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Fam Proc 31:187-195, 1992
CORRESPONDENCE Truth in [sic] Consequences To the Editor.The purpose of these comments is to address the issues presented by three articles recently published in Family Process. Taken separately they present a problem; taken together they suggest the solution. At the outset, let me say that I think these articles are all excellent studies, and I do not question the findings and conclusions. Rather, this discussion is an effort to integrate what these articles have to teach us. (I am grateful to Judy Grunebaum for her editorial help and for suggesting the title.) The first article, "Do Better Trainees Make Worse Family Therapists? A Followup Study of Client Families," by Yvonne Stolk and Amaryll J. Perlesz (1990), concludes with a paradox. These authors found that the further students progressed in their training in family therapy, the greater was the family members' dissatisfaction with the treatment they were getting! They concluded that certain initial, humane attributes of the students become submerged as they gained technical skills, and that this leads to family dissatisfaction. Stolk and Perlesz do not, however, discuss their findings as possibly related to the theory underlying the training program at the Bouverie Family Therapy Center in Victoria, Australia, and, thus, the treatment the families received. In a preceding article ("Patterns of Learning in Family Therapy Training") in the same issue of the journal, Perlesz, Stolk, and Firestone (1990) stated: "The strategic/ systemic therapeutic approach taught in the program is best exemplified in the work of therapists such as Selvini-Palazzoli and her colleagues" (p. 31). I will suggest that the better trained the student becomes in the underlying theory being taught is, in fact, the reason for the increased dissatisfaction of families. The second article, "The Unraveling of a Treatment Paradigm: A Followup Study of the Milan Approach to Family Therapy," by Mashal, Feldman, and Sigal (1989), presented data showing that families "dislike" treatment based on a Milan model when conducted by experienced therapists. Lack of satisfaction was experienced by all family members at a frequency of 56% of mothers, 47% of fathers, and 44% of identified child-patients. The Milan approach of this group involved the interviewer as a "neutral, dispassionate, information-gatherer" (p. 461) who used circular questioning and "resisted the family's attempts to engage in postprescription discussions" (p. 462). Mashal and colleagues conclude: "This coldness and lack of empathy are the opposite of the ingredients shown to be effective in the treatment of individuals and in the prevention of family therapy dropouts" (p. 467; references omitted). Their statement is similar to what Stolk and Perlesz say: "Feedback from families acts as a poignant reminder that our clients require respect, understanding, warmth, and positive regard, not merely thought-provoking and systemically correct hypotheses and interventions" (p. 56). The third and most recent article, "Outcomes of Systemic/Strategic Team Consultation: III. The Importance of Therapist Warmth and Active Structuring," by Robert-Jay Green and Mary Herget (1991), presents findings that relate family improvement to therapist warmth and active structuring. The authors conclude that families seen in one "systemic/strategic" team consultation, in addition to "regular ongoing" therapy (p. 327), improved more than control families that had no consultation, and that therapist warmth is essential for a strong therapeutic alliance. It seems clear that we may have an answer to the paradox raised by Stolk and Perlesz. If it is the case that experienced therapists employing a Milan-based therapy have dissatisfied clients, then it is no surprise that, as trainees learn this approach, their clients also become dissatisfied. It is not training per se that leads to family unhappiness but, rather, the specific approach that is being taught. Now what about the systemic/strategic consultation that was helpful? It would be interesting to learn whether the fact that "consultation" families seemed to benefit more than control cases is related to the fact that the therapist had the benefit of collegial input, or is related to the specific theory underlying the consultation. From the data presented we can only conclude that consultation itself is helpful, but not necessarily what kind of consultation. Certainly, most therapists find presenting a case to their colleagues useful. However, we can go beyond this and wonder if the concepts underlying strategic/systemic/Milan therapy should not be questioned. Indeed, it was precisely this question that led Green and Herget to modify the strict strategic/systemic approach they had been using, and to carry out the study they report. Although they privilege their theory and the interventions, they do suggest that therapist warmth and active structuring are vital to a strong therapeutic alliance. I would suggest, however, that therapist warmth and activity should be central to the theory building and the design of interventions, rather than placed in the less intellectually interesting rubric (irony intended) of alliance making. I wonder if Green and Herget are not moving in this direction. We may note that psychoanalysis itself has moved increasingly in the direction of making the relationship central (object relations and self-psychology) rather than privileging insight. A research study I carried out supports the belief that theoretically orthodox therapists who endeavor to be neutral and to limit their interventions to interpretations are often experienced by patients as harmful. Using therapists as subjects, I found 1
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that about one-third of the 49 subjects interviewed felt they had been significantly harmed by a cold, distant, and theoretically correct psychoanalysis or psychotherapy. A third of the subjects described being harmed by an overtly or covertly seductive therapist. These issues were discussed long ago by Aristotle, who delineated the differences between episteme (scientific knowledge), techne (the knowledge of how to engage in a craft), and phronesis (wisdom of human affairs). Parenthetically, it is interesting that Greek philosophers often likened phronesis to the clinical judgment used by physicians. I believe that, by and large, family therapists are consulted for their wisdom and understanding of how to conduct human relationships, for phronesis, and for their humanity, warmth, and empathy. Contrary to our perennial hopes, efforts at basing family theories on episteme, "scientific" theories are misguided. We should give up our hopes that if we only found the "right" theory, we could arrive at the one and only correct intervention for each situation. Growth in knowledge is incremental, and the latest theory is not a substitute for what we have learned previously but, rather, an addition to it. We are searching for simplicity in our efforts to understand and help people with problems that are complex. These articles should serve as a warning to family therapists. We are too easily beguiled by the latest fad. Teachers and public figures in the field have too often reinvented themselves; their understanding of the latest intellectual fashion is often superficial and mistaken. Our interest in postmodernism and narrative approaches is a current example. Theories may offer guidance, but we are stuck being human beings, trying to help others with what wisdom we have. Henry Grunebaum, M.D. The Couples and Family Center The Cambridge Hospital (MA) 1. 2. 3. 4. 5.
