Keywords: the family of origin as a therapeutic resource; emotional encounter; forgiveness and reconciliation.

Premise: an integrated protocol for motivated and competent patients

The aim of this article is to argue for and illustrate the importance of involving the family of origin in the individual psychotherapy of a competent patient who asks for help, historically classified within the neurotic area or that of existential malaise: very often these will be young adults, but the model is also particularly suited to people of a more advanced age.

In the field of Italian family therapy, after the purist phase of the nineteen-seventies, people began, once the eighties had arrived, to speak of the rediscovery of the individual (the special issues of the journal Terapia Familiare of 1985 and 1989) and of systemic individual therapy. [See Loriedo, Angiolari and De Francisci (1989) as well as Boscolo and Bertrando (1996).] More recently, the debate in the journal Terapia Familiare has been taken up again by Viaro (2004 and 2005) and by other authors: what is striking in these proposals, already twenty years old, is that no systemic author ever speaks of the habitual and systematic convening of significant family members (which we ourselves call expansions). This practice, although it had already been tried out and theorized, in a less systematic way, by a founding father such as Framo (1992), was revived by the directors and teachers of the Mara Selvini Palazzoli School of Family Psychotherapy in the early 2000s, under the influence of the collaboration with Alfredo Canevaro (Sorrentino, 2004), who had become the individual therapist of many of the school’s students.

Moreover, proposals for expansion during individual psychotherapies are becoming frequent in various schools of psychotherapy; see, for example, De Bernart (2005, p. 111), Loriedo (2005, p. 106) or Yalom (1989).

A preliminary study

In order to be able to reason on quantitative data as well, we asked the patients themselves to collaborate. The study was carried out on a sample of 82 people who had undergone individual therapy with A. Canevaro between 2001 and 2006. Studying the therapies of a single therapist made it possible to study a homogeneous population; the participation of the second author as judge (without his having been involved in the therapies) guaranteed greater objectivity in the evaluation.

At the end of the therapy, they were sent a questionnaire made up of an open question on the overall evaluation of the therapy and of a few further questions, also open, aimed mainly at exploring any difficulties the patient had in accepting the expansions, the evaluation he or she made of them, and whether the therapy had had repercussions on his or her profession.

Of these 82 subjects, 66, that is to say no fewer than 80.5% of the sample, answered the questionnaire.

Description of the sample

The average age of the sample is about 32 years, although in the majority of cases the malaise began before that age. These are therefore adult patients, belonging to normally constituted families (80.3%), of average status (90.9%), who in 51.5% of cases work in a helping profession (psychologists and psychotherapists) and who sought a consultation for relational problems of a neurotic type (80.3%); borderline cases are fewer (15.2%) and only 3 cases with psychotic symptoms are to be found (4.5%). 68.2% of the sample show good socio-affective functioning and 31.8% had already attempted a previous therapy.

Description of the therapy

The duration of the therapies was brief in 51% of cases, with a number of sessions that in 61% of cases ranged between 11 and 30 (minimum 3 sessions, maximum 93).

In the majority of cases (60.6%), the patients did not use psychotropic drugs, and a collaborative relationship was created between patient and therapist (according to the therapist’s evaluation); in only 8 cases was the relationship marked by fluctuations and ambivalence. In general, the first session with the expansion took place at the fourth (22.7%) or the fifth meeting (18.2%), precisely because, as we shall say later, it is important to assess the patient’s capacity for change and to create a good therapeutic alliance with him or her. The number of expanded sessions was, in the majority of cases, four (or fewer), and in only one particular case did the expansion extend over fourteen sessions.

In 23 cases, the expansion involved the parents and the partner; other expansions involved only the parents (13 cases), or the parents and the siblings (10 cases), or else the parents, the siblings and the partner (7 cases); the remaining 13 cases, by contrast, extended participation in the session to other people significant for the patient, such as the grandmother.

The patient’s general evaluation of the therapy and of the expansions

The general evaluation given by the subjects to the usefulness of the therapy was, in the great majority of cases (89.4%), positive or very positive, and only 7 declared themselves dissatisfied. It is interesting to note that those who give the most negative evaluation of the therapy are the patients who had a long therapy (6 out of 31 judged the therapy negatively), compared with those who had a brief therapy (1 out of 33 evaluated the therapy negatively).

