International Journal of Group Psychotherapy
ISSN: 0020-7284 (Print) 1943-2836 (Online) Journal homepage: http://www.tandfonline.com/loi/ujgp20
Family Therapy, Group Therapy Donald A. Bloch To cite this article: Donald A. Bloch (1976) Family Therapy, Group Therapy, International Journal of Group Psychotherapy, 26:3, 289-299, DOI: 10.1080/00207284.1976.11491950 To link to this article: https://doi.org/10.1080/00207284.1976.11491950
Published online: 29 Oct 2015.
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Family Therapy, Group Therapy DONALD A. BLOCH, M.D.
in which group and family therapy are the same . Indeed, considering the multiple guises in which each comes, the variety of formats, the range of techniques, communicational modes, and theoretical emphases, one is hard put to generalize about either . What, after all, is the core of group therapy? And is there a central theme to family therapy that is distinctively different from this? No single person, certainly not this author , has the right to speak for all family therapists. My own view, though, is that we are talking about a meaningful distinction: at bottom, family therapy abandons the centrality of the individual and teaches a different epistemology, the epistemology of contexts. This orientation is a major therapeutic tool; it is not only the stance from which the therapist views human phenomena but the direction toward which he proposes to shift family members in their perception and understanding of themselves in the world. Consider how this works in regard to treatment . Let us imagine that the presenting problem is a delinquent adolescent boy, a 17 -yearold high school failure who is drinking to excess. Orie might look on this as a suitable case for individual psychotherapy. From this perspective the therapist would plan to see the youngster on some regular schedule of dyadic interviews. Patient and therapist might attempt to formulate the problem in terms of the self-destructive aspects of the patient's behavior patterns ; these would be explored as defenses against psychic pain. The relationship with the therapist would be studied so as to differentiate distorted perceptions and affective responses , and these "distortions" (labeled transferential) LIERE ARE CERTAINLY MANY WAYS
Dr. Bloch is Director, Nathan Ackerman Familv Institute, N ew York, N.Y.
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would be explored as to their "reality," the degree to which they influence relations with other authorities, their origins in the parental interaction . Historical issues likely would be considered at length, and there would be some review of the here-and-now , of the actual context of the youngster's life. This would aim at an understanding of circular feedback patterns of experience for the adolescent patient , and would lead to a consideration of the boy's own part in eliciting responses from the real figures in his world that circularly act to maintain repetitive behavioral patterns and selfpercepts. This part of the work, of necessit y, would be highly inferential and highly vulnerable to limitations of memory, communication blocks, and so on. Important work would be virtually impossible to do. The index patient might know that his school failure activated rage in his father but would have enormous difficulty in connecting this to awareness of an underlying depression in the father that the father struggles against by overachievement and denies by projecting his passivity on his son . Nor can the embeddedness of this pattern of the father in his relationship with his wife and his own parents be explored, let alone changed . In individual therapy the inferential link back to the.>e circular, interlocked experiential patterns is tenuous and weak. Much of the technique and theory of individual psychotherapy aims to give some vision to the therapist in his blind groping toward such understandings. The essential point, though , is that only one set of the stabilizing gyroscopes maintaining durable patterns of interpersonal behavior is being considered, those at the systems level of the individual. The thrust of the dyadic context, the orientation toward the patient's thoughts , feelings , and behavior, the absence of direct information about any other interpersonal field than the one constructed with the therapist operate together to support this epistemological stance . How is it with group therapy? Much the same, I believe. The emphasis is still on the target behavior of an individual and on those self-contained mechanisms , the gyroscopes of the previous paragraph , that keep him a cting in a "distorted" way in new environments . In a therapeutic group, as an added dimension the patient could explore firsthand the specifics of his interaction with other
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group members. Peer relationships in the group , for example, wiii cer tainly have similar configurations to those with siblings at home as well as to those with schoolmates . Happenstance, to a greater or lesser degree, will determine the specific relevance for any single individual of the unfolding group phenomena. An orientation toward the use of the group for dealing with defined problems in living wiii help arrange these priorities , but the style and techniques of the leader will obviously be influential as well as the group composition. We can assume an extension into the real world of the patterns. Nevertheless , it is only by congruence of these behavioral patterns ofthe individual in the group , and the behavioral patterns of the individual in the real world, and by their connection to the problems for which the group member seeks help, or is sent for help, that their relevance can be established . Riess quotes Knobloch quite effectively as to the nature of the th e rap eutic group, but one is tempted to ask, "Why settle for substitutes?" After all , when one talks about the patient's group schema , we are talking about multiplexed schema for the family group first. Granted that there are layering on of group schema with the passage of time, the earlier are more powerful and are