the light of this, you and I will be able to arrive at conclusions. If you and I disagree, I shall make my view clear to you and you have a right to follow the course you wish without my concurrence as to its wisdom, but still with my support. If we agree, you will be able to carry on with my concurrence.” Support is never withheld, there is no upset at advice not followed, blame and guilt are not part of the transaction, and for the patients to change their mind later is a possibility. But the therapist does not shirk being involved in decision making. Skill cannot develop in situations where there is avoidance of responsibility.
- Diagnosis must precede therapy and not be confused with it. To garner information, to develop insight are elements of diagnosis. But diagnosis and information collecting must proceed to the point of relevance only. To avoid decision making, it is easy to slip into a situation where it can be said “but we have too little information”. This puts off the evil day of decision making. It is not usually relevant to know the colour of the maternal great grandmother’s hair before coming to a conclusion as to whether William should live with his father or his mother.
- Insight is not enough. To explore a situation and reveal why a trauma was suffered is not of itself therapeutic. Insight is a prelude to the constructive phase which of itself is therapeutic. To be aware that one’s finger hurts because it has turned septic does not of itself open the abscess, but it is an essential prelude to effective therapy. In psychotherapy, the constructive phase is much more difficult and hence there is a tendency to be content with insight.
- In decision making, the family or individual has no greater wisdom than the therapist; if the latter is competent, he should have considerably more wisdom than the patient. To shirk responsibility it is easy, when convenient, to say, “The patient knows best and can make the decision”. But it is the patient’s confusion that has brought him looking for help. Psychopathology is a complex field for the most experienced; the patient is usually lost in it and the more disturbed he is, the greater his confusion.
The warming-up period
In every course of therapy, there is an initial phase of warming-up which may extend from a few minutes to several interviews. This is inevitable, as the therapist and the family have to get to know one another. The family has to go through a period of convincing itself that it can allow the therapist to join the family, that it can trust him, have confidence in him, and confide in him as an equal partner. To some extent every interview starts with a warming-up period. The therapist must be sensitive to the need for a warming-up period.
It is valuable, at the start of therapy, to explain to the family the expected organisation in general terms. It is possible also to explain to them in outline the rationale of therapy, as sated above. Furthermore, it is wise to point out some of the rules under which the family is meeting; for instance, every member of the family has equal voice, whether it be child or grandparent. Not all these working rules will be acceptable at first. Again, the family will go through a testing-out period, but the attitude of the therapist continually reminds the family of the working rules.
The facts and no interpretation
Interpretation in family group therapy is in a sense a contradiction in terms. The only truth is the truth of an event within the life experience of a particular family member or a particular family itself. The event does not need interpretation, it is a fact. Thus, a therapist enslaved by interpretation theory will be less effective. It is only the family who know the facts at first.
It can be educative to hear three experts discussion information conveyed by a patient. They can radically disagree amongst themselves, biased by their personal experiences and their school of interpretive psychopathology, but the only true meaning of the information is that given by the fourth person, the patient himself. Broadly, people’s experiences follow the same pattern, but the significance of events is unique to each person. Stereotyped interpretations have little significance. The therapist must constantly be on guard against assuming that other people’s life experiences are like his own and have to be interpreted in the same context.
The greatest errors are made because of dogma – situations and words are distorted to fit in with the creed. Let me illustrate. A therapist is helping a husband and wife with their marital problems. Discussion turns to sex and they reveal a most unsatisfactory situation in the physical act which has steadily deteriorated since the start of the marriage. The therapist, by his canons, traces everything back to sexual disharmony. Yet data are produced to show that both partners have had satisfactory sex relationships before marriage, succeeded early in marriage and do now on the rare occasions when they are happy together. The partners insist that their problem is one of personal incompatibility. The therapist insists it is sexual incompatibility. They seek help for their relationship as they are convinced, and know, that given harmony the sexual intercourse would be satisfactory. But they are offered advice for the sexual disharmony alone.
Some regard objects and even words as having special significance and always to be rigidly interpreted in a particular way, eg one therapist equates “dog” with “prostitute”. Any mention of a dog carries this hidden meaning. For some people in special circumstances this might be so, but for a large number of people a dog is a dog. The term “gas” by the same therapist is equated with the anus and hides anal eroticism. The word “piece” is equated with an “attractive woman”, whenever it is mentioned.
We can see how remote from reality the explanations become when we study this brief extract from an interview:
Father picks at his nails. Therapist observes this and calls attention to it. At this point son, in defending his father, is critical of his mother as the mother has said this is a disgusting habit. Therapist then makes the remark to son, “What kind of piece would you like to pick out of your mother?”
