Tuesday, September 2, 2014

The Individual or the Family for Psychotherapy?

My interest as a therapist has always been finding what is called a "metatheory." Psychological theories, particularly those which try to explain why people who seek therapy are often so self-destructive, tend to focus on just one aspect of the problem almost to the exclusion of many other important considerations. 

In looking at patients, therapists from different "schools" of therapy that deal only with individuals focus solely on just one of the following: environmental factors which seem to trigger the behaviors, thoughts that are irrational and lead to counterproductive feelings and behaviors, seemingly inappropriate affects, or internal conflicts which pit one’s biological urges against values learned and internalized from one’s family or culture. 

Psychiatrists these days tend to focus just on biological and neurological processes.

Therapists with training in social psychology or family systems theory may look at either the family dynamics or at larger sociocultural influences.

There are mental health professions who are trying to counter this myopia (also called reductionism) and who would like to integrate all of these viewpoints. The typical metaphor employed by those folks is the famous story of the blind men and the elephant. One blind man feels the tail of the beast and makes conclusions about what the elephant looks like based solely on this, while others feel other parts of the elephant such as the hind quarters or the trunk, and make conclusions about the what the elephant might look like from those alone.

Some "integrationists” want to look at the whole elephant, so to speak, but are overly cautious about it. They stick to just looking for commonalities among the theories of the various blind men, rather than the whole picture. They are afraid that "integrated" therapy would be just one more school. This is reflected in the absurd name of their organization: Society for the Exploration of Psychotherapy Integration (SEPI). 

In other words, do not actually integrate anything, just "explore" the possibility. Luckily, there are a few members of SEPI who want to understand the whole elephant as a complete unit unto itself. I count myself among their number, and am part of something called the Unified Psychotherapy Project.

My main theory, which is the force behind the type of psychotherapy I do with those of my patients who present with repetitive self-destructive behavior patterns -  I call it Unified Therapylooks at the relationship between individuals and their internal processes, and the processes of the social groups to which they belong. Many of the conclusions I have drawn are based on the following series of propositions:
1.            The relationship between a self and its social system is not a constant but a variable.
2.             As children get older, their "self" differentiates from it social system - in most cases his or her family of origin - in a process known as separation-individuation. In other words, children gradually gain the ability to separate and express their own intellectual and emotional functioning when it is different from or disagrees with that of most of their family members.
3.             All individuals go through this process as they negotiate the passages of individual development whether they want to or not.
4.     Human culture has evolved over history so that, at each stage of human childhood and adult development, individuals have been able to differentiate more and more from the collec­tive as they go through the process of separation-individuation. The overall balance between individual expression and group conformity has, at least in developed countries, gradually shifted over history towards the former.
5.             Consensual validation from other members of the family system is necessary for  individuals to feel comfortable expressing individuated behavior, also called self-actualization.
6.             Because individuals have an inborn biological propensity to concern       themselves with the survival of the species, they are willing to sacrifice themselves, or aspects of themselves, in order to further what they perceive to be the greater good of their own family and ethnic group (kin selection).
7.             When individuals find that certain differentiated aspects of self seem to threaten the immediate representatives of the species, the family system, they will attempt to sup­press or completely sacrifice those self-aspects.
8.             In order to do so, they develop a false self, or persona, which is then maintained by a variety of self-suppressive devices such as self-scaring through the irrational thoughts catalogued by cognitive therapists (catastrophizing for example)- also called self-mortification - and through the use of the traditional defense mechanisms catalogued by psychoanalysts like Anna Freud. The de­velopment of a persona often causes individuals to appear to be incapable of certain kinds of activities, which makes them appear to be defective in ways that they are not.
9.             The needs of the family system to respond to the cultural forces which seem to mandate the evolu­tion of increased self-actualization often conflict with the needs of the system for stability and predictability (family homeostasis).
10.              Younger members of the family are often induced by the needs of the larger culture to behave in a fashion that is far more differentiated than the behavior of the parents. The parents, who are the leaders of the family system and its most important constituents, may be unable to com­fortably tolerate such behavior, even when they are them­selves attracted to it. The whole family system becomes threat­ened.
11.              This problem often cannot be solved in ways other than through the sacrifice of the younger system members' individuality because of two factors: the tendency of fam­ily members to protect one another from anxiety and shame, leading to an avoidance of discussing what is going on between them (metacommunication), and secondly, the tendency of family members to rely on past experience in evaluating new family behavior, leading to the so-called game without end.
12.             These factors not only lead to impaired individual func­tioning but hamper the family from adjusting to new cul­tural contingencies. The efforts of individuals to protect one another, in particular, lead to eventual harm for everyone. I call this the altruistic paradox (or sometimes the Mother Teresa paradox).

A therapist can help solve the problem of self-sacrifice by work­ing with individuals and teaching them how to avoid the difficul­ties that lead to impaired family problem solving. The pioneer in this approach was Murray Bowen. He used education, logic, and collaboration to coach his patients on how to deal differently with their families. However, what he tought them often involved techniques other than education, logic, and cooperation. 

In Unified Therapy, the  ther­apist instead teaches patients to adopt a problem-solving ap­proach with their families.
Specifically, patients can learn to overcome both their own and their family's resistances to metacommunicating about family difficulties. They can learn to bring up systemic problems in ways that do not induce negative reactions from other members of their family systems. The keys to effective metacommunica­tion are empathy, avoidance of moralistic blaming behavior, and respect for the integrity and potency of all family members.

In therapy, patients come to an expert to learn how they are induced by the reactions of others to behave in self-destruc­tive ways and why the others behave in the ways that they do. Patients learn to empathize with and understand the reasons for the negative behavior of other system members without agree­ing that the behavior is good and without sacrificing their own thoughts or emotions.

They learn to differentiate between emotional reac­tivity and emotional reactions. They learn to tolerate and to sub­vert attempts made by other family members to stop them from proceeding in the task of metacommunicating. They have an op­portunity to practice what they have learned by role playing with the therapist.

Specifically, the patient is trained to deal with various maneuvers that the rest of the system uses to get them to shut up and not challenge the rules by which the family operates. These maneuvers represent attempts to withdraw consen­sual validation from the patient and include such things as accusations of self­ishness, changing the subject, unreasonable behavior, double binds, blame shifting, nitpicking, overgeneralization, mental gymnastics, and fatalism. 

The patient is also trained to prevent family members from uniting in various combinations to defeat the patient's efforts to metacommunicate. Once the systemic problem has been dealt with, mal­adaptive and self-destructive behavior problems begin to disappear, along with many types of anxiety and mood symptoms


  1. Amen to that!

    I am currently attempting to metacommunicate with cousins but feel that I am metabanging my meathead against a metabrick wall.

    One day I will learn to stop poking the skunk!

    1. The more distant the genetic link, the less leverage you have. And of course metacommunication is a very tricky endeavor.