vectored with special affective intensity. What is more devastating than to return as an adult to one's family of origin, only to be cast back into interactive responses which had long seemed extinguished? (The answer, perhaps , is to find oneself doing the same thing with one 's husband or wife that one did with one's parents .) This paper will consider family psychotherapy and group psychotherapy as to their similarities and possible differences. My principal object is to define some meaningful dimensions along which this consider ad on can reasonably be conducted and then to consider wh a t consequences, if any, flow from these differences . This author's limitations of experience and his biases ought to be mentioned. For the most part , my experience is limited to individual and family therapy, with a small amount of direct involvement with therapy groups a number of years ago . Those therapy groups were mostly of delinquent adolescents; in more recent years my contact with group therapy has mostly been through the literature (except for multiple family groups), through discussions with profes sional colleagues, and as a participant in group dynamics-oriented
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discussions in working groups of which I have been a member. Over the years, I have had an increasingly heavy commitment to, and bias in favor of, the theory and practice of family therapy, with a general systems theory orientation. While the unfolding of a professional career along these lines may be evidence of revealed truth, it is reasonable to assume strong personal predilections in that direction as well. This paper and the companion piece by Dr. Riess have been written in order to struggle with the question as to whether there are differences between group and family psychotherapy, and if so, whether they are meaningful. My view is that the key to this question lies in what it is that one proposes to change by the intervention called therapy rather than in how the therapy is carried out. For the family therapist this is reasonably clear. What unites all family therapists is the view that change, which is significant to the psychotherapeutic endeavor, takes place in the family system. (To the extent that this is true as well of many practitioners who consider themselves to be group therapists but not family therapists, there is the intriguing possibility that many practice family therapy without intending to do so.) By assigning priority to the issue of the locus of change, i.e., in the family system rather than in the individual patient, my view is that we are putting the most important distinction first. 1 If I read his paper correctly, Riess would certainly agree with this distinction. As he puts it in his summary, "The group in group therapy never becomes the patient." The goals of the group therapist as to change in the group itself are only incidental to his goals for change in the individual members. FORMATS: WHO IS IN THE ROOM It is desirable at the outset to attempt to deal with a troublesome question: can we classify therapies according to some way of cata1 Readers of a philosophical bent may note that the intention of the therapist is taken to be critical as to this distinction. An article by Haley and Montalvo (1973) seems to disagree with this view. They suggest ingeniously that child therapists do better in some instances because they aim to change the child rather than the family system. The thrust of their argument is that child therapists in so doing relieve such pressures on family system as guilt in the parents, thereby permitting change in a
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loguing the persons participating? Thus, to take relatively simple examples, we might speak of some such classification as individual (dyadic) , couples, or marital, family, group, and multiple family therapies according to whether the therapist is dealing with one person, a couple (or several such), a family (however defined), or a group of unrelated persons, or several families. An anecdote may illustrate the inadequacy of this approach. A colleague was recently asked by a pharmaceutical company to prepare a brochure on depression from the point of view of family therapy for distribution to general practitioners. He prepared a simple and interesting essay advancing the view that depression in one family member could be understood as an expression of dysfunction in the family system. One lucidly presented clinical example considered the possibility of therapeutic work with the parents of a depressed college student so as to assist them to cope better with his increased distance after the death of the maternal grandfather disturbed the equilibrium of the family system. The drug house commented appreciatively on the material but went on to say that it was not exactly what they had had in mind. When they spoke of depression and the family, they meant that the family should be educated to look for signs in the index patient that he or she was not taking his or her medication and that the family could be helpful in maintaining an adequate drug regimen. Such an approach, while in keeping with the medical model, would not aim at change in the family system but, rather, would support a dysfunctional scapegoating maneuver. Thus, it would not qualify as family therapy by the standard being suggested here. The point I wish to make is that format does not provide an infallible guide even when the family comes for the consultation. Conversely, a group of strangers might be brought together with the goal of assisting its members to effect changes in their own families of origin . (Our training groups at the Nathan W. Ackerman Family Institute do this .) One preferred family therapy format (Bowen) brings three couples together; work proceeds with one couple at a time and with one person of that couple at each point in time so as to facilitate changes for all in their patterns of relatedness to their useful direc tion to take place . While I would not quarrel that this sequence occurs, what m akes it family therapy is the judgment as to the locus of change.