Green, R. -J. and Herget, M., Outcomes of systemic/strategic team consultation: The importance of therapist warmth and active structuring, Family Process, 30, 321-336, 1991. Grunebaum, H., Harmful psychotherapy experience. American Journal of Psychotherapy, XL, 415-23, 1986. Mashal, M., Feldman, R. B. and Sigal, J. J., The unraveling of a treatment paradigm: A followup study of the Milan approach to family therapy, Family Process, 28, 457-470, 1989. Perlesz, A. J., Stolk, Y. and Firestone, A. F., Patterns of learning in family therapy training. Family Process, 29, 29-44, 1990. Stolk, Y. and Perlesz, A. J., Do better trainees make worse family therapists? A followup study of client families, Family Process, 29, 45-58, 1990.
Editor's Comment: In that the above letter from Henry Grunebaum made specific reference to several previously published articles in our journal, I invited the authors of these papers to respond if they so chose. Two of these responses are printed below. In Reply.The thrust of our most recent article (Green & Herget, 1991) was to weave therapist warmth and active structuring into a more comprehensive theory about how, and under what circumstances, systemic/strategic techniques promote improvement. Thus, I fully agree with Grunebaum's statement that "therapist warmth and activity should be central to the theory building and the design of interventions..." In my view, the therapeutic alliance is a core dimension of systemic/ strategic therapy and gives contextual meaning and emotional valence to every specific, theory-based technique used in treatment. However, I strongly oppose Grunebaum's seemingly wholesale dismissal of theory in general and of systemic/strategic theory in particular. For example, Grunebaum makes an unwarranted conclusion, based on the Stolk and Perlesz (1990) results, that the orientation of their training program (strategic/systemic) led to a decline in the "humane attributes" of graduate students. On the contrary, it may be that training in any orientation or simply more years in doing therapy reduces therapist relationship skills over the course of graduate school. In fact, Grunebaum's own qualitative study (1986) showed that even highly trained psychodynamic therapists can be "cold and distant," and that these "theoretically correct" psychodynamic therapists can be quite harmful to their clients. Based primarily on the findings of Mashal, Feldman, and Sigal (1989), Grunebaum later makes the sweeping generalization that "experienced therapists employing a Milan-based therapy have dissatisfied clients." His conclusion is directly refuted by our research, which showed that 82% of the clients in our Milan-informed consultations had generally positive evaluations of their sessions (Green & Herget, 1991). Also, we found no difference in satisfaction between clients treated with systemic/strategic consultations versus those treated with only eclectic-oriented therapy (Green & Herget, 1989). In our 3-year outcome study, a single systemic/strategic team consultation (combined with ongoing, regular therapy sessions) produced superior outcomes when compared with ongoing, regular therapy sessions alone. There is no basis for 2
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presuming, as Grunebaum does, that another form of consultation (for example, psychodynamic) would have worked as well as our Milan-informed approach. To answer this question, one would have to do a comparative outcome study of different consultation approaches. I do not agree with Grunebaum that therapist "humaneness" or "wisdom" (if these mean "warmth" and "activity") are sufficient alone to trigger therapeutic improvement. One cannot not have a theory, and one cannot not have techniques! Anything a therapist says or does can be considered an aspect of technique. Therapist warmth and activity (or their lack) always occur simultaneously with the delivery of technical interventions that are relevant to the client's life and problem. One needs a theorypreferably coherent, explicit, and carefully tailored to the client's uniquenessin order to select meaningful things to say and do in the sessions. The therapeutic task requires improvising from a theory that allows one to be both engaged as a human being and purposeful in one's goal-oriented actions during the session. I have come to believe that a wide variety of theoretical orientations, as long as they include a sustained focus on clear goals, are probably equally effective in the presence of an emotionally meaningful therapeutic alliance (that is, one in which the client views the therapist as trustworthy, caring, and possessing "wisdom"). However, there is no orientation, no technique that will be of use in an emotionally threatening or barren therapeutic relationship. Thus, in any definition of therapeutic "wisdom," I would argue that we need to include (rather than exclude, as Grunebaum does) the therapist's theory and technique, as well as the therapist's relationship skills. Furthermore, I view wisdom as part of an interpersonal process, not purely an individual, therapist trait. Wisdom is something experienced in a collaborative relationship, something intersubjective. It sometimes emerges when a therapist with a theory and a set of techniques meets a client with a problem, and when, together, they develop a close relationship, a meaningful story about the client's dilemma, and a new path on which to walk toward the client's life goals. There are some very useful systemic theories and some flexible strategic (nonparadoxical) techniques a therapist can learn, and these increase the likelihood that "wisdom" will be experienced in a given therapeutic relationship. With Grunebaum's last point, I am in total agreement. Having been in this field for over 20 years, I am completely repulsed by its faddishness, commercialism, overdevotion to obscure theory, and the sometimes groundless pronouncements of its self-styled gurus. Many of our graduate programsespecially some of the external-degree, Masters-level programsare an ethical disgrace (Green, 1990). Unfortunately, these problems cannot be solved by Grunebaum's simple, non-empirical appeal for generic "wisdom," especially given that nobody in our field, no matter how poorly trained, seems to think they are without it. At the very least, we can put some of our field's longer-lasting fads to the empirical test, just as we subjected the Milan approach and some of its more speculative claims to a rigorous, experimental test. To address the issues raised in Grunebaum's letter, the field has to create training, research, and organizational contexts in which humility, rigorous empiricism, high intellectual standards, and more deeply felt personal/emotional commitments to clients can emerge. Finally, I am somewhat more optimistic than Grunebaum about the enduring values that might grow out of our field's latest crazes (the "narrative" and "social constructionist" approaches). Despite some of the usual philosophical excesses and baseless claims, I am heartened by their focus on the co-constructed "story"a quintessentially human and participative metaphor for therapy. It represents a move away from depersonalized theories toward something more humanistic, as we proposed was necessary in our most recent (1991) article. Historically, it is interesting to note that one of the field's pioneers, R.D. Laing (1967), pointed the way to a more collaborative, human-scale theory long ago. He termed it "social phenomenology," and I believe we still have much to learn from Laing's early works: We have had accounts of people as animals, people as machines, people as biochemical complexes with certain ways of their own, but there remains the greatest difficulty in achieving a human understanding of people in human terms. [pp. 28-29] Any technique concerned with the other without the self, with behavior to the exclusion of experienced[,] ... and most of all, with an object-to-be-changed rather than a person-to-be-accepted, simply perpetuates the disease it purports to cure. And any theory not founded on the nature of being human is a lie and a betrayal ... An inhuman theory will inevitably lead to inhuman consequences ... [p. 52] In the tradition of Laing and current theorists such as Mony Elkaïm (1990), I believe it is essential to incorporate subjective experience into our systems theories. I propose we build on our strong systemic tradition by: (1) more firmly embracing some of the values and goals of humanistic therapy (for example, subjectively experienced "authenticity" and "intimacy" in family relationships); (2) developing new strategies and a stronger commitment to help clients overcome socioeconomic and political constraints in their lives; and (3) extending systemic/strategic theory to include the experiential
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and affective aspects of therapist-client relationships. Unlike! Grunebaum, I am doubtful of high-minded notions such as therapist "wisdom," and I would be suspicious of any therapist whose wisdom is self-ascribed. Robert-Jay Green, Ph.D. Family/Child Psychology California School of Professional PsychologyBerkeley/Alameda (CA) 1. 2. 3. 4. 5. 6. 7. 8.
