A short history, a long past

Systemic and relational therapy has a short history but a long past. For many years, therapists resisted the idea of seeing the family members of their patients, in order to preserve the intimacy and confidentiality of the therapist-patient relationship. The Freudians excluded the real family in order to bring to light the unconscious, introjected family. The Rogerians kept the family at a distance so as to offer their clients the unconditional acceptance they deemed necessary for the rediscovery of their own inner impulses. And hospital psychiatrists advised against family visits, which disturbed the serene and protective atmosphere of the hospital wards.

Despite the good reasons for keeping family members away from the psychotherapy of individuals, there was also a series of obvious drawbacks. Individual psychotherapy presupposes a certain instability in the patient’s environment, failing which there would be no point in extracting that individual from their surroundings in order to make them change. And when families are going through a crisis or a conflictual situation, it often happens that the patient’s improvement makes the family worse. It thus became evident that a change in any one person changes their whole family system. And, on the other hand, people began to see that changing the family could be the most effective method for changing the patient.

Once people began to measure the reciprocal impact of patients and their families, several therapists decided to attempt the treatment of the whole family together. What seems curious, seen from today, is not that families should have such a powerful effect on patients, but that it should have taken so long to put the implications of this fact into practice. When clinicians began to experiment with family therapy, they drew on work already accomplished in various fields.

The sources of family therapy

Psychoanalysis

In the first place, psychoanalysis, which had highlighted the role of the family in the development of the individual’s personality, but which completely isolated the family from treatment. Freud discovered many things that were useful to family therapists; but, on the other hand, a number of his conclusions did not sit well with family therapy and created a series of prejudices that later had to be overcome. He shed light on the impact of the first years of family life on the structuring of the personality, but he neglected the crucial periods of adolescence. He revealed the power of irrational and unconscious forces, but underestimated the powers of reason. He discovered the distorted images of the family in projections, transference and fantasy, but he lost sight of the reality of actual family interaction.

Most of the pioneers of family therapy were familiar with Freudian theory or came from the field of psychoanalysis, and they found its basic concepts of enormous value for understanding people, though less so for their treatment of families, neutralising its tendency to isolate the individual from the group and to dissociate the inner world of the mind from external behaviour and interaction.

Other psychoanalysts also turned their attention to certain aspects of Freudian theory, among them Fromm, Horney and Sullivan, whose interpersonal theory of psychiatry placed greater emphasis on the social forces acting on personalities. Although they did not go so far as to treat families, their ideas inspired those who did.

Group therapy

Moreover, the obvious parallel between small groups and families led some family therapists to treat the latter as if they were just another form of group, and some group therapists to treat groups as if the group were a model of family functioning, with the therapist as father, the group members as siblings and the group, collectively, as mother. Some group therapists experimented with couples in groups, and other family therapists began to run therapy groups bringing together several families, among them John Bell, who continues to exert a great influence in the field of multiple family therapy. Over time, most family therapists found that the group therapy model did not suit families and moved on to various systemic models.

The child guidance movement

The child guidance movement brought the team approach to family therapy. At first, the members of interdisciplinary teams were assigned to the different members of the family, but they gradually began to perceive the interconnection between the behaviour patterns of the different patients, and to integrate and combine their efforts. Child guidance clinics soon went beyond the field of the juvenile courts and young offenders to devote themselves to a broader child population, including a whole range of other disorders, while extending the unit of treatment from the child to the family. At first, family therapy was regarded as the best way of helping the patient; it later came to be regarded as the way of meeting the needs of the whole family.

Research on schizophrenia

Research on the family dynamics of schizophrenia is probably one of the best-known chapters in the history of family therapy. The names of Gregory Bateson, Don Jackson, Jay Haley, Murray Bowen, Theodore Lidz and Lyman Wynne are known to all, as are some of their concepts: metacommunication, double bind, differentiation, triangulation, marital schism and skew, rubber fence and pseudo-mutuality. But there are a few reservations to be expressed about research on schizophrenia in families. In the first place, the interactional mechanisms observed in these families cannot be applied to normal families; in the second place, the role of the family in the production of schizophrenia proves difficult to reconcile with the evidence of genetic determinants. Observational studies of the families of schizophrenics say more about the onset and maintenance of schizophrenia than about its aetiology. Nevertheless, the researchers who studied the family dynamics of schizophrenia did more than anyone else to launch the family therapy movement.

Marriage counselling and couple therapy

As a form of treatment, family therapy was preceded by marriage counsellors and by the psychoanalytic treatment of couples. Counsellors have contributed enormously to a great many family therapy techniques and continue to offer solutions to family problems. On the other hand, psychoanalysts have long recognised that couples are bound together by complementary unconscious motivations and, in order to modify these reciprocal influences, some began to treat spouses first concurrently, then conjointly. Jackson, Ackerman and Whitaker speak of their own versions of marital therapy, but the field of couple therapy has, on this point, been absorbed by that of family therapy.