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families of origin. Others work with several multigenerational families in a group at the same time to review fam ily functioning and, hopefull y, to change it. Thus , family in th e room, as in the drug com pany example , need not mean famil y therapy , and a group of unrelated persons can be involved in family therapy, as in our training groups. THE FAMILY AS PRIMARY NATURAL GROUP Natural and constructed groups should be distinguished from each other. It is possible to do therapy with either , yet there are important ways in which they differ. The natural group, such as the family , has a structure and set of purposes that extend b eyond the time frame of the therapy experience ; the therapy group does not . There are , of course , other natural groups, many of them; work groups and friendship groups are examples . It is possible to be a change agent with such groups, that is, to do therapy with them . For examples, one may consult the recent writing of Speck and Attneave (1972) on network therapy. H ybrids of natural and contrived social systems ought to be mentioned since they are becoming increasingly common. People in social networks , let us say fri endship networks or work networks, undertake to do therapy together. Conversely, people in therapy groups may go on to have other kinds of relationships with each other. Indeed, one might construct a continuum ranging at one extreme from the fa mily with its multiple perduring functions, through the pure therapy group that deliberatel y eschews any other contact between its members . Conceptually , a most challenging hybrid is the simulated family. Simulations are not new, but they are being used more commonly both as teaching and therapeutic devices . vVe mean by simulation any technique that explicitly casts nonrelated persons in a family relationship to each other. The simulation may be of a specific family, yours or mine, for example, or , of a nonspecific family, as in, "you be sister , you be mother," and so on . Their interest lies in two aspects. Simulations come closer to blending family and group therapy than any other format I know of. Moreover , they do this by drawing on a shared cultural and experiential reservoir of myths,
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roles, functions , and communicative modes that, when observed, is stagger ingly complex and powerful. Riess's quote from J ung is felicitous indeed in speaking of "an impersonal karma within a fam ily which is passed on from parents to children ." J ung asks himself if these questions posed by fate are more personal or general in nature ; my answer would be that they a re both personal and general. Access to particular myths of a family is important because it relates to the matter of our central concern , the unfolding of specific individual human destinies. Family therapy, especially of a multigenerational family, provides just the access that is needed to achieve this kind of particular understanding . T he format of family therapy focuses on context and on the way in which current experience is understandable from m oment to moment a s a se t of u nfolding processes. Thus , the emphasis is on a different view ofre ality; distorted perception is seen to be accurate in the given context. T he underlying calculus of interpersonal events is demonstrated in statu nascendz~ and the oppor tu nity for altering feedback patterns that maintain dysfunction occurs at the very time and with the very persons with whom they originate . Persons b rought together for group psychotherapy, however , are almost always strangers to each other; they have no shared past , no purposes other than that of using the group experience for effecting personal change , and no collective future. Criteria for admission to membership in the group can be defined; people can be refused admission or , if necessary, eliminated ; eventually the group disbands, and there is no residual function left to it when this happens. T he p ure therapy group ostensibly has only one mission: to provide an aren a and a laboratory where group process can be displayed, examined , and used to facilitate individual change. Contrast this with family. The family of origin has a past that extends to the farthest reaches of antiquity. Perhaps these remote bio -psycho -social origins are unknown or only dimly perceived, but no o n e can d oubt their influence . And in the same way we are infl uenced by our procreative future , or, more exactly, by our a pprehension of it. Even the decision not to have children profoundly affects the current patterning of our intimate networks, although this probably is of lesser impact than actual involvement in
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the human generational chain . Family perdures. However we define it , humans must belong to an ongoing, intimate social network that inescapably has other functions than therapy, that nourishes, pleasures, comforts, and protects. Does this distinction make a difference? I believe so. The family, because of the characteristics alluded to, presents special diagnostic and therapeutic possibilities. It also poses problems not as common among therapy groups . DISADVANTAGES OF THE FAMILY AS A THERAPY SYSTEM Most of the problems of the family as a therapeutic system stem from its stability. As one might expect, families are exceptionally resistant to externally induced systems change , although they vary considerably as to this characteristic and as to the kind of impetus which will effectively cause them to change . The art and science of family therapy are concerned with developing improved methods for working against those forces that operate in the family so as to reduce the impact of external intervention. A principal reason for those forces is the time and method of recruitment of new members for the family group : by the birth of new humans and by sexual joining. The psychosocial consequences of these two methods of recruitment of new group members are , of course, quite different. They are similar in one important way: in both instances the new individual is in a condition of heightened plasticity and reactivity. It is unnecessary to comment on the malleability of the newborn. In a quite different way mating and the alliance of the families of the marital pairs is an intense and overdetermined joining (Napier, 1971 ). A volume could, of course, be written explicating the previous paragraph. The focus here is on recruitment of new family members, perhaps an odd way to put the matter although it has the virtue of aligning the issue with the recruitment of new members for a therapy group. Put this way, it is easy to see tha t the processes are vastly different in their effective ability to gear the behavior patterns of the component persons to the overall system patterning. Recruitment of new members for therapy groups in conditions of personal crisis is a process that is somewhat similar. Even so, there are important differences of degree that determine the extent to