Elkaïm, M., (1990). If you love me, don't love me: Constructions of reality and change in family therapy (translator, H. Chubb). New York: Basic Books. Green, R. -J., Family therapy training: The rising tide of mediocrity. AFTA Newsletter, 40 (Summer), 3-8, 1990. Green, R. -J. and Herget, M., Outcomes of systemic/strategic team consultation: I. Overview and one-month results. Family Process, 28, 37-58, 1989. Green, R. -J. and Herget, M., Outcomes of systemic/strategic team consultation: III. The importance of therapist warmth and active structuring. Family Process, 30, 321-336, 1991. Grunebaum, H., Harmful psychotherapy experience, American Journal of Psychotherapy, XL, 415-423, 1986. Laing, R. D., (1967). The politics of experience. New York: Ballantine Books. Mashal, M., Feldman, R. B. and Sigal, J. J., The unraveling of a treatment paradigm: A followup study of the Milan approach to family therapy. Family Process, 28, 457-470, 1989. Stolk, Y. and Perlesz, A. J., Do better trainees make worse family therapists? A followup study of client families. Family Process, 29, 45-58, 1990.
In Reply.Dr. Grunebaum's central thesis in his correspondence appears to be that application of the Milan approach to family therapy, by both experienced and trainee therapists, leads to a fairly high level of dissatisfaction for family members in therapy. We have several comments to make in response to this challenging proposition. First, apropos of our own Bouverie Training Program, we did not confine ourselves to teaching the Milan approach, as suggested by Dr. Grunebaum. We sought, rather, to familiarize our students with a range of different "strategic/ systemic theoretical approaches to family therapy" as "exemplified in the work of therapists such as Selvini-Palazzoli and her colleagues" (Perlesz, Stolk, & Firestone, 1990, p. 31). In the same paragraph, and with equal emphasis, we acknowledged the influence of Tomm; Watzlawick, Weakland, and Fisch; Weakland and colleagues; and White. Second, in addition to the range of theorists and clinicians represented here, our teachers were also influenced by the work of Haley, Madanes, and Stierlin, among others. Because we were not teaching a specific therapy model to our students, it is difficult for us to share Dr. Grunebaum's conclusion that teaching a specific approach, that is, the Milan method, contributed to family unhappiness rather than to the training process per se. For the sake of argument, however, let us propose that, from a range of inputs, our students were most captured by the writings of Selvini-Palazzoli and her colleagues, and therefore more likely to apply this approach in their clinical work. Our next comment, then, relates to the question "What is Milan-based therapy?" We assume that Dr. Grunebaum is referring to the collaborative work by Selvini-Palazzoli, Boscolo, Cecchin, and Prata during their time together at the Center for Family Studies in Milan, prior to and including 1979 and 1980 (the 2 years marking the team's separation). Dr. Grunebaum's implied definition of their work seems to be best summarized by his citing Mashal, Feldman, and Sigal's (1989) description of the interviewer as "a neutral, dispassionate, information-gatherer" using circular questioning and resisting "the family's attempts to engage in postprescription discussions"(pp. 461, 462). We wonder if this description isn't rather misleading. Matteo Selvini (1988) acknowledges that the Milan therapists' intellectual efforts concentrated on "contriving interventions" that would disrupt (like exploding bombs) the family's philosophy, and that the therapist's relationship with the family does contain an antagonistic component that is rather like an "athletic "attempt to beat "the adversary." Most importantly, however, and often missed in discussions of the Milan approach, Selvini goes on to point out that this "does not... do away with the other fundamental and indispensable component: the warm collaborative commitment, rich in respect and trust" (p. 105). In a footnote, Selvini spells this out even further: "Mara Selvini and her current collaborators disagree radically with the Manichean views of Dell, Keeney, and de Shazer, i.e., with the idea that there is a sharp opposition between aesthetics and pragmatics or between cooperation and challenge. In good family therapy, an intervention will be pragmatically effective precisely because it is aesthetic" (p. 105). We agree with Dr. Grunebaum that family therapists "are too easily beguiled by the latest fad." Disciples of a method of family therapy may be more inclined to attempt to force the family to fit in with their method rather than to change their method in order to engage the family. However, the adopted method in itself may not be the problem as much as how the method, or techniques, are interpreted and put into practice. For instance, colleagues of ours, Furlong and Lipp (1991), have recently proposed that there are at least eight distinct ways in which the term "neutrality" has been theoretically and clinically interpreted in the family therapy literature. It may be, then, contrary to Dr. Grunebaum's conclusion, that it is not the specific approach that is being taught that leads
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to family unhappiness, but, rather, it is trainees' subjective interpretations and beliefs about what they "ought" to be doing; and, because of their inexperience, they are as yet unable to integrate the aesthetics and pragmatics of therapy. This prevents them from being true to themselves as genuine, compassionate human beings, thereby precluding congruency as therapists. As for "experienced disciples," by virtue of their being disciples, they too may be constrained from acting creatively, fiexibly, and empathically as therapists. However, like being an acolyte to a Milan approach, the espousal of warmth and collaborative attitudes can in itself become a fad or trend. In our teaching of family therapy, we have always assumed that warmth, empathy, and genuinely positive regard are the sine qua non of any theoretical and clinical therapeutic practice being taught. This leaves warmth and empathy as qualities not necessarily incompatible with challenge and interventive strategies, but merely more difficult to integrate in the process of learning new therapeutic skills. It is precisely because this integration is so difficult that we have unashamedly published the findings of the Bouverie training evaluation, in order to inspire discussion about methods of integrating challenge and nurture in the therapeutic process. Amaryll Perlesz, M.D. Bouverie Family Therapy Center Victoria, Australia Yvonne Stolk, M.A. Office of Psychiatric Services Victoria Health Department Melbourne, Australia 1. 2. 3. 4.