The therapist claims he made this remark to bring out son’s erotic interest in his mother, ie mother is a “piece”. But he is arguing from analogy, and very approximately at that, and giving special meanings to words. It is father who picks at his nails and not son, even if we accept that to pick at one’s nails is hostility. But it is son who is hostile and he is not “picking”. Hostility and picking are given to the son when hostility alone belongs to him. The therapist in his mind then links picking with a “piece”; piece is equated with “attractive woman” (when it could just be a piece of nail or anything). But the word “piece” was first used by the therapist and might reflect his views, but hardly those of the son. Then it is further assumed that the son has an erotic interest in the mother, even though he did not use the term. This is sheer fanciful invention decreed by dogma and takes us away from the facts. The true meaning is simpler and more direct; the son wishes to support his father against the hostility of the mother and the therapist, who has made a partnership with her/
Again, take statements based on preconceived ideas such as: “The child is in love with its mother. This is why he is hostile to his father.” But he may love both. Or: “This child (of three) always wants to go to the parents’ bedroom in the mornings. He wants his father out of his mother’s bed, so that he can have intercourse with his mother.” An interpretation is put upon a situation which is not proven; many other explanations are possible. Furthermore, as ideas are based on sexual pathology alone, adult notions are transferred to the child. Situations are made to fit fixed ideas. Chance associations are given casual significance. This distorts the truth.
Patients, individuals and families, do not always find it easy to grasp the significance of events. They are not psychopathologists. They more readily see the significance of a chain of material, rather than of emotional, events. They wish to forget what is hurtful, embarrassing and damaging to the “idea of self”. Thus, they must be led to the truth and the truth lies in real events. To misinterpret adds to their difficulties. (But they can come to believe the misinterpretation.) The exercise is only necessary and justifiable if it can lead to what they want – help. Thus, it is necessary to point out, explain, clarify, underline, reveal – but not to distort.
The therapist, equally, may not know. He has not the capacity to know simply by wanting to. He is dependent on data. He must have facts and the facts must be real. The facts are concerned with the people he helps. The therapist may, by his greater knowledge of similar situations, arrive at the truth before the family. He should guide them to the truth – by revelation, clarification, explanation, and sometimes by repetition. Explanation must be in words they can understand. If a family comes to the truth in terms of a dogma, then it is likely that the therapist is imposing foreign notions upon them.
There is a time and a way of making a revelation. It should add to security and not take away from it. It should not be a confrontation or a display of hostility. It should be so judged that the family can cope with it, without upset, and it should be used constructively. A statement can be attenuated and pitched at a level which is acceptable at that time. There has to be a delicacy about these things based upon experience of life and a need not to hurt others. Damage can easily be done – a brutal statement to a lady that she is getting old, however true, is unconstructive.
But truth never emerges without rapport; the darker the secret, the deeper the rapport needs to be, and rapport makes for security.
Degree of insight
Insight is the understanding by the family of the mechanisms of the emotions. The greater the disturbance in the family, the less the insight. The developing understanding of the significance of emotional events takes longer with a more disturbed family, but time spent on insight is essential. Understanding, however, is not therapy. It is discernment, diagnosis. Having seen the course of events, it is essential to re-experience and to reconstruct.
Intelligence has no correlation with insight. Dull, undisturbed people can have remarkable insight. Very intelligent, highly disturbed people may have no insight. Intelligence can help or retard interviews; insight has great relevance to the speed of progress.
The family has to learn that silence on the part of the therapist is an invitation to talk. The easiest interview for the family is when the therapist does all the talking, but this interview is the least worthwhile. The greater the security of the family, the more silent their therapist can be; the greater the skill of the therapist, the more silent also will he be. The therapist moves to non-verbal communication, significant and time-saving. Silence is the biggest and yet gentlest pressure that the therapist can put upon the family to get it to work. However, the family may need to be silent from time to time. During this silent period it is working in contemplation; afterwards may come a true move forward in the family’s affairs.
The aim should always be to interrupt as little as possible; interruptions result in a break, an artificial break, in the flow of the family’s thinking; the wrong comment or question may cause it to go off on a line of thought of less significance, or may give it an opportunity to avoid discussing something which is relevant. Direct questions very rarely bring profitable results. Far better to ask indirect questions, which will inevitably lead to the area being discussed. For example, it is of little value asking an individual, “How did you get on with your mother as a child?” It would be much more profitable to suggest topics which will inevitably throw light on the relationship between mother and daughter.