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which the new member will become a thoroughly integral part of the social system being joined. It is not necessary to labor over an exposition of the special qualities of the newborn in this regard, nor to point out the vast difference between the exposure of an infant to the psychosocial forces of a family and the minimal exposure of a new group member to such forces. If nothing else, there is the vast difference in the amount of time spent in each impersonal field. Indeed , it seems reasonable to explain the cohesiveness of therapy groups almost entirely on the fact that members can draw on a shared pool of meanings, needs, and associated affects learned in their developing years as family members. The excessive stability of a family system can make it so resistant to change that it is impractical to attempt to do so. In some instances it is necessary to advise those family members (usually the index patient) who retain some hope and vitality that the family system cannot be looked to for modification and that a psychosocial amputation from it must be performed. This situation is commonly met with, in my experience, in families with a young adult schizophrenic member, and it is this person who most often is the last possessor of hope and vitality in an otherwise moribund system. ADVANTAGES OF THE FAMILY AS A THERAPY SYSTEM The principal advantage of the family as a therapy system stems, as well, from the fact that it is a natural group and primary group. Natural groups, as already noted, are ongoing. For better or worse, their effects are. long-lasting. Family therapy first developed when it became clear that changes in child patients could not be maintained in the face of the influence of the family system. I recall one little .boy we interviewed as part of a study of a therapeutic camp . Each summer his asthma would be relieved, only to reappear at home . After the third summer the improvement was maintained at home . When queried about this , the youngster said, "I taught my mother to treat me the way the counselors treat me at camp." Unintended family therapy . It can be said that all therapies function by virtue of their ability substantially to replicate within their confines the patterns of conflictual interaction that existed for each group member in his fam-
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ily. That this can be done is beyond doubt. What is at issue is the desirability of dealing with surrogates when the real thing is at hand . (Interestingly, for the husband and wife, families of procreation are surrogates for families of origin in a sense, although of such a nature that they need to be regarded as in a special class. It is not possible to go into this issue here beyond identifying it and establishing its importance.) It is economical to work with a primary group because, among other reasons , the problem of salience is efficiently dealt with. We can know with reasonable certainty that the pattems of conflict and d efense characterizing a person's embeddedness in his family are those which are signifi cant in his life. Not so the pattems that may evolve in a therapy group. It is quite possible in the latter instance for aspects of the gro up process to dominate the scene that are of little relevance to one individual's difficulties in living. Many group therapy members have wisely terminated for exactly this reason; the therapy group is struggling with issues that really are of little concern to them . Indeed , considerable effort is often expended in groups to demonstra te to individual members that what is going on is relevant to their lives. The problem of salience is minimized or eliminated in family therapy; we know the issues which surface in family therapy matter.
FAMILY- AS IN FAMILY THERAPY On occasion, family therapy is dismissed with the observation that the standard nuclear family is archaic. The nuclear family is held to have had a brief life during the last half century, and even during this time to have been more of an ideal than a reality, honored more in the breech than in the observance. In Western society today one need not look much past the rising divorce rate and the falling birth rate to support the claim that the nuclear family, or perhaps the extended nuclear family, is rapidly disappearing as a social form. Some may see this as a pity, others as a blessing . However these social changes are regarded, I believe it to be an irreducible fact of human existence that we live our essential lives in two intimate social networks, that into which we are born and grow up and th at which sustains us as adults; the shape and
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vicissitudes of the second are meaningfully and lawfully related to the shape and vicissitudes of the first. The connection between and congruence of these two intimate networks profoundly influences, more exactly is, what we like to think of as our individual lives. Each of these intimate networks may appear to be quite different from the other; their boundaries and membership rules and structures may seem hard to devine and pattern similarities between them difficult to discover. Nevertheless, the relationship of individual persons to these systems and of the systems to each other critically determines human behavior. In this enlarged sense, however varied and apparently diffuse the forms may be, there always will be family; to the extent that we wittingly, or unwittingly, intervene in and influence these systems, there will always be family therapy.
REFERENCES Bloch, D.A., and Le Perriere, K. (1973 ), Techniques of Family Therapy: A Con· ceptual Primer. In: T echniques of Family Psychotherapy, ed. D. A . Bloch. New York: Grune & Stratton. Haley, J. , and Montalvo , D. (1973), In Defense of Child Therapy. Family Process, 12 :227-244. N apier, A . (1971) , The Marriage of Families , Cross Generational Complementarity . Family Process, 10:373-396. Speck R ., and Attneave , C . (1972), Network Therapy. In : The Book of Family Th erapy, ed. Ferber, Mendelsohn , and Napier. New York: Science House.