The majority of participants state that they had no problem accepting the expansion, even though 25 patients expressed difficulties in involving their own relatives. It is interesting to note that it was the patients working in a helping profession (psychologists and psychotherapists) who expressed the most difficulty in accepting the expansions (16 out of 33 stated that they had had difficulty accepting the expansion), compared with patients working in other professions (7 out of 31).

In 83.3% of cases, they gave a positive evaluation of the expansion, regarding it as an emotionally powerful experience (45%) that allowed them both to feel a sense of closeness and belonging with regard to relatives whom they had until then felt to be distant, and to experience a positive personal feeling: more self-confidence, greater well-being, and so on.

45.5% of the part of the sample working in a helping profession (psychologists and psychotherapists) also stated that this had had positive repercussions on their own profession. They indeed felt more determined to ask their own patients to carry out expansions, and more able to understand the advantages and the difficulties of this experience.

The ten subjects who evaluated the expansion negatively stated, on the other hand, that they had found it useless (5 cases) or had experienced it as something imposed by the therapist (2 cases). It is important to emphasize that in only 3 cases was the negative evaluation due to a negative reaction on the part of the relatives.

We shall analyze these data in detail later on: we wanted here to anticipate a few of them in summary form, in order to give a measure of the strong sense of feasibility and success that we experience with this therapeutic model.

The underlying philosophy of our therapeutic model

In all models of individual psychotherapy, precisely, the therapist tries to enhance the patient’s capacity to believe in himself and to seek his own identity freely and spontaneously. Our model is partly different, because it seeks to ensure that the parents (or the other relatives) also deliver a fundamental message of acceptance and confirmation: I accept you as you are. This process cannot take place on the cognitive level, but only through an intense emotional encounter. The backpack experience (see below) is a paradigmatic example of it.

Very often, child-parent couples taken one by one remain caught in an endless game in which each lives to make the other change, trying precisely to set an example of the way the other ought to live: a typical case is that of the spiral, or complementary bogging down, between a sanctimonious mother with an excessive sense of duty and a transgressive, hedonistic daughter. The experience of a powerful emotional encounter, of a genuine reciprocal acceptance, makes both of them freer to understand how they really want to be and to live, abandoning the compulsion to sanctimoniousness or to transgression.

The underlying philosophy of this model of individual therapy consists in changing the relationship by enhancing a sense of belonging to the family: a change that takes place inside the family, through emotional rapprochement and not through physical and psychological distancing. The patient’s further growth and differentiation will occur spontaneously, thanks to the need every human being has to explore the world and to trace out his or her own existential project. The therapist’s effort will consist in helping them to remove the obstacles that clog the relationship and prevent it from being a relationship from person to person (and not from role to role).

The centrality of the patient as protagonist of change

The first objective of the first sessions with the patient alone is to verify his resources, in order to be reasonably sure that he can be the protagonist of a change in himself. Why do we think that, with the type of patients we are dealing with here, it is neither indicated nor effective to convene the significant family members immediately? Not because of old myths of the kind: in the phase of disengagement from the family of origin, we should help him to distance himself from it physically or emotionally, or else he does not accept the presence of relatives (Boscolo and Bertrando, 1996). The fundamental reason is that seeking psychotherapy for oneself is usually (in the most favorable cases, those of so-called authentic motivation) the result of a long journey of suffering and of reflection on that suffering. There will have been attempts to get out of it through changes of life, the use of medication, separations, journeys, new passions, changes of job, and so on. At a certain point, the person feels that he cannot manage alone: he needs help and senses his own significant responsibility in maintaining the malaise. At the same time, he is capable of reacting to pessimism and defeatism: a hope has been born in him. These are three fundamental steps: coming to ask for help, accepting responsibility for one’s own life and letting a hope grow within oneself, three steps that have often required a very long journey in order to overcome denial of the problem, the omnipotence of wanting to manage alone, the victimhood that attributes responsibility for the malaise to some other self, and to emerge from the feeling of helplessness (the four stages that precede access to a psychotherapy, Selvini, 2007).