Furlong, M. and Lipp, J., (1991). Getting out of Manuscript in preparation. Mashal, M., Feldman, R. B. and Sigal, J. J., The unraveling of a treatment paradigm: A followup study of the Milan approach to family therapy. Family Process, 28, 457-470, 1989. Perlesz, A. J., Stolk, Y. and Firestone, A. F., Patterns of learning in family therapy training, Family Process, 29, 29-44, 1990. Selvini, M. (Ed.), (1988). The work of Mara Selvini-Palazzoli. Northvale NJ: Jason Aronson.
Do Cultures Clarify Models or Do Models Clarify Cultures? To the Editor.Family therapy acknowledges the influence of sociocultural context in organizing patterns of family functioning. Less consideration is given to the likelihood that culture also organizes the interpretation of family patterns as healthy vs. dysfunctional. This can lead to cultural bias in diagnosis and treatment when one culture's (or subculture's) categories and norms are applied to another culture (or subculture). In a recent article entitled "A Cross-Cultural Examination of Proximity and Hierarchy as Dimensions of Family Structure," Guler Okman Fisek (1991) makes a significant contribution to the field by outlining this problem and proposing an empirical solution. Her solution is to test family models cross-culturally to see if they sustain their reliability and validity in cultures other than the one in which they were conceived. Dr. Fisek explored the cross-cultural validity of the Proximity/Hierarchy Model (Wood, 1985) by replicating this American family study with Turkish families. Results were interpreted to support proximity as a valid dimension, moderated by SES, mother's working status, family size, and clinical status. It was concluded that hierarchy was not a valid dimension because the Turkish cultural norm of strong hierarchy suppressed variation. I disagree with this conclusion and submit that there are some important distinctions to be made in this regard. Dr. Fisek found a limited range in the hierarchy scores in the study sample of Turkish families. These families all had quite strong hierarchy (compared to American families), which suggests a ceiling effect in the Turkish culture. From this it was concluded that while hierarchy is a valid construct, it may not be a valid continuum, since there was essentially no continuum evidenced in the Turkish culture (Fisek, personal communication). This lack of hierarchy variability may render hierarchy relatively useless in terms of explaining variance in other sociocultural or psychosocial variables within the Turkish culture. However, the lack of variability within a culture of a particular continuous construct does not invalidate it as a cross-cultural construct. In fact, if one were to look at the hierarchy of Turkish and American families, the data would lend support to the validity of the hierarchy continuum, with American families in the moderate range and Turkish families at the high end of the continuum. Furthermore, the observation that the degree of hierarchy variability is high for American families and low for Turkish families is interesting and important, and does not invalidate the construct or the model. Rather, these findings are a compelling instantiation of the usefulness of this model for cross-cultural comparisonit is the model itself that permitted these cross-cultural differences in hierarchy level and variability to become evident! The proximity/hierarchy model was intentionally developed to be as culturally neutral as possible. Specifically, it derives
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from an ethological paradigm (Hinde & Stevenson-Hinde, 1976) that is not culture-specific. Furthermore, it incorporates two basic characteristics of all biological and social systems: (1) the patterns and degrees of interconnectedness among the components of a system (proximity) and (2) the patterns and strength of the control aspects of the system (hierarchy) (see Simon, 1962, for further explication.) Finally, and perhaps most importantly, proximity and hierarchy, as constructs, are neutral with respect to function and dysfunction. No patterns or degrees of proximity and/or hierarchy are a priori predicted to be associated with family or individual pathology. The model is strictly neutral in this regard. It is this conceptual neutrality that permits relatively unconfounded empirical assessment of which, if any, patterns and degrees of proximity and hierarchy are associated with which, if any, forms of family and individual dysfunction. In addition, it is important to emphasize that the proximity/hierarchy model does not propose cultural universals, except insofar as all families (and all cultures), as systems, have some proximity/hierarchy configuration. The patterns and categories of proximity and hierarchy themselves would be expected to vary from culture to culture, as would the meaning of these patterns as embedded in the culture, and their interaction with family and individual functioning. The value of the proximity/ hierarchy model for cross-cultural (and subcultural) research is that it can provide a general framework which can give shape to the more specific patterns of similarities and differences found in cross-cultural analysis of family function and dysfunction. Dr. Fisek's ground-breaking study is an excellent case in point. None of these points detract from Dr. Fisek's excellent analysis of the complex problems associated with investigating the sociocultural contexts of family function and dysfunction. Her main point is well taken: we must study the context-dependency of family therapy models in order to avoid culturally biased attributions of health and pathology. I would only add that precise transcultural application of models that are constructed to be neutral with respect to function/dysfunction can also contribute importantly to further knowledge in the ethnic, racial, and gender aspects of family and marital function. (See Wood, 1991, for an updated model.) In conclusion, the answer to the question posed in the title of this commentary is that both statements are true: cultures clarify models and models clarify cultures (and subcultures). It is a bootstrap operation. Beatrice Wood, Ph.D. Department of Human Development Psychotherapy and Psychosocial Consultation Child Study Institute Bryn Mawr College (PA) 1. 2. 3. 4. 5.
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Fisek, G. O., A cross-cultural examination of proximity and hierarchy as dimensions of family structure. Family Process, 30, 121-133, 1991. Hinde, R. A. and Stevenson-Hinde, J., (1976). Towards understanding relationships: Dynamic stability. In P.G. Bateson & R.A. Hinde (eds.), Growing points in ethology. Cambridge: Cambridge University Press. Simon, H. A., The architecture of complexity. Proceedings of the American Philosophical Society, 106, 467-482, 1962. Wood, B., Proximity and hierarchy: Orthogonal dimensions of family interconnectedness. Family Process, 24, 487-507, 1985. Wood, B., Responsivity: A conceptual focus for integration of individual and family systems level theory. Under editorial review.