Dr. Bloch 's address: N athan Ackerman Family Inst. 149 East 78th St. New York, N.Y. 10021
ISSN: 0020-7284 (Print) 1943-2836 (Online) Journal homepage: http://www.tandfonline.com/loi/ujgp20
Family Therapy, Group Therapy Donald A. Bloch To cite this article: Donald A. Bloch (1976) Family Therapy, Group Therapy, International Journal of Group Psychotherapy, 26:3, 289-299, DOI: 10.1080/00207284.1976.11491950 To link to this article: https://doi.org/10.1080/00207284.1976.11491950
Published online: 29 Oct 2015.
Submit your article to this journal
Article views: 1
View related articles
Citing articles: 2 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ujgp20
Family Therapy, Group Therapy DONALD A. BLOCH, M.D.
in which group and family therapy are the same . Indeed, considering the multiple guises in which each comes, the variety of formats, the range of techniques, communicational modes, and theoretical emphases, one is hard put to generalize about either . What, after all, is the core of group therapy? And is there a central theme to family therapy that is distinctively different from this? No single person, certainly not this author , has the right to speak for all family therapists. My own view, though, is that we are talking about a meaningful distinction: at bottom, family therapy abandons the centrality of the individual and teaches a different epistemology, the epistemology of contexts. This orientation is a major therapeutic tool; it is not only the stance from which the therapist views human phenomena but the direction toward which he proposes to shift family members in their perception and understanding of themselves in the world. Consider how this works in regard to treatment . Let us imagine that the presenting problem is a delinquent adolescent boy, a 17 -yearold high school failure who is drinking to excess. Orie might look on this as a suitable case for individual psychotherapy. From this perspective the therapist would plan to see the youngster on some regular schedule of dyadic interviews. Patient and therapist might attempt to formulate the problem in terms of the self-destructive aspects of the patient's behavior patterns ; these would be explored as defenses against psychic pain. The relationship with the therapist would be studied so as to differentiate distorted perceptions and affective responses , and these "distortions" (labeled transferential) LIERE ARE CERTAINLY MANY WAYS
Dr. Bloch is Director, Nathan Ackerman Familv Institute, N ew York, N.Y.
289
290
Donald A . Bloch
would be explored as to their "reality," the degree to which they influence relations with other authorities, their origins in the parental interaction . Historical issues likely would be considered at length, and there would be some review of the here-and-now , of the actual context of the youngster's life. This would aim at an understanding of circular feedback patterns of experience for the adolescent patient , and would lead to a consideration of the boy's own part in eliciting responses from the real figures in his world that circularly act to maintain repetitive behavioral patterns and selfpercepts. This part of the work, of necessit y, would be highly inferential and highly vulnerable to limitations of memory, communication blocks, and so on. Important work would be virtually impossible to do. The index patient might know that his school failure activated rage in his father but would have enormous difficulty in connecting this to awareness of an underlying depression in the father that the father struggles against by overachievement and denies by projecting his passivity on his son . Nor can the embeddedness of this pattern of the father in his relationship with his wife and his own parents be explored, let alone changed . In individual therapy the inferential link back to the.>e circular, interlocked experiential patterns is tenuous and weak. Much of the technique and theory of individual psychotherapy aims to give some vision to the therapist in his blind groping toward such understandings. The essential point, though , is that only one set of the stabilizing gyroscopes maintaining durable patterns of interpersonal behavior is being considered, those at the systems level of the individual. The thrust of the dyadic context, the orientation toward the patient's thoughts , feelings , and behavior, the absence of direct information about any other interpersonal field than the one constructed with the therapist operate together to support this epistemological stance . How is it with group therapy? Much the same, I believe. The emphasis is still on the target behavior of an individual and on those self-contained mechanisms , the gyroscopes of the previous paragraph , that keep him a cting in a "distorted" way in new environments . In a therapeutic group, as an added dimension the patient could explore firsthand the specifics of his interaction with other
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group members. Peer relationships in the group , for example, wiii cer tainly have similar configurations to those with siblings at home as well as to those with schoolmates . Happenstance, to a greater or lesser degree, will determine the specific relevance for any single individual of the unfolding group phenomena. An orientation toward the use of the group for dealing with defined problems in living wiii help arrange these priorities , but the style and techniques of the leader will obviously be influential as well as the group composition. We can assume an extension into the real world of the patterns. Nevertheless , it is only by congruence of these behavioral patterns ofthe individual in the group , and the behavioral patterns of the individual in the real world, and by their connection to the problems for which the group member seeks help, or is sent for help, that their relevance can be established . Riess quotes Knobloch quite effectively as to the nature of the th e rap eutic group, but one is tempted to ask, "Why settle for substitutes?" After all , when one talks about the patient's group schema , we are talking about multiplexed schema for the family group first. Granted that there are layering on of group schema with the