In all cases where a request for individual psychotherapy is the fruit of this fundamental journey (which is sometimes, in itself, an important factor of improvement, even before the therapy has begun), it would be truly mistaken to humiliate such progress with an immediate expanded convening, which implicitly communicates a devaluation of that journey and runs the risk of delivering powerful implicit and mistaken messages of the kind: the therapist’s help is not enough; if your relatives do not change, you will never get out of your difficulties. The patient may have taken an important step against his omnipotence and his defeatism (an integrative movement with respect to this classic polarization), and the immediate expanded convening risks pushing him back toward a dramatic pathogenic polarization: either toward victimhood (it is all their fault) or toward helplessness (they will never change, I will never manage).

The first four or five sessions with a patient who is asking for help serve precisely to verify and consolidate the journey that has led the patient to individual therapy: is he really capable of accepting, thinking about and elaborating his responsibilities (Yalom, 1989) in the malaise? Can his hope of change be supported and enhanced? Can the patient benefit from sharing; does he feel better for no longer being alone in the search for answers and solutions? If the answers to these questions are positive, then a good therapeutic alliance is possible, and this will give us a good basic prognosis for the success of the individual therapy.

However, the very long and historic experiences of systemic, psychoanalytic, cognitive and other individual psychotherapies, founded on these excellent starting points, demonstrate to us that the risk of failure nevertheless remains high, and that the durations of therapies are, alas, too long for the real possibilities of many patients.

Brevity and effectiveness are strongly linked dimensions: a project that is too long is often impracticable, and one therefore loses the potential effectiveness.

Historically, psychoanalysis placed all the therapeutic factors on the relationship between analyst and patient, maintaining that the analyst should have no contact with the patient’s relatives, because that would have contaminated or distorted the transference relationship. This technique has usually proved impracticable with the most severe patients, and it has made it necessary to lengthen enormously the duration of the therapy and the number of weekly sessions. Our experience demonstrates, on the contrary, that involving the relatives of a patient who is asking for help, if it is done in the right way and at the right moment, can shorten the length of the therapy and improve its effectiveness.

The fundamental reasons for the expansions

Thanks to the expansions, the effectiveness of therapies improves for two fundamental reasons. In individual therapy without expansions, the therapist may need very long periods for the patient to experience, in the relationship with him, the different aspects of his personality; at the same time, the therapist cannot but believe the description of the relatives that the patient brings him (Kohut, 1979). The therapist will thus inevitably be contaminated by the patient’s distortions of reality (Selvini, 1993) and he will need, here again, intense work on his own countertransference in order to be able to make the patient understand his responsibilities in inducing negative attitudes toward himself in others.

Convening significant family members, on the basis of a good therapeutic alliance, very effectively counters this factor of amplification or distortion in individual psychotherapies founded on a kind of autism for two. The patient who, in the individual sessions, shows only her traits of depression, fragility, incapacity and dependence with regard to her relatives, seen together with them, reveals a quite different face of her personality, perhaps attacking them for trivial reasons, becoming tyrannical and seeking to dominate them with absurd demands.

Such a session opens up a new and fundamental field of work for the individual therapist.

The other essential potential of the expansion lies in the confrontation between the description of the relatives given by the patient and the therapist’s direct observation (and, where appropriate, that of his team). For example, the father who had been described to us as a chronic psychotic, aggressive and abusive, we see as a sick old man, confused, helpless and depressed. What, then, can explain the fact that our patient still carries within her such a violent, explosive rage against him? This feeling of hers finds no foundation in the present behavior of this poor man stuffed with medication. What prevents her rage from subsiding? What paralyzes a physiological empathic movement toward a father in such a bad way? Such a confrontation opens up new territories for individual therapy, territories that would have remained inaccessible if, for years, we had gone on thinking with her and like her about the present necessity of defending herself from a dangerous madman, without supposing that the rage conceals an ardent desire for a positive emotional encounter.

But why has the classic psychoanalytic technique, that is to say the phobia of joint sessions, been so successful and why does it continue to be so?