Fam Proc 31:187-195, 1992
CORRESPONDENCE Truth in [sic] Consequences To the Editor.The purpose of these comments is to address the issues presented by three articles recently published in Family Process. Taken separately they present a problem; taken together they suggest the solution. At the outset, let me say that I think these articles are all excellent studies, and I do not question the findings and conclusions. Rather, this discussion is an effort to integrate what these articles have to teach us. (I am grateful to Judy Grunebaum for her editorial help and for suggesting the title.) The first article, "Do Better Trainees Make Worse Family Therapists? A Followup Study of Client Families," by Yvonne Stolk and Amaryll J. Perlesz (1990), concludes with a paradox. These authors found that the further students progressed in their training in family therapy, the greater was the family members' dissatisfaction with the treatment they were getting! They concluded that certain initial, humane attributes of the students become submerged as they gained technical skills, and that this leads to family dissatisfaction. Stolk and Perlesz do not, however, discuss their findings as possibly related to the theory underlying the training program at the Bouverie Family Therapy Center in Victoria, Australia, and, thus, the treatment the families received. In a preceding article ("Patterns of Learning in Family Therapy Training") in the same issue of the journal, Perlesz, Stolk, and Firestone (1990) stated: "The strategic/ systemic therapeutic approach taught in the program is best exemplified in the work of therapists such as Selvini-Palazzoli and her colleagues" (p. 31). I will suggest that the better trained the student becomes in the underlying theory being taught is, in fact, the reason for the increased dissatisfaction of families. The second article, "The Unraveling of a Treatment Paradigm: A Followup Study of the Milan Approach to Family Therapy," by Mashal, Feldman, and Sigal (1989), presented data showing that families "dislike" treatment based on a Milan model when conducted by experienced therapists. Lack of satisfaction was experienced by all family members at a frequency of 56% of mothers, 47% of fathers, and 44% of identified child-patients. The Milan approach of this group involved the interviewer as a "neutral, dispassionate, information-gatherer" (p. 461) who used circular questioning and "resisted the family's attempts to engage in postprescription discussions" (p. 462). Mashal and colleagues conclude: "This coldness and lack of empathy are the opposite of the ingredients shown to be effective in the treatment of individuals and in the prevention of family therapy dropouts" (p. 467; references omitted). Their statement is similar to what Stolk and Perlesz say: "Feedback from families acts as a poignant reminder that our clients require respect, understanding, warmth, and positive regard, not merely thought-provoking and systemically correct hypotheses and interventions" (p. 56). The third and most recent article, "Outcomes of Systemic/Strategic Team Consultation: III. The Importance of Therapist Warmth and Active Structuring," by Robert-Jay Green and Mary Herget (1991), presents findings that relate family improvement to therapist warmth and active structuring. The authors conclude that families seen in one "systemic/strategic" team consultation, in addition to "regular ongoing" therapy (p. 327), improved more than control families that had no consultation, and that therapist warmth is essential for a strong therapeutic alliance. It seems clear that we may have an answer to the paradox raised by Stolk and Perlesz. If it is the case that experienced therapists employing a Milan-based therapy have dissatisfied clients, then it is no surprise that, as trainees learn this approach, their clients also become dissatisfied. It is not training per se that leads to family unhappiness but, rather, the specific approach that is being taught. Now what about the systemic/strategic consultation that was helpful? It would be interesting to learn whether the fact that "consultation" families seemed to benefit more than control cases is related to the fact that the therapist had the benefit of collegial input, or is related to the specific theory underlying the consultation. From the data presented we can only conclude that consultation itself is helpful, but not necessarily what kind of consultation. Certainly, most therapists find presenting a case to their colleagues useful. However, we can go beyond this and wonder if the concepts underlying strategic/systemic/Milan therapy should not be questioned. Indeed, it was precisely this question that led Green and Herget to modify the strict strategic/systemic approach they had been using, and to carry out the study they report. Although they privilege their theory and the interventions, they do suggest that therapist warmth and active structuring are vital to a strong therapeutic alliance. I would suggest, however, that therapist warmth and activity should be central to the theory building and the design of interventions, rather than placed in the less intellectually interesting rubric (irony intended) of alliance making. I wonder if Green and Herget are not moving in this direction. We may note that psychoanalysis itself has moved increasingly in the direction of making the relationship central (object relations and self-psychology) rather than privileging insight. A research study I carried out supports the belief that theoretically orthodox therapists who endeavor to be neutral and to limit their interventions to interpretations are often experienced by patients as harmful. Using therapists as subjects, I found 1
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that about one-third of the 49 subjects interviewed felt they had been significantly harmed by a cold, distant, and theoretically correct psychoanalysis or psychotherapy. A third of the subjects described being harmed by an overtly or covertly seductive therapist. These issues were discussed long ago by Aristotle, who delineated the differences between episteme (scientific knowledge), techne (the knowledge of how to engage in a craft), and phronesis (wisdom of human affairs). Parenthetically, it is interesting that Greek philosophers often likened phronesis to the clinical judgment used by physicians. I believe that, by and large, family therapists are consulted for their wisdom and understanding of how to conduct human relationships, for phronesis, and for their humanity, warmth, and empathy. Contrary to our perennial hopes, efforts at basing family theories on episteme, "scientific" theories are misguided. We should give up our hopes that if we only found the "right" theory, we could arrive at the one and only correct intervention for each situation. Growth in knowledge is incremental, and the latest theory is not a substitute for what we have learned previously but, rather, an addition to it. We are searching for simplicity in our efforts to understand and help people with problems that are complex. These articles should serve as a warning to family therapists. We are too easily beguiled by the latest fad. Teachers and public figures in the field have too often reinvented themselves; their understanding of the latest intellectual fashion is often superficial and mistaken. Our interest in postmodernism and narrative approaches is a current example. Theories may offer guidance, but we are stuck being human beings, trying to help others with what wisdom we have. Henry Grunebaum, M.D. The Couples and Family Center The Cambridge Hospital (MA) 1. 2. 3. 4. 5.