The pioneers of the fifties

Many still wonder who was the first to practise family therapy. What is certain is that in the early fifties, in the United States, family therapy began independently in four different places: John Bell began treating the families of schizophrenics at the Menninger Clinic; Nathan Ackerman inaugurated his psychoanalytic family therapy in New York; and Don Jackson and Jay Haley initiated their communicational therapy in Palo Alto.

All these pioneers had markedly different backgrounds and diverse clinical orientations, and this diversity still characterises the field of family therapy today.

In those fifties, family therapy was a radically new experiment, practised in relative isolation by a small group of clinicians who had little contact with one another. In the sixties, family therapy emerged as a growing force within the field of mental health; those who practised it were strengthened by shared ideas, but had to confront the psychiatric establishment, which regarded them as violators of sacred norms and resisted the idea of treatment within the family.

The relational approach and drug addiction

These new developments emerged and were confirmed when, towards the beginning of the sixties, the treatment of troubled adolescents also began to be linked with drug abuse and, more generally, with antisocial behaviour. Salvador Minuchin carried out an extraordinary experiment in the Puerto Rican ghetto of Philadelphia, confronting desperate and dramatic situations through the systemic involvement of families. This was the experience of Families of the Slums.

From there, a new vision of the drug-addiction symptom began to take hold, linked also to the enormous expansion of this type of problem and to the unprecedented situations arising in the facilities devoted to treatment.

In 1973, L. Cancrini and his team described the results of a vast research project whose fundamental hypothesis was that of a significant connection between drug use and the family dynamics of people with drug addiction.

In the United States, meanwhile, the practice of family treatment of drug users was gaining considerable ground, stimulated by remarkable clinical results. These results are described by Erik and Pauline Kaufman and, above all, by Duncan Stanton, who directed a fairly extensive clinical and research programme for the Philadelphia Child Guidance Clinic.

In Europe, alongside the emergence of therapeutic communities, the family treatment of drug addicts developed as a very concrete way of confronting the problems arising in the life of this field. Cancrini repeatedly describes the effectiveness of the results as well as their theoretical and clinical basis.

The relational approach from the theoretical point of view: a few notions of general systems theory

What is the relational point of view on the drug-addiction symptom? And, more broadly, what is the relational point of view on the psychiatric symptom in general?

The relational outlook is largely founded on general systems theory (GST) applied to human systems and, above all, to the family. According to GST, every system or group is made up of a series of interacting elements, endowed with an organisation such that a change in the state of one of the elements will be followed by changes in the others.

Human systems (just like non-human systems) are subject to general rules such as homeostasis, non-summativity and equifinality.

Homeostasis

Homeostasis (or feedback) is the characteristic whereby the system always tends to maintain the status quo, that is, not to change. Without embarking on a tortuous theoretical journey that has already been made many times over, we will say that by “non-change” we mean the activity of the system in defending its action and its general objectives against the whole set of internal and external conditions liable to threaten them.

The simplest example is that of an electric water heater: programmed to supply and keep water at a certain temperature, the appliance processes information about the thermal state of the water it contains, about the quantity of hot water delivered and about the cold water received. This information, gathered by the thermostat, activates the heating element, which stays on until the temperature reaches the set value. Thus the water heater, through small changes, through the use of electrical energy and thanks to its control device, manages to keep its state almost unchanged.

Non-summativity

Systems are also “non-summative”, which means that it is not possible to make a simple algebraic sum of the properties in order to identify the whole set of functions. To explain this concept briefly, we may recall how, in other sciences too, the interaction between two or more elements produces results whose complexity can never be explained simply by resorting to the set of properties of the individual components of the system.

Equifinality

The principle of equifinality shifts the observer’s attention from the starting conditions of a given system to the nature of the path the system follows and to the parameters of the system itself. This means that questions about the “who” and the “why” of a given action are replaced by inquiry into “how” the process of change took place or developed.

The circularity of sequences of events

Another cornerstone of the relational and systemic outlook is that of the “circularity of sequences of events”. By avoiding the question of who caused what, the dynamics of a process seen and described from a relational outlook are confined to noting the merely temporal relationship that links one behaviour to another. The observer will thus avoid the concept of blame and, ultimately, the cause-effect link. An effective description of the consequences of this way of proceeding can be found in P. Watzlawick’s best-known book, Pragmatics of Human Communication:

We thus discover that the participants in the relationship systematically use what is called the “punctuation of the sequence of events”, that is, a reading of the relationship that makes a given act the consequence of an act by the other, as if this were perfectly legitimate and natural.