Because expanded convenings require an oriented, directional conduct for which most individual psychotherapists are absolutely untrained. The expanded session cannot be based on listening, at least in the great majority of cases. By definition, the family therapist knows that he cannot allow the family to interact in the session as it currently and habitually functions. This problem arises less, and in a different way, in the individual setting. Individual settings, in their various models, are structured precisely so as to be in themselves a new emotional and cognitive experience.

But in the expanded setting, things change: the same techniques cannot work. We must protect our patient from the risk of being attacked, disqualified and humiliated, or ignored, but at the same time we must also protect from the same risks the relatives we have invited. By definition, the session cannot be an unpleasant and useless experience, the repetition of old and painful dynamics. It must be a new experience, and this obliges the therapist to adopt a directive conduct that allows him to control and program the experience of that session.

In family therapy, the therapist’s position must be one of multidirectional partiality (Boszormenyi-Nagy), that is to say he must be allied with all and complicit with none; with this model, by contrast, the centrality of the patient and the alliance with him must be solid and beyond discussion. The relatives come in order to help him and if, in the future, one of them were to request a further session for himself, the therapist could grant it only in the presence of his patient as co-therapist: he will have to help him to help his suffering relative, by giving affection and understanding, as an adult child to a father or a mother, and no longer as a patient. This prevents any manipulation by the relative, who might request a session solely in order to talk about obscure or unknown matters concerning our patient. Should psychotherapy be necessary for a relative, the therapist will have to refer him to another colleague and never conduct it himself, because that could be experienced by the patient as a betrayal.

Countering the risk of a forced and destructive separation from the family of origin

A myth that is very widespread among individual therapists of all orientations maintains the necessity of moving physically and emotionally away from a dysfunctional family in order to be able to differentiate. This is what is called “emotional cutoff” or cut-off, described by Bowen (1978) in his historic writings. Many individual therapists, incapable of mastering the complexity of the therapeutic journey, gravely underestimating the importance of the feeling of positive belonging to one’s own family, over-identifying uncritically with the anti-family part of their patient, put into practice a therapeutic strategy that would like to devote itself to supporting his capacities for self-affirmation, but which in reality ends up as a banal incitement against relatives and partner. Especially with patients in the border area, characterized by discontinuity or disorganization between idealizing and demonizing aspects with regard to relatives, such a strategy is iatrogenic, because it in no way favors rebalanced integrative processes; on the contrary, it unbalances and polarizes toward demonizing negativity. In such cases, seeing the relatives directly is the best of supervisions! (Selvini, 2004, p. 236.) Therapists who listen to their patients’ complaints without taking their ambivalence into consideration are like those (friends or relatives) who listen separately to the members of a couple in crisis, without seeing them interact. All will end up saying: “If your partner is so unreliable, so neglectful, if he mistreats you and does not love you, separate! It will be better for you!” By seeing them interact, they will understand that what counts is the relationship, circularly, in the explanation of their sufferings (and of their pleasures), and that an individual reading will never be able to explain the complexity of their bond.

The adult human being struggles permanently along an axis that oscillates between two great needs: the need for belonging to a family system that gave us life and our name, with which we have accumulated thousands upon thousands of interactions, and the need for differentiation, a spontaneous impulse that leads us to explore the world and to design an autonomous existential project so as to integrate ourselves creatively into the surrounding culture and, where appropriate, to recycle ourselves with our descendants in a transgenerational mechanism for the survival of the positive values we have inherited.

Carrying within us hatred for a father with whom we have not been able to clarify our relationship will make us hate a part of ourselves forever or, worse still, we shall see enemies everywhere, or in our partners or our children, in an illusory attempt to relieve that suffering: it is resentment that binds us, more than love!

As long as the parents are alive, and no matter at what age, a therapeutic encounter that can address the unresolved knots and possibly untie them can change a life. We have seen situations dragged out for years without a solution which, by means of an adequate clarification and, where possible, the hearing of a sincere request for forgiveness from an elderly father who acknowledges his mistakes, can completely change a patient’s experience.

