Two therapists working “systemically” What are the similarities and differences?

This blog turned into a rather long essay-the following are key excerpts. There is a link to the full paper at the end.

Two family therapists, both working with systems in mind, take on the same case.  What commonalities will their work share? What are the differences? Are the differences just different personal styles: or a product of differences in theoretical understanding of symptoms? Is it more constructive to focus on what we share in common? Do the differences make a difference?

Redbank Conference Reflections

Last November I was privileged to be part of the Redbank Conference entitled ‘What does it mean to work systemically?’  Both myself and esteemed family therapist Dr Laurie Mackinnon (1) did a taped role play of the same family clinical scenario and used this to illustrate and present to the audience how we think about family systems and how this guides our practice. I was keen to see on the day of the conference the similarities and differences in the way we work “systemically” and to see what I could learn about varying approaches to systems therapy. The following are my observations of the common ground and the differences in our approaches.  While common ground can be the more comfortable part of this exercise, the consideration on our divergences that has brought the most learning for me and continues to challenge and sharpen my thinking. I thought I’d attempt to share some of these observations and learning and I trust it may stimulate some ongoing thoughtful conversation and clarification.

Laurie’s overview of systems influences & case formulation

Laurie gave her summary of the evolution of systems theory from general systems theory to cybernetics, Batesons’s influence and second order cybernetics, with the observing system seen as part of the social construction of a family system that is seeking help.

I understood that Laurie’s case formulation used sequences of interaction between mother and child (adolescent) and the input of the father and sometimes the siblings, to see the ways that the young person’s attention seeking behaviours were being reinforced cognitively, behaviourally and relationally by the responses of her mother and other family members.

A natural systems view compared to cybernetics and social constructionist lenses – common ground and divergences

It is interesting that Bowen’s natural systems theory was not described as part of the evolution of systems frameworks.   In many ways this is appropriate as this theory evolved quite independently as Bowen shifted from Freudian theory to the natural sciences.  I described the common ground between Bateson and cybernetic theories and Bowen’s natural systems theory. Both streams of family therapy theory have emphasised circularity as opposed to linear cause and effect explanations for symptoms.  Both theoretical lenses have come to see the importance of viewing the interaction of the helping system with the family as an important unit of attention.  Cybernetic theories, as I see it, focus on how interactions influence meaning systems in each individual. Interventions are directed at reframing the intentions of behaviour and shifting symptom reinforcing perceptions.  Bowen’s natural systems theory is grounded mostly in Charles Darwin’s work.  The theory is based [quote color=””]“on the assumption that the human is a product of evolution and that human behaviour is a significantly regulated by the same natural processes that regulate the behaviour of all other living things” (Kerr & Bowen, p3)[/quote]. Human interactions are viewed similarly to other species, particularly other social mammals. Hence this systems approach attends to the automatic (biological) responses to tension in each organism and how reducing anxious reactivity changes the functioning of the whole system.

The interactional sequences are viewed as driven by instinctual reactivity more than my each family member’s thinking about the problem.  The humans’ thinking about the problem is secondary to the tension that drives certain relationship patterns. Cybernetic systems theories work to shift individual member’s meanings that have been ascribed to behaviours and relationships whereas Bowen natural systems theory works to educate individuals about how they get anxiously aroused and how they respond so that they can learn to reduce the degree of anxiety that they contribute to system interactions. Of course there is more depth to both approaches but in simple terms one theory works to shift perceptions and the other to increase awareness of and shift anxiety levels.

My reflections from the 2 role plays

Watching the 2 case examples raised my curiosity about these similarities and differences.  Laurie’s case had all family members present while I had both parents present without children. Much looked very similar as both therapists refrained from defining the problem and invited family members to do so. Therapist engagement in both sessions was achieved through the use of attentive questions that conveyed respect and curiosity for family member’s descriptions.  There were no direct empathic responses as the connection between therapist and family members was developed in the context of attentive collaborative investigation.  In both sessions family members would have had the opportunity to hear each other differently and think about what each family member was up against.

Without the copies of the 2 role plays it has not been easy to compare objectively the 2 approaches. Much of what I have written is based on my observations and recollections.  What we think we see and say is often unreliable. However the following are my comparisons in point from which can be read in full with Laurie’s responses in the link.

• Both of us drew out interactional sequences with Laurie helping the family (parents in particular) to think about the meanings being generated and whether their beliefs about the problem logically fitted the interactions; and myself assisting each parent to become aware of their reactions and seeing the patterns they used to manage tension.
• An interesting difference could be observed in the end of session summations. I remember that Laurie highlighted family observations about the father’s distance. On this basis it was suggested he become more involved as a parent.  I heard a summary that the mother was feeling overwhelmed and that the father could step up to be more of a resource.  After reading my draft blog, Laurie gave me the following feedback with her explanation of this intervention that aimed to shift the positioning of the father:”In answering my relationship focused questions, family members revealed the father’s lack of involvement and the effect on the mother and her relationships with the daughters and ultimately how all of this connected to the presenting problem. They want the presenting problem resolved. The question is: in what way is their current relationship context making the presenting problem necessary and how can relationships change to enable them to be free of the problem?” 
• In my wrap up I summarised what the parents descriptions had helped me to understand the way the husband distances and the wife increases her responsibility for others when they are stressed.   I shared my thinking that each pattern the parents described, particularly in the triangle with the symptomatic child, was a coping mechanism.  The suggestion was that each was co-creating their relationship with their reactions and counter reactions affecting the other.  With a focus on physiological responses and counter-responses, rather than on meaning maps, the focus of attention is less on social inequalities (while these are not discounted) and more on seeing one’s own part in the interactions that are not helping the family.

In the discussion panel at the end of the day Laurie observed that my approach did not use a systems intervention but was educative.  I think that this may reflect the view that an intervention from a cybernetic frame (albeit a second order one that acknowledges the observer’s influence) is about shaking up the system in a deliberate way in order to generate change (positive feedback loops).   As I have increasingly worked from a natural systems frame I endeavour to intervene without entering the reactive patterns of the family but to help family members to understand the system dynamics.  This is educative in that it draws from family member’s descriptions and information to teach them to see predictable systems dance steps (patterns).  In this approach change happens less in the actual therapy session and more through increasing awareness of self and others in between therapy sessions.  Laurie did level a criticism at Bowen theory saying (as I recall it) that it is not valid to describe a system as being anxious as only an individual can be anxious. Her view was that Bowen’s writing on anxious systems needs to be revised.  I responded by acknowledging that the idea of anxiety transfers between people is a different way to think to a DSM medical definition.  I wondered whether there may be those in the audience who at that very moment were living the experience of anxiety being generated in a system. Any who may be instinctively sensitised to the threat of conflict may be noticing their arousal levels increase as they hear Laurie and myself discuss points of difference.  I hear how confusing it can be to broaden anxiety beyond an individual diagnostic framework.  I sometimes wonder if words like “tension”, “stress arousal” and” hyper- sensitive” might be easier to hear attached to a relationship system than the word anxiety.  I understand that any human stress response is first and foremost experienced in an individual’s physiology and it becomes a system phenomena as those in contact have their physiological stress response triggered and respond in instinctive ways to reduce this discomfort.

I appreciated the good candour and mutual respect displayed in the reflection time.   Liaising with Laurie and the conference committee to thoughtfully consider what it means to work systemically has generated valuable learning for me.  Considering the similarities in approaches, affirms for me the value of the collaborative, respectful nature of much systems work; work that draws from well formulated theory to guide a therapist’s questions and focus of attention.  Clarifying differences in systems approaches has required me to push past my own instinctive preference to gloss over points of contention and settle for togetherness.   I appreciate the maturity workout of thinking through and expressing points of disagreement, particularly with a former teacher whose work and contribution to field I hold in high regard.

Link to full discussion including more of Laurie’s responses

*Reference:  Kerr, M., & Bowen, M. (1988). Family Evaluation. New York: Norton.

1. Laurie MacKinnon PhD has private consulting practice in Sydney.  In 2012 she received the Distinguished Contribution to Family Therapy Theory and Practice Award from The American Family Therapy Academy and the Australian and New Zealand Journal of Family Therapy  award for her significant leadership and contribution to family therapy in Australasia. http://insiteconsulting.com.au/