The function of the symptom

Within this organisation, the question would be: what is the value and meaning of the symptom? In other words, what function does the symptom have in the relationship? The symptom is regarded as a communication perfectly integrated into the whole set of rules of the system itself. It can be seen as a necessary part of the organisation of that system, since its absence would “oblige” the members to seek a different equilibrium. Let us take an example: the stabilising function of the depression symptom can be observed if we think of the great changes that its unexpected disappearance could bring about in a system in which one member had been depressed: the role of the person who, until then, had acted as nurse would no longer make sense; the person who, until then, had played the “optimistic part” would have to change habits, behaviours, and so on. Anyone with clinical experience of psychiatric patients knows well what modifications an unexpected disappearance of symptomatic behaviour brings about. The fact that the symptom has a function of its own does not mean that it is the behaviour that causes and underpins the whole organisation of the system. It is, in any case, an important part of it. We can explain this concept better by drawing on an example from C. H. Waddington: none of the parts of an aeroplane is capable on its own of flying. A propeller, the wings, the fuselage, the engine itself cannot stay in the air. Yet, together and organised in a certain way, they manage to leave the ground. The symptom must therefore be regarded as an integral part of the organisation of the system.

The family life cycle and the drug-addiction symptom

In other words, how are we to explain the function of a symptom such as drug addiction? To do so, we will draw on the theoretical contribution of Jay Haley, who worked on what is known as the family life cycle. The idea arises from the observation that the onset of symptomatic behaviour generally coincides with certain particular periods in people’s lives. These periods are those in which the effort of adapting to changing living conditions is greatest. Haley defines the moments of greatest risk as:

As can be observed, each of these moments presupposes a strong change in the rules of functioning of the family system and demands the abandonment of habits, patterns and roles, both on the part of the parents, as parents and as a couple, and on the part of the children.

A family system may be unable to withstand such “stress”, and the symptom that emerges in one of its members makes it possible not to face the change.

In particular, the drug-addiction symptom seems clearly to refer to the difficulties linked to the young adult’s search for autonomy and independence from their parents, and the parents’ from the young adult. Dependence on the use and abuse of narcotic substances clearly blocks a process of differentiation. The young person goes through this whole nodal period, which is supposed to allow them to build their adult life, immersed in a lifestyle that prevents them from building it; and, in the meantime, the family too fails to face the necessary changes, absorbed as it is in managing this serious problem. This is what has been called the function of the symptom: drug addiction in fact allows the family nucleus not to modify its functioning excessively. The mother will continue to be, and to feel, the most self-sacrificing and the most affected; the father will feel increasingly peripheral and estranged; the drug-addicted son will continue to experience as a “challenge” to the family what is in fact a dependence; a possible sister or brother may continue to be “the good example”, and their leaving home will also be difficult, since it would mean “abandoning” the parents in their suffering.

Referring to Haley’s work, Cancrini sums up the value of the symptom and the organisation that follows from it as follows:

From this point of view, drug addiction comes to play a blocking and obstructing role in the evolution of the family and its members towards a development centred on the formation of an autonomous individuality, which must always arise from complementary processes of differentiation and union.

The dysfunctional family is not, in other words, capable of fulfilling its functions of support and backing for growth.

Consequences for intervention

An attempt at classifying drug-addiction situations will be proposed elsewhere. It is nevertheless fairly clear that the relational approach gives priority to the dysfunctionality of the family nucleus over the specificity of the drug-addiction symptom. It is in this sense that one can explain the analogies between the rules of functioning of the family with a drug-addicted member and those of other families whose identified patients suffer from anorexia, or of families whose members are affected by psychosomatic or psychotic disorders. In other words, the choice of the symptom through which the family expresses itself is of secondary value compared with the rules, the redundancies, the complete organisation of the family system. One consequence of considerable importance follows: the clinical approach will have very little to do with drug addiction in the strict sense.

According to Bateson, the way a system organises itself cannot be defined as “predetermined”; the possibility of predicting precisely that a given system will have a given future is slight. All this is defined as a stochastic process, that is: “an occurrence of events in a partially random manner, since some of them have a greater probability of taking place. If a succession of events combines a random component with a selective process, in such a way that only certain outcomes of chance can endure, such a succession can be defined as stochastic.”

The objective of intervention, from this perspective, will focus on the formation of the therapeutic system, setting aside the habit of drug abuse, or on the attempt to introduce changes into the very structure of the family, in terms of hierarchy, alliances, coalitions, individual and collective behaviours.

A further consequence of this way of proceeding concerns the impossibility of codifying a single intervention that could work in situations regarded as “unique” and therefore requiring original and diverse solutions. The intervention will be codified, once again, not on drug use, but on the characteristics of the systems. From this point of view, we will analyse a series of elements relating to the construction of the therapeutic system which, without being an exclusive characteristic of drug-addiction treatments, will be the object of particular reflection.