The problem of the indications for this type of intervention

The three criteria we have spoken of – responsibility, request and hope – are therefore the basis for evaluating the indications for this type of treatment, which is usually brief: from twenty to forty sessions over about two years. As Sorrentino (2004) emphasizes, the basic indication therefore concerns patients capable of telling their own story (good autobiographical competence), adults endowed with existential autonomy, and adolescents who are asking for help and whose parents are the referrers and are consenting. In other cases (children, reluctant or ambivalent adolescents, adults presenting significant pathologies), the indication remains that of family therapy.

In an earlier work, Canevaro (2005) provided us with a composite portrait of the patients with whom he has successfully tried out this model of intervention.

Good individual care can also be useful and fundamental with far more severe patients: for example people devoid of family resources and victims of criminal behavior (sexual abuse, maltreatment), or presenting severe personality disorders and psychotic symptoms. In such cases, however, the therapeutic philosophy will be entirely different, because the psychotherapy centered on the patient will not be, as in the model presented here, the only intervention: it will on the contrary form part of an integrated, multidisciplinary network of interventions on the person, the family and the living environment.

Conducting the first sessions

In the first sessions, the therapist builds the therapeutic alliance with a series of techniques on which we cannot dwell here: description of the problem, history of the patient’s personal life, first explanations concerning personal and defensive functioning, agreement on a consultation that will involve significant family members, gradual gathering of the three-generational history of the family (genogram), formulation of a hypothesis about the relational meaning of the symptom, possible psychoeducational prescriptions for containing the symptom and for experimenting with alternative behavioral modes, up to the negotiation of the convening of the relatives.

Reflecting with the patient on the people we convene

We must discuss with the patient the overall objectives of the expansion that we have set out in the preceding pages.

1. To have more elements for understanding who he is and how he functions in his most important relationships.
2. To have more data for understanding who his relatives are and how they function in their relationship with him.
3. To try to understand where the distortion of one or another aspect of his perception of himself is situated.
4. To try to understand where the distortion of his perception of one or another aspect of his relatives is situated.

To all this may be added a few more specific objectives, which usually have to do with a problem of emotional distance and lack of a sense of belonging: the joint session is particularly useful for those important people whom we feel to be distant, with whom communication is minimal. Often these may be siblings, or even one of the two parents, usually the father.

Another specific problem may be that the relatives are unaware of important aspects of the patient’s life: for example, they do not know how severe his symptoms and his suffering are. In that case, an expanded session that involves everyone in the sharing of this new and painful information can be useful.

Negotiating with the patient whom to convene and when is part of the evaluation of his active role: for example, the father alone if the mother has historically always made it difficult for the child to get close to him, and if the father himself has often shied away. In the event that the patient is paralyzed by doubt, it is fundamental that the therapist be capable of taking on the risk of the decision.

A child may have been placed too rigidly in a protective role toward one of his parents or toward both: he has thus had to manage on his own and has not even had the strength to protest against these behaviors that made him suffer. For example, an expanded session could be used so that an adult woman may at last communicate to her father her suffering at the brutal and disrespectful rejection of her first boyfriend. A behavior that still hurts today, because it remains true that the father continues to take for granted that his daughter will behave according to the patterns he has attributed to her. In many cases, the theme of excessive emotional distance between the patient and his significant family members is linked to a role reversal, whether active or passive. The patient has never shared his most troubling feelings so as not to burden or worry his relatives. In such cases, the convening itself is very difficult for the patient to accept, because it breaks the old rules: for the first time, the child asks for himself instead of giving help; for the first time he asks awkward or thankless questions. The session must then be well prepared, so as to prevent the patient from remaining silent once again and the encounter from being reduced to a useless and formal ceremony. In reality, this risk is not very frequent, because the very fact of being convened for a therapy is accompanied by an effective and innovative emotional message.

Without any doubt, expanded convening, in its various formats, appears indicated for those personality types in which the various forms of role reversal and distancing are particularly present and deeply rooted: symbiotic/dependent (passive role reversal), avoidant (lack of a sense of belonging), parentification (active role reversal) and obsessional (protection of the parents through obedience and success).