Green, R. -J. and Herget, M., Outcomes of systemic/strategic team consultation: The importance of therapist warmth and active structuring, Family Process, 30, 321-336, 1991. Grunebaum, H., Harmful psychotherapy experience. American Journal of Psychotherapy, XL, 415-23, 1986. Mashal, M., Feldman, R. B. and Sigal, J. J., The unraveling of a treatment paradigm: A followup study of the Milan approach to family therapy, Family Process, 28, 457-470, 1989. Perlesz, A. J., Stolk, Y. and Firestone, A. F., Patterns of learning in family therapy training. Family Process, 29, 29-44, 1990. Stolk, Y. and Perlesz, A. J., Do better trainees make worse family therapists? A followup study of client families, Family Process, 29, 45-58, 1990.
Editor's Comment: In that the above letter from Henry Grunebaum made specific reference to several previously published articles in our journal, I invited the authors of these papers to respond if they so chose. Two of these responses are printed below. In Reply.The thrust of our most recent article (Green & Herget, 1991) was to weave therapist warmth and active structuring into a more comprehensive theory about how, and under what circumstances, systemic/strategic techniques promote improvement. Thus, I fully agree with Grunebaum's statement that "therapist warmth and activity should be central to the theory building and the design of interventions..." In my view, the therapeutic alliance is a core dimension of systemic/ strategic therapy and gives contextual meaning and emotional valence to every specific, theory-based technique used in treatment. However, I strongly oppose Grunebaum's seemingly wholesale dismissal of theory in general and of systemic/strategic theory in particular. For example, Grunebaum makes an unwarranted conclusion, based on the Stolk and Perlesz (1990) results, that the orientation of their training program (strategic/systemic) led to a decline in the "humane attributes" of graduate students. On the contrary, it may be that training in any orientation or simply more years in doing therapy reduces therapist relationship skills over the course of graduate school. In fact, Grunebaum's own qualitative study (1986) showed that even highly trained psychodynamic therapists can be "cold and distant," and that these "theoretically correct" psychodynamic therapists can be quite harmful to their clients. Based primarily on the findings of Mashal, Feldman, and Sigal (1989), Grunebaum later makes the sweeping generalization that "experienced therapists employing a Milan-based therapy have dissatisfied clients." His conclusion is directly refuted by our research, which showed that 82% of the clients in our Milan-informed consultations had generally positive evaluations of their sessions (Green & Herget, 1991). Also, we found no difference in satisfaction between clients treated with systemic/strategic consultations versus those treated with only eclectic-oriented therapy (Green & Herget, 1989). In our 3-year outcome study, a single systemic/strategic team consultation (combined with ongoing, regular therapy sessions) produced superior outcomes when compared with ongoing, regular therapy sessions alone. There is no basis for 2
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presuming, as Grunebaum does, that another form of consultation (for example, psychodynamic) would have worked as well as our Milan-informed approach. To answer this question, one would have to do a comparative outcome study of different consultation approaches. I do not agree with Grunebaum that therapist "humaneness" or "wisdom" (if these mean "warmth" and "activity") are sufficient alone to trigger therapeutic improvement. One cannot not have a theory, and one cannot not have techniques! Anything a therapist says or does can be considered an aspect of technique. Therapist warmth and activity (or their lack) always occur simultaneously with the delivery of technical interventions that are relevant to the client's life and problem. One needs a theorypreferably coherent, explicit, and carefully tailored to the client's uniquenessin order to select meaningful things to say and do in the sessions. The therapeutic task requires improvising from a theory that allows one to be both engaged as a human being and purposeful in one's goal-oriented actions during the session. I have come to believe that a wide variety of theoretical orientations, as long as they include a sustained focus on clear goals, are probably equally effective in the presence of an emotionally meaningful therapeutic alliance (that is, one in which the client views the therapist as trustworthy, caring, and possessing "wisdom"). However, there is no orientation, no technique that will be of use in an emotionally threatening or barren therapeutic relationship. Thus, in any definition of therapeutic "wisdom," I would argue that we need to include (rather than exclude, as Grunebaum does) the therapist's theory and technique, as well as the therapist's relationship skills. Furthermore, I view wisdom as part of an interpersonal process, not purely an individual, therapist trait. Wisdom is something experienced in a collaborative relationship, something intersubjective. It sometimes emerges when a therapist with a theory and a set of techniques meets a client with a problem, and when, together, they develop a close relationship, a meaningful story about the client's dilemma, and a new path on which to walk toward the client's life goals. There are some very useful systemic theories and some flexible strategic (nonparadoxical) techniques a therapist can learn, and these increase the likelihood that "wisdom" will be experienced in a given therapeutic relationship. With Grunebaum's last point, I am in total agreement. Having been in this field for over 20 years, I am completely repulsed by its faddishness, commercialism, overdevotion to obscure theory, and the sometimes groundless pronouncements of its self-styled gurus. Many of our graduate programsespecially some of the external-degree, Masters-level programsare an ethical disgrace (Green, 1990). Unfortunately, these problems cannot be solved by Grunebaum's simple, non-empirical appeal for generic "wisdom," especially given that nobody in our field, no matter how poorly trained, seems to think they are without it. At the very least, we can put some of our field's longer-lasting fads to the empirical test, just as we subjected the Milan approach and some of its more speculative claims to a rigorous, experimental test. To address the issues raised in Grunebaum's letter, the field has to create training, research, and organizational contexts in which humility, rigorous empiricism, high intellectual standards, and more deeply felt personal/emotional commitments to clients can emerge. Finally, I am somewhat more optimistic than Grunebaum about the enduring values that might grow out of our field's latest crazes (the "narrative" and "social constructionist" approaches). Despite some of the usual philosophical excesses and baseless claims, I am heartened by their focus on the co-constructed "story"a quintessentially human and participative metaphor for therapy. It represents a move away from depersonalized theories toward something more humanistic, as we proposed was necessary in our most recent (1991) article. Historically, it is interesting to note that one of the field's pioneers, R.D. Laing (1967), pointed the way to a more collaborative, human-scale theory long ago. He termed it "social phenomenology," and I believe we still have much to learn from Laing's early works: We have had accounts of people as animals, people as machines, people as biochemical complexes with certain ways of their own, but there remains the greatest difficulty in achieving a human understanding of people in human terms. [pp. 28-29] Any technique concerned with the other without the self, with behavior to the exclusion of experienced[,] ... and most of all, with an object-to-be-changed rather than a person-to-be-accepted, simply perpetuates the disease it purports to cure. And any theory not founded on the nature of being human is a lie and a betrayal ... An inhuman theory will inevitably lead to inhuman consequences ... [p. 52] In the tradition of Laing and current theorists such as Mony Elkaïm (1990), I believe it is essential to incorporate subjective experience into our systems theories. I propose we build on our strong systemic tradition by: (1) more firmly embracing some of the values and goals of humanistic therapy (for example, subjectively experienced "authenticity" and "intimacy" in family relationships); (2) developing new strategies and a stronger commitment to help clients overcome socioeconomic and political constraints in their lives; and (3) extending systemic/strategic theory to include the experiential
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and affective aspects of therapist-client relationships. Unlike! Grunebaum, I am doubtful of high-minded notions such as therapist "wisdom," and I would be suspicious of any therapist whose wisdom is self-ascribed. Robert-Jay Green, Ph.D. Family/Child Psychology California School of Professional PsychologyBerkeley/Alameda (CA) 1. 2. 3. 4. 5. 6. 7. 8.