The above does not contradict the need to guide. The therapist can pick up cues from what has been said and lead the family to an area requiring exploration. Sensitive areas may be avoided or skirted at first. The therapist makes a note of these and guides the family back to them on a later occasion. This may need several excursions. As rapport and security improve, so the sensitive, but highly significant areas, are dealt with.
Allies in the family
The most disturbed of families has assets. These are of two kinds: (i) Disturbed family members have elements in their personalities that are beneficial to other disturbed members. (ii) A family may have a comparatively healthy member who, given new cues and insight, can have a beneficial effect – even when there is no formal therapy. A therapist must evaluate the assets of the family and use them to the full. Thus family members can be allies in therapy.
Families are naturally uncomfortable when embarrassing, hurtful material springs up. Thus, there will be not only avoidance of such topics, but invention of apparently good reasons for not discussing them. They miss interviews, are late so as to allow little time for discussion, keep silent, raise superficial, irrelevant topics, attack the therapist for his inadequacy, etc. This behaviour is based upon insecurity. Avoidance is hanging on to old coping devices. These are moments for particular patience and tolerance. Even more effective than discussion of this behaviour is to raise topics that will deepen the rapport. As this improves the avoidance melts away.
During the course of therapy, the mood of various family members will change; as one improves, another deteriorates, and so forth. These swings are to be expected in the course of therapy. Indeed the mood of the whole family in normal circumstances is a variable entity.
Danger to the family
Management of severe, acute situations in the present or re-enactment of material from the past naturally provokes acute symptomatology. The therapist has a responsibility to control matters in such a way that the risk is reduced to what is reasonable. Family members prone to being epileptic (10% of the population) may have epileptic attacks; others may become accident prone; ulcers perforate; cerebral thrombosis and coronary thrombosis are a possibility; suicidal attempts are made. A careful eye must be kept on the somatic and emotional health of the whole family. Danger must not rise above a manageable limit. Irrelevant, but highly traumatic events, eg war experiences, are sometimes best circumvented and left encapsulated in their coping defences. It is not effective therapy irreparable to harm or kill the family – or have the family kill others.
Acting to real trauma and not the object of stress
Some of the trauma in the present is evoked by trauma in the past, eg a husband’s attitude reminds the patient of mother or father. But the patient reacts to the image of father or mother only if the husband’s behaviour is like that of the father or the mother. The behaviour is the stimulus and not the conveyor of it. Thus, a man who behaves aggressively provokes a bigger response in a person sensitive to aggression than does a man who looks like the patient’s aggressive father, but who is not aggressive.
Levels of discussion
The family moves through certain levels of experience in the course of therapy. At first, its concern is with superficial matters of the moment, then it moves to transactions in the present family, then it moves back to its experiences from its early days as a family and, lastly, it moves to the preceding families. The most fundamental therapy takes place at the last level.
Much profit comes from getting a family to describe actual instances in its own immediate life experience and, as time goes on, in its past life experiences. This is description without interpretation. In this way, a far more factual picture is obtained of real family events and its reactions to them. Subsequently the therapist and the family together can give significance to the events.
Therapy ceases when the aim outlined at the start has been achieved. Usually there is a weaning-off period which may last for either a few minutes or several hours of therapy, depending upon the family, its needs, and its degree of disturbance and thus of dependence.
This must go hand in hand with psychic therapy.
The individual or family reacts as a whole to psychic noci-vectors – thus the soma is affected. Rarely does psychonosis in an individual or family present without somatic complaints which may be severe and life-threatening.
Somatic therapy will be required for:
- The somatic disorders produced by the psychonosis. Any system in the body may be affected. Examples would be: migraine, ulcerative colitis, thyrotoxicosis, gastric ulceration, asthma, coronary thrombosis, cerebral thrombosis, etc. Furthermore, existing somatic disorders, eg multiple sclerosis, epilepsy, will be aggravated by psychonosis. Psychonotics, especially the elderly, eat badly and therefore dietary and vitamin deficiencies may need correction. There may be anaemia for the same reasons.
- Iatrogenic disorders. These are conditions precipitated by therapy, anc can include any of the above.
- Symptomatic relief. Tranquilizers reduce tension, anti-depressants make depression more tolerable, sedatives and hypnotics guarantee a night’s sleep, etc. All these medications carry with them emotional elements – hope, a gift from the therapist, encouragement of something done, suggestive value, and a bridge with the therapist. Drugs must nonetheless be used with caution. In some patients, as they fear any drug medication, they may have a deleterious effect. Also drugs may produce toxic states in some patients and confuse diagnosis.