Discussing patients’ resistances with regard to the expansions

The convening is always full of doubts and anxieties. “Will my relatives fall apart if I really set out what I think?” “Won’t Dad, who has had a heart attack, have a stroke during the session?” One might answer: “If he had a heart attack, it is because he was never able to free his heart from his anxieties. Let him speak freely. In thirty years of holding these meetings (Canevaro), nothing of the kind has ever happened (so far). Usually, patients tell me: “My father is very much at ease and communicative. The meeting did him good!”” “And what if, after the meeting, the family falls apart?” “How will they cope with all the anxieties and distress that are going to be reawakened?” Answer: “Family systems are very strong organizations, which recompose themselves easily after a shock. We individuals, patients or therapists, are much more fragile, but out of that weakness can be born the strength to shake things up in order to stimulate and encourage a change.”

In the preceding paragraph, we have already touched on some of the most frequent themes: reversing a history of role reversal through an explicit request for help, giving voice to feelings that have always been repressed, countering distance and formalism through genuine sharing, through intimacy and closeness.

These objectives can then be aimed specifically at different people. For example, an over-responsibilized brother or sister is often followed by another polarized in the opposite direction, toward a more egocentric, hedonistic and transgressive existential position. The expanded session can then be oriented toward reflection on the advantages and disadvantages of this polarization, so as to be able to counterbalance it, perhaps through a fairer distribution of support for the aging parents. As we have seen, in other cases a child may have been the “private property” of the mother; bringing the father back into play is then the objective of the expansion.

The expansion will take place only when the patient is at least partly convinced of its usefulness. Some patients may find the expansion impossible and unacceptable. This may be the case with patients presenting significant schizoid or paranoid traits, who, already in extreme difficulty as regards the possibility of stabilizing a basic trust in the therapist, will experience the expansion as destined to turn against them: they are terrified at the idea that the therapist may go over to the side of their relatives.

The expansion will also have to be very carefully considered and prepared with patients presenting significant discontinuities of personality (the borderline area), where the risk of impulsive and aggressive movements is greater, both from the relatives toward the patient and from the patient toward the relatives. In such cases, the expansion will begin with the relatives experienced as the most allied, certainly not with those historically regarded as enemies (see the whole debate on the contraindications to family sessions, Selvini, 2004, p. 228-229; and Cuccuru, 2006).

A frequent perplexity, again in the already mentioned area of parentification and role reversal, is encountered with educated, university-trained children of parents with only an elementary education. The child may fear the father’s humiliation; the therapist must therefore explain that he will conduct the session in such a way as to help the father to make the most of his affective and emotional contribution, leaving aside all intellectual sophistication.

Deciding on the first convening and those that follow

We have already anticipated several answers to this question. In summary, it may be said that, especially in situations of intense triangulation and conflict (separated and/or conflicting parents, harsh rivalries among siblings), one will proceed by one invitation at a time, beginning with the least conflictual relative. Or else we shall begin with the siblings, in order to develop a network of alliance intended to help the parents who are in difficulty. As we have already said, in other cases preference will be given to the relative with whom reducing the emotional distance appears the most useful.

Expanded convening of the whole family can be used to affirm the family’s existence in all those situations where this collective identity (cohesion and sense of belonging) is rather fragile.

Another criterion may be to invite relatives who might hold interesting information that has not been shared.

With patients characterized by notable traits of protection and compliance (the dependent-symbiotic area, see Selvini, 2007), there is a risk that, in an advanced phase of the therapy, the persistence of significant difficulties may be concealed from the therapist, because they do not want to cause him disappointment. In this case, an expansion to relatives or partners represents a very important verification of the actual effectiveness of the intervention, and can allow a turning point in a treatment that has become bogged down after an initial phase of excellent progress.

Techniques for conducting the expanded session

The fundamental criterion will be to compare the different perceptions, both of the patient’s characteristics and of the key elements of the family history.

The relatives will always be asked how they received the invitation to take part and how it was conveyed to them (whether each was told separately, whether someone else, usually the mother, was asked to pass it on, and so forth). This is important information, which makes it possible to understand how information circulates within the family system. Once, at the beginning of a meeting with a patient’s mother and two sisters, the mother began to speak vehemently. Canevaro interrupted her after a few minutes to ask her whether she was a widow, since in her account she never mentioned her husband. She replied: “No, not at all. It is simply that I told him nothing about this meeting because he is always outside our affairs… he never takes any interest in them…”

After clarifying the reaction to the invitation and the way it was communicated, the therapist explains the reason for the invitation: “So-and-so has come to me to seek help for his or her problems and, since I consider the family to be very important in the life of an individual, I would like to ask for your collaboration and your information in order to help him or her better. I therefore ask you to speak openly about the problems that exist, about the reasons for these problems and about the solutions you propose. Help me to help him.”