passage of time, the earlier are more powerful and are vectored with special affective intensity. What is more devastating than to return as an adult to one's family of origin, only to be cast back into interactive responses which had long seemed extinguished? (The answer, perhaps , is to find oneself doing the same thing with one 's husband or wife that one did with one's parents .) This paper will consider family psychotherapy and group psychotherapy as to their similarities and possible differences. My principal object is to define some meaningful dimensions along which this consider ad on can reasonably be conducted and then to consider wh a t consequences, if any, flow from these differences . This author's limitations of experience and his biases ought to be mentioned. For the most part , my experience is limited to individual and family therapy, with a small amount of direct involvement with therapy groups a number of years ago . Those therapy groups were mostly of delinquent adolescents; in more recent years my contact with group therapy has mostly been through the literature (except for multiple family groups), through discussions with profes sional colleagues, and as a participant in group dynamics-oriented
292
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discussions in working groups of which I have been a member. Over the years, I have had an increasingly heavy commitment to, and bias in favor of, the theory and practice of family therapy, with a general systems theory orientation. While the unfolding of a professional career along these lines may be evidence of revealed truth, it is reasonable to assume strong personal predilections in that direction as well. This paper and the companion piece by Dr. Riess have been written in order to struggle with the question as to whether there are differences between group and family psychotherapy, and if so, whether they are meaningful. My view is that the key to this question lies in what it is that one proposes to change by the intervention called therapy rather than in how the therapy is carried out. For the family therapist this is reasonably clear. What unites all family therapists is the view that change, which is significant to the psychotherapeutic endeavor, takes place in the family system. (To the extent that this is true as well of many practitioners who consider themselves to be group therapists but not family therapists, there is the intriguing possibility that many practice family therapy without intending to do so.) By assigning priority to the issue of the locus of change, i.e., in the family system rather than in the individual patient, my view is that we are putting the most important distinction first. 1 If I read his paper correctly, Riess would certainly agree with this distinction. As he puts it in his summary, "The group in group therapy never becomes the patient." The goals of the group therapist as to change in the group itself are only incidental to his goals for change in the individual members. FORMATS: WHO IS IN THE ROOM It is desirable at the outset to attempt to deal with a troublesome question: can we classify therapies according to some way of cata1 Readers of a philosophical bent may note that the intention of the therapist is taken to be critical as to this distinction. An article by Haley and Montalvo (1973) seems to disagree with this view. They suggest ingeniously that child therapists do better in some instances because they aim to change the child rather than the family system. The thrust of their argument is that child therapists in so doing relieve such pressures on family system as guilt in the parents, thereby permitting change in a
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loguing the persons participating? Thus, to take relatively simple examples, we might speak of some such classification as individual (dyadic) , couples, or marital, family, group, and multiple family therapies according to whether the therapist is dealing with one person, a couple (or several such), a family (however defined), or a group of unrelated persons, or several families. An anecdote may illustrate the inadequacy of this approach. A colleague was recently asked by a pharmaceutical company to prepare a brochure on depression from the point of view of family therapy for distribution to general practitioners. He prepared a simple and interesting essay advancing the view that depression in one family member could be understood as an expression of dysfunction in the family system. One lucidly presented clinical example considered the possibility of therapeutic work with the parents of a depressed college student so as to assist them to cope better with his increased distance after the death of the maternal grandfather disturbed the equilibrium of the family system. The drug house commented appreciatively on the material but went on to say that it was not exactly what they had had in mind. When they spoke of depression and the family, they meant that the family should be educated to look for signs in the index patient that he or she was not taking his or her medication and that the family could be helpful in maintaining an adequate drug regimen. Such an approach, while in keeping with the medical model, would not aim at change in the family system but, rather, would support a dysfunctional scapegoating maneuver. Thus, it would not qualify as family therapy by the standard being suggested here. The point I wish to make is that format does not provide an infallible guide even when the family comes for the consultation. Conversely, a group of strangers might be brought together with the goal of assisting its members to effect changes in their own families of origin . (Our training groups at the Nathan W. Ackerman Family Institute do this .) One preferred family therapy format (Bowen) brings three couples together; work proceeds with one couple at a time and with one person of that couple at each point in time so as to facilitate changes for all in their patterns of relatedness to their useful direc tion to take place . While I would not quarrel that this sequence occurs, what m akes it family therapy is the judgment as to the locus of change.