Elkaïm, M., (1990). If you love me, don't love me: Constructions of reality and change in family therapy (translator, H. Chubb). New York: Basic Books. Green, R. -J., Family therapy training: The rising tide of mediocrity. AFTA Newsletter, 40 (Summer), 3-8, 1990. Green, R. -J. and Herget, M., Outcomes of systemic/strategic team consultation: I. Overview and one-month results. Family Process, 28, 37-58, 1989. Green, R. -J. and Herget, M., Outcomes of systemic/strategic team consultation: III. The importance of therapist warmth and active structuring. Family Process, 30, 321-336, 1991. Grunebaum, H., Harmful psychotherapy experience, American Journal of Psychotherapy, XL, 415-423, 1986. Laing, R. D., (1967). The politics of experience. New York: Ballantine Books. Mashal, M., Feldman, R. B. and Sigal, J. J., The unraveling of a treatment paradigm: A followup study of the Milan approach to family therapy. Family Process, 28, 457-470, 1989. Stolk, Y. and Perlesz, A. J., Do better trainees make worse family therapists? A followup study of client families. Family Process, 29, 45-58, 1990.
In Reply.Dr. Grunebaum's central thesis in his correspondence appears to be that application of the Milan approach to family therapy, by both experienced and trainee therapists, leads to a fairly high level of dissatisfaction for family members in therapy. We have several comments to make in response to this challenging proposition. First, apropos of our own Bouverie Training Program, we did not confine ourselves to teaching the Milan approach, as suggested by Dr. Grunebaum. We sought, rather, to familiarize our students with a range of different "strategic/ systemic theoretical approaches to family therapy" as "exemplified in the work of therapists such as Selvini-Palazzoli and her colleagues" (Perlesz, Stolk, & Firestone, 1990, p. 31). In the same paragraph, and with equal emphasis, we acknowledged the influence of Tomm; Watzlawick, Weakland, and Fisch; Weakland and colleagues; and White. Second, in addition to the range of theorists and clinicians represented here, our teachers were also influenced by the work of Haley, Madanes, and Stierlin, among others. Because we were not teaching a specific therapy model to our students, it is difficult for us to share Dr. Grunebaum's conclusion that teaching a specific approach, that is, the Milan method, contributed to family unhappiness rather than to the training process per se. For the sake of argument, however, let us propose that, from a range of inputs, our students were most captured by the writings of Selvini-Palazzoli and her colleagues, and therefore more likely to apply this approach in their clinical work. Our next comment, then, relates to the question "What is Milan-based therapy?" We assume that Dr. Grunebaum is referring to the collaborative work by Selvini-Palazzoli, Boscolo, Cecchin, and Prata during their time together at the Center for Family Studies in Milan, prior to and including 1979 and 1980 (the 2 years marking the team's separation). Dr. Grunebaum's implied definition of their work seems to be best summarized by his citing Mashal, Feldman, and Sigal's (1989) description of the interviewer as "a neutral, dispassionate, information-gatherer" using circular questioning and resisting "the family's attempts to engage in postprescription discussions"(pp. 461, 462). We wonder if this description isn't rather misleading. Matteo Selvini (1988) acknowledges that the Milan therapists' intellectual efforts concentrated on "contriving interventions" that would disrupt (like exploding bombs) the family's philosophy, and that the therapist's relationship with the family does contain an antagonistic component that is rather like an "athletic "attempt to beat "the adversary." Most importantly, however, and often missed in discussions of the Milan approach, Selvini goes on to point out that this "does not... do away with the other fundamental and indispensable component: the warm collaborative commitment, rich in respect and trust" (p. 105). In a footnote, Selvini spells this out even further: "Mara Selvini and her current collaborators disagree radically with the Manichean views of Dell, Keeney, and de Shazer, i.e., with the idea that there is a sharp opposition between aesthetics and pragmatics or between cooperation and challenge. In good family therapy, an intervention will be pragmatically effective precisely because it is aesthetic" (p. 105). We agree with Dr. Grunebaum that family therapists "are too easily beguiled by the latest fad." Disciples of a method of family therapy may be more inclined to attempt to force the family to fit in with their method rather than to change their method in order to engage the family. However, the adopted method in itself may not be the problem as much as how the method, or techniques, are interpreted and put into practice. For instance, colleagues of ours, Furlong and Lipp (1991), have recently proposed that there are at least eight distinct ways in which the term "neutrality" has been theoretically and clinically interpreted in the family therapy literature. It may be, then, contrary to Dr. Grunebaum's conclusion, that it is not the specific approach that is being taught that leads
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to family unhappiness, but, rather, it is trainees' subjective interpretations and beliefs about what they "ought" to be doing; and, because of their inexperience, they are as yet unable to integrate the aesthetics and pragmatics of therapy. This prevents them from being true to themselves as genuine, compassionate human beings, thereby precluding congruency as therapists. As for "experienced disciples," by virtue of their being disciples, they too may be constrained from acting creatively, fiexibly, and empathically as therapists. However, like being an acolyte to a Milan approach, the espousal of warmth and collaborative attitudes can in itself become a fad or trend. In our teaching of family therapy, we have always assumed that warmth, empathy, and genuinely positive regard are the sine qua non of any theoretical and clinical therapeutic practice being taught. This leaves warmth and empathy as qualities not necessarily incompatible with challenge and interventive strategies, but merely more difficult to integrate in the process of learning new therapeutic skills. It is precisely because this integration is so difficult that we have unashamedly published the findings of the Bouverie training evaluation, in order to inspire discussion about methods of integrating challenge and nurture in the therapeutic process. Amaryll Perlesz, M.D. Bouverie Family Therapy Center Victoria, Australia Yvonne Stolk, M.A. Office of Psychiatric Services Victoria Health Department Melbourne, Australia 1. 2. 3. 4.
Furlong, M. and Lipp, J., (1991). Getting out of Manuscript in preparation. Mashal, M., Feldman, R. B. and Sigal, J. J., The unraveling of a treatment paradigm: A followup study of the Milan approach to family therapy. Family Process, 28, 457-470, 1989. Perlesz, A. J., Stolk, Y. and Firestone, A. F., Patterns of learning in family therapy training, Family Process, 29, 29-44, 1990. Selvini, M. (Ed.), (1988). The work of Mara Selvini-Palazzoli. Northvale NJ: Jason Aronson.
Do Cultures Clarify Models or Do Models Clarify Cultures? To the Editor.Family therapy acknowledges the influence of sociocultural context in organizing patterns of family functioning. Less consideration is given to the likelihood that culture also organizes the interpretation of family patterns as healthy vs. dysfunctional. This can lead to cultural bias in diagnosis and treatment when one culture's (or subculture's) categories and norms are applied to another culture (or subculture). In a recent article entitled "A Cross-Cultural Examination of Proximity and Hierarchy as Dimensions of Family Structure," Guler Okman Fisek (1991) makes a significant contribution to the field by outlining this problem and proposing an empirical solution. Her solution is to test family models cross-culturally to see if they sustain their reliability and validity in cultures other than the one in which they were conceived. Dr. Fisek explored the cross-cultural validity of the Proximity/Hierarchy Model (Wood, 1985) by replicating this American family study with Turkish families. Results were interpreted to support proximity as a valid dimension, moderated by SES, mother's working status, family size, and clinical status. It was concluded that hierarchy was not a valid dimension because the Turkish cultural norm of strong hierarchy suppressed variation. I disagree with this conclusion and submit that there are some important distinctions to be made in this regard. Dr. Fisek found a limited range in the hierarchy scores in the study sample of Turkish families. These families all had quite strong hierarchy (compared to American families), which suggests a ceiling effect in the Turkish culture. From this it was concluded that while hierarchy is a valid construct, it may not be a valid continuum, since there was essentially no continuum evidenced in the Turkish culture (Fisek, personal communication). This lack of hierarchy variability may render hierarchy relatively useless in terms of explaining variance in other sociocultural or psychosocial variables within the Turkish culture. However, the lack of variability within a culture of a particular continuous construct does not invalidate it as a cross-cultural construct. In fact, if one were to look at the hierarchy of Turkish and American families, the data would lend support to the validity of the hierarchy continuum, with American families in the moderate range and Turkish families at the high end of the continuum. Furthermore, the observation that the degree of hierarchy variability is high for American families and low for Turkish families is interesting and important, and does not invalidate the construct or the model. Rather, these findings are a compelling instantiation of the usefulness of this model for cross-cultural comparisonit is the model itself that permitted these cross-cultural differences in hierarchy level and variability to become evident! The proximity/hierarchy model was intentionally developed to be as culturally neutral as possible. Specifically, it derives
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from an ethological paradigm (Hinde & Stevenson-Hinde, 1976) that is not culture-specific. Furthermore, it incorporates two basic characteristics of all biological and social systems: (1) the patterns and degrees of interconnectedness among the components of a system (proximity) and (2) the patterns and strength of the control aspects of the system (hierarchy) (see Simon, 1962, for further explication.) Finally, and perhaps most importantly, proximity and hierarchy, as constructs, are neutral with respect to function and dysfunction. No patterns or degrees of proximity and/or hierarchy are a priori predicted to be associated with family or individual pathology. The model is strictly neutral in this regard. It is this conceptual neutrality that permits relatively unconfounded empirical assessment of which, if any, patterns and degrees of proximity and hierarchy are associated with which, if any, forms of family and individual dysfunction. In addition, it is important to emphasize that the proximity/hierarchy model does not propose cultural universals, except insofar as all families (and all cultures), as systems, have some proximity/hierarchy configuration. The patterns and categories of proximity and hierarchy themselves would be expected to vary from culture to culture, as would the meaning of these patterns as embedded in the culture, and their interaction with family and individual functioning. The value of the proximity/ hierarchy model for cross-cultural (and subcultural) research is that it can provide a general framework which can give shape to the more specific patterns of similarities and differences found in cross-cultural analysis of family function and dysfunction. Dr. Fisek's ground-breaking study is an excellent case in point. None of these points detract from Dr. Fisek's excellent analysis of the complex problems associated with investigating the sociocultural contexts of family function and dysfunction. Her main point is well taken: we must study the context-dependency of family therapy models in order to avoid culturally biased attributions of health and pathology. I would only add that precise transcultural application of models that are constructed to be neutral with respect to function/dysfunction can also contribute importantly to further knowledge in the ethnic, racial, and gender aspects of family and marital function. (See Wood, 1991, for an updated model.) In conclusion, the answer to the question posed in the title of this commentary is that both statements are true: cultures clarify models and models clarify cultures (and subcultures). It is a bootstrap operation. Beatrice Wood, Ph.D. Department of Human Development Psychotherapy and Psychosocial Consultation Child Study Institute Bryn Mawr College (PA) 1. 2. 3. 4. 5.
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Fisek, G. O., A cross-cultural examination of proximity and hierarchy as dimensions of family structure. Family Process, 30, 121-133, 1991. Hinde, R. A. and Stevenson-Hinde, J., (1976). Towards understanding relationships: Dynamic stability. In P.G. Bateson & R.A. Hinde (eds.), Growing points in ethology. Cambridge: Cambridge University Press. Simon, H. A., The architecture of complexity. Proceedings of the American Philosophical Society, 106, 467-482, 1962. Wood, B., Proximity and hierarchy: Orthogonal dimensions of family interconnectedness. Family Process, 24, 487-507, 1985. Wood, B., Responsivity: A conceptual focus for integration of individual and family systems level theory. Under editorial review.