This sincere request for help on the therapist’s part is very important in order to place the family in favor of the therapeutic process and not against it. The therapist’s art consists in channeling these forces in favor of an intervention which, very often out of prejudice, is labeled as useless. Many people, often the parents, begin by saying that they do not believe in these therapies, but that, out of love for their child, they are willing to help. Most of the time, and without any clarification being necessary, they do interact, and it is frequent for these same people, reluctant at the outset, to give thanks at the end of the meeting and to commend their relative to our attention.

Veronica’s need to take leave of her family on the occasion of her forthcoming marriage allowed all her siblings and her parents to say what they had to say and to wish her a fine experience. The mother, who habitually maintained an exclusive relationship with Veronica (excluding the father), had to make room for a long development by the usually silent father on the affection he had always felt for his daughter and on how he would have liked to remain in contact with the new couple. The tender embrace that Veronica gave her father, and then each of the others, created a deeply moving atmosphere that represented for her a genuine ritual of farewell and of passage to a new stage of her life.

When there is an emotional divorce between the parents, it is appropriate to hold separate meetings, oriented toward consolidating a positive personal relationship with each of the parents, and at the same time to define as “mission impossible” our client’s therapeutic attempts to try to bring them back together. When young patients desperately try to help their parents in their quarrels, we show them how, by interposing themselves in order to avoid the confrontation – an altruistic and positive thing – they at the same time unconsciously avoid an encounter between the parents that could be enlightening and decisive.

The relative is never invited as a patient, but always as a privileged witness called upon to help the therapist by expressing his point of view both on the patient’s limits and on his resources, indicating what might be a path that helps him to live better. Sometimes, simply comparing points of view allows a liberating clarification of old misunderstandings and long-standing misapprehensions.

As we said above, the therapist’s observation will usually not be able to rest on a position of mere listening. With his patient, the therapist will have prepared in advance a few key questions, which one or the other will address to the relatives involved.

With patients in the neurotic border area, characterized by intense feelings of victimhood with regard to their relatives, a journey that helps them to understand their parents’ three-generational dramas can dissolve the negative mythology built up about them, can allow the parents themselves to ask forgiveness for the sufferings they have unintentionally caused, and can open the way to an authentic process of forgiveness and reconciliation.

The therapist must be very active in promoting communication, relational exchange and the creation of the therapeutic climate that makes the encounter possible. He must be highly directive in organizing the therapeutic setting and in the structural and experiential maneuvers, and absolutely neutral as regards the changes that occur and that depend on the psychological and emotional vectors at play, modified by this contextual intervention.

The body, the emotions and the counter-avoidance maneuvers

We consider it very useful, at a certain moment of the session (never at the beginning), in the heat of the psychotherapy, when highly demanding themes or highly conflictual situations are being addressed, to encourage a physical encounter that allows resistances to be resolved.

Just as the Chinese say that a picture is worth more than a thousand words, we might paraphrase them by saying the same of an embrace. When it occurs at the right moment, it can modify a therapeutic outcome. At the right moment means never before having removed the rage and resentment that prevent that emotional encounter, which is almost always ardently desired, even after exasperated reproaches, which very often represent a request (Canevaro, 2003).

Language, the supreme acquisition of living beings, can unfortunately also be used to lie, to falsify or to mystify aspects of personal, family or psychotherapeutic life.

By contrast, feelings never lie.

Understanding non-verbal communication (75% of human communication) is an irreplaceable art in therapy. Reading tones of voice, movements of the face and proxemics (the study of the spatial distribution of the members of a group) can be fundamental for making an interpersonal relationship coherent.

To say to a person who claims to be serene, while she is shaking her leg uncontrollably: “What will your leg think of what you are saying?”, is to integrate contradictory aspects that cancel out a double message or make a behavior more understandable.