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families of origin. Others work with several multigenerational families in a group at the same time to review fam ily functioning and, hopefull y, to change it. Thus , family in th e room, as in the drug com pany example , need not mean famil y therapy , and a group of unrelated persons can be involved in family therapy, as in our training groups. THE FAMILY AS PRIMARY NATURAL GROUP Natural and constructed groups should be distinguished from each other. It is possible to do therapy with either , yet there are important ways in which they differ. The natural group, such as the family , has a structure and set of purposes that extend b eyond the time frame of the therapy experience ; the therapy group does not . There are , of course , other natural groups, many of them; work groups and friendship groups are examples . It is possible to be a change agent with such groups, that is, to do therapy with them . For examples, one may consult the recent writing of Speck and Attneave (1972) on network therapy. H ybrids of natural and contrived social systems ought to be mentioned since they are becoming increasingly common. People in social networks , let us say fri endship networks or work networks, undertake to do therapy together. Conversely, people in therapy groups may go on to have other kinds of relationships with each other. Indeed, one might construct a continuum ranging at one extreme from the fa mily with its multiple perduring functions, through the pure therapy group that deliberatel y eschews any other contact between its members . Conceptually , a most challenging hybrid is the simulated family. Simulations are not new, but they are being used more commonly both as teaching and therapeutic devices . vVe mean by simulation any technique that explicitly casts nonrelated persons in a family relationship to each other. The simulation may be of a specific family, yours or mine, for example, or , of a nonspecific family, as in, "you be sister , you be mother," and so on . Their interest lies in two aspects. Simulations come closer to blending family and group therapy than any other format I know of. Moreover , they do this by drawing on a shared cultural and experiential reservoir of myths,
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roles, functions , and communicative modes that, when observed, is stagger ingly complex and powerful. Riess's quote from J ung is felicitous indeed in speaking of "an impersonal karma within a fam ily which is passed on from parents to children ." J ung asks himself if these questions posed by fate are more personal or general in nature ; my answer would be that they a re both personal and general. Access to particular myths of a family is important because it relates to the matter of our central concern , the unfolding of specific individual human destinies. Family therapy, especially of a multigenerational family, provides just the access that is needed to achieve this kind of particular understanding . T he format of family therapy focuses on context and on the way in which current experience is understandable from m oment to moment a s a se t of u nfolding processes. Thus , the emphasis is on a different view ofre ality; distorted perception is seen to be accurate in the given context. T he underlying calculus of interpersonal events is demonstrated in statu nascendz~ and the oppor tu nity for altering feedback patterns that maintain dysfunction occurs at the very time and with the very persons with whom they originate . Persons b rought together for group psychotherapy, however , are almost always strangers to each other; they have no shared past , no purposes other than that of using the group experience for effecting personal change , and no collective future. Criteria for admission to membership in the group can be defined; people can be refused admission or , if necessary, eliminated ; eventually the group disbands, and there is no residual function left to it when this happens. T he p ure therapy group ostensibly has only one mission: to provide an aren a and a laboratory where group process can be displayed, examined , and used to facilitate individual change. Contrast this with family. The family of origin has a past that extends to the farthest reaches of antiquity. Perhaps these remote bio -psycho -social origins are unknown or only dimly perceived, but no o n e can d oubt their influence . And in the same way we are infl uenced by our procreative future , or, more exactly, by our a pprehension of it. Even the decision not to have children profoundly affects the current patterning of our intimate networks, although this probably is of lesser impact than actual involvement in
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the human generational chain . Family perdures. However we define it , humans must belong to an ongoing, intimate social network that inescapably has other functions than therapy, that nourishes, pleasures, comforts, and protects. Does this distinction make a difference? I believe so. The family, because of the characteristics alluded to, presents special diagnostic and therapeutic possibilities. It also poses problems not as common among therapy groups . DISADVANTAGES OF THE FAMILY AS A THERAPY SYSTEM Most of the problems of the family as a therapeutic system stem from its stability. As one might expect, families are exceptionally resistant to externally induced systems change , although they vary considerably as to this characteristic and as to the kind of impetus which will effectively cause them to change . The art and science of family therapy are concerned with developing improved methods for working against those forces that operate in the family so as to reduce the impact of external intervention. A principal reason for those forces is the time and method of recruitment of new members for the family group : by the birth of new humans and by sexual joining. The psychosocial consequences of these two methods of recruitment of new group members are , of course, quite different. They are similar in one important way: in both instances the new individual is in a condition of heightened plasticity and reactivity. It is unnecessary to comment on the malleability of the newborn. In a quite different way mating and the alliance of the families of the marital pairs is an intense and overdetermined joining (Napier, 1971 ). A volume could, of course, be written explicating the previous paragraph. The focus here is on recruitment of new family members, perhaps an odd way to put the matter although it has the virtue of aligning the issue with the recruitment of new members for a therapy group. Put this way, it is easy to see tha t the processes are vastly different in their effective ability to gear the behavior patterns of the component persons to the overall system patterning. Recruitment of new members for therapy groups in conditions of personal crisis is a process that is somewhat similar. Even so, there are important differences of degree that determine the extent to
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which the new member will become a thoroughly integral part of the social system being joined. It is not necessary to labor over an exposition of the special qualities of the newborn in this regard, nor to point out the vast difference between the exposure of an infant to the psychosocial forces of a family and the minimal exposure of a new group member to such forces. If nothing else, there is the vast difference in the amount of time spent in each impersonal field. Indeed , it seems reasonable to explain the cohesiveness of therapy groups almost entirely on the fact that members can draw on a shared pool of meanings, needs, and associated affects learned in their developing years as family members. The excessive stability of a family system can make it so resistant to change that it is impractical to attempt to do so. In some instances it is necessary to advise those family members (usually the index patient) who retain some hope and vitality that the family system cannot be looked to for modification and that a psychosocial amputation from it must be performed. This situation is commonly met with, in my experience, in families with a young adult schizophrenic member, and it is this person who most often is the last possessor of hope and vitality in an otherwise moribund system. ADVANTAGES OF THE FAMILY AS A THERAPY SYSTEM The principal advantage of the family as a therapy system stems, as well, from the fact that it is a natural group and primary group. Natural groups, as already noted, are ongoing. For better or worse, their effects are. long-lasting. Family therapy first developed when it became clear that changes in child patients could not be maintained in the face of the influence of the family system. I recall one little .boy we interviewed as part of a study of a therapeutic camp . Each summer his asthma would be relieved, only to reappear at home . After the third summer the improvement was maintained at home . When queried about this , the youngster said, "I taught my mother to treat me the way the counselors treat me at camp." Unintended family therapy . It can be said that all therapies function by virtue of their ability substantially to replicate within their confines the patterns of conflictual interaction that existed for each group member in his fam-
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ily. That this can be done is beyond doubt. What is at issue is the desirability of dealing with surrogates when the real thing is at hand . (Interestingly, for the husband and wife, families of procreation are surrogates for families of origin in a sense, although of such a nature that they need to be regarded as in a special class. It is not possible to go into this issue here beyond identifying it and establishing its importance.) It is economical to work with a primary group because, among other reasons , the problem of salience is efficiently dealt with. We can know with reasonable certainty that the pattems of conflict and d efense characterizing a person's embeddedness in his family are those which are signifi cant in his life. Not so the pattems that may evolve in a therapy group. It is quite possible in the latter instance for aspects of the gro up process to dominate the scene that are of little relevance to one individual's difficulties in living. Many group therapy members have wisely terminated for exactly this reason; the therapy group is struggling with issues that really are of little concern to them . Indeed , considerable effort is often expended in groups to demonstra te to individual members that what is going on is relevant to their lives. The problem of salience is minimized or eliminated in family therapy; we know the issues which surface in family therapy matter.
FAMILY- AS IN FAMILY THERAPY On occasion, family therapy is dismissed with the observation that the standard nuclear family is archaic. The nuclear family is held to have had a brief life during the last half century, and even during this time to have been more of an ideal than a reality, honored more in the breech than in the observance. In Western society today one need not look much past the rising divorce rate and the falling birth rate to support the claim that the nuclear family, or perhaps the extended nuclear family, is rapidly disappearing as a social form. Some may see this as a pity, others as a blessing . However these social changes are regarded, I believe it to be an irreducible fact of human existence that we live our essential lives in two intimate social networks, that into which we are born and grow up and th at which sustains us as adults; the shape and
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vicissitudes of the second are meaningfully and lawfully related to the shape and vicissitudes of the first. The connection between and congruence of these two intimate networks profoundly influences, more exactly is, what we like to think of as our individual lives. Each of these intimate networks may appear to be quite different from the other; their boundaries and membership rules and structures may seem hard to devine and pattern similarities between them difficult to discover. Nevertheless, the relationship of individual persons to these systems and of the systems to each other critically determines human behavior. In this enlarged sense, however varied and apparently diffuse the forms may be, there always will be family; to the extent that we wittingly, or unwittingly, intervene in and influence these systems, there will always be family therapy.
REFERENCES Bloch, D.A., and Le Perriere, K. (1973 ), Techniques of Family Therapy: A Con· ceptual Primer. In: T echniques of Family Psychotherapy, ed. D. A . Bloch. New York: Grune & Stratton. Haley, J. , and Montalvo , D. (1973), In Defense of Child Therapy. Family Process, 12 :227-244. N apier, A . (1971) , The Marriage of Families , Cross Generational Complementarity . Family Process, 10:373-396. Speck R ., and Attneave , C . (1972), Network Therapy. In : The Book of Family Th erapy, ed. Ferber, Mendelsohn , and Napier. New York: Science House.
Dr. Bloch 's address: N athan Ackerman Family Inst. 149 East 78th St. New York, N.Y. 10021