In dysfunctional communication, relatives are past masters in the art of avoiding the emotions liable to disturb the rationality of the encounter.

Frequent examples are:

• hiding behind the role of parent instead of speaking as a person;
• changing the subject when a controversial theme is approached;
• looking elsewhere and not into the eyes of the interlocutor;
• moving one’s body away from the interlocutor, preventing a physical encounter;
• trivializing or disqualifying the request, especially if the therapist asks for a physical rapprochement;
• speaking to the therapist about one’s son or daughter and not speaking to him or her directly (avoidance compounded by a triangulation of the therapist). Example: “He knows that I love him” is not the same as telling him so directly, looking him in the eyes;
• giving a formal embrace and not a “full” one. Giving a pat on the back and not holding the person in one’s arms.

The therapist must be very active in the counter-avoidance maneuvers, waiting for the right moment to ask for the moves and rapprochements that may frighten people.

Waiting for the right moment means raising the emotional intensity, by addressing universal themes that awaken deep emotions: love, death, madness, transmission to the following generations, and so on.

• asking people to speak to each other while looking into each other’s eyes;
• asking that they answer neither evasively nor ambiguously;
• having people sit facing each other, holding hands and looking into each other’s eyes.

It is impossible not to communicate in this position, unless one looks at the therapist or addresses him. It is enough to tell that person to look at her interlocutor in order to neutralize the avoidance maneuver.

Requiring that one speak to the interlocutor and not about the interlocutor is very important and, at times, it has to be done repeatedly in the face of patients’ reluctance to change their attitude.

In our culture, it is considered a merit to control one’s emotions, especially in order to bring up one’s children better. I have heard it said several times in session: “Children should be kissed while they are asleep…” As though kissing them were perceived as an emotional vulnerability and as something anti-educational.

When one succeeds in encouraging an emotional encounter, it is very frequent for people to weep or for unproductive defenses to fall, which encourages a more sincere communication of what one really feels and sometimes cannot manage to express. A psychotherapy founded on this approach is not a right-thinking or naive therapy, since what really is in the relationship and cannot be expressed does occur. Clarifying the true emotional coloring of a relationship can help to define it, both in the sense of expressing the need for attachment and tenderness and in that of hatred or accumulated resentment. The therapist can only encourage the expression of what is in the relationship; he cannot create feelings that do not exist.

Only once these feelings have been manifested can the members of the relationship metacommunicate about it or clarify aspects of their own behavior or their own history. It is in this way that one very often arrives at the understanding of a lifetime of misunderstandings, sometimes born in an earlier generation.

Typical course of a therapy with this model

Scheme 1

• Sessions 1 to 5: patient alone
• Session 6: patient and father
• Sessions 7 and 8: patient alone
• Session 9: patient and mother
• Sessions 10 and 11: patient alone
• Session 12: patient and sister
• Sessions 13 to 18: patient alone
• Session 19: patient and partner
• Sessions 20 to 30: patient alone

This may be regarded as the scheme of a long therapy, with fortnightly sessions, and longer intervals in the final phase, with two quarterly check-ups, lasting about two years.

The sessions that follow the first ones

When the therapist feels that he has established a good, reflective and cooperative climate with the relatives as well, he can introduce specific exercises oriented toward a vigorous attack on the techniques of avoiding emotional rapprochement that patients and relatives often continue unconsciously to put into practice. A very effective exercise was invented by Alfredo Canevaro and called la mochila, the backpack (Canevaro, 1999).

A therapeutic ritual to encourage the positive redefinition of the parent-child relationship: the backpack

Once the first phases of defining the problem and convening the relatives to the session are over, we are in the middle of the third phase, the one that is central to the therapeutic encounter oriented toward clarifying misunderstandings. When a good climate of collaboration has been created, the parents and the patient are invited to try out this exercise.

The formula is more or less this: “At this moment, it would be very useful to have an experience together. You (to the parents), place yourselves facing your son and, one after the other, begin this experience, while the other sits beside and waits his or her turn, watching in silence what happens.

Let us begin with you, Laura. Sit facing your son, knees together and without crossing your legs. Take each other’s hands and look into each other’s eyes. At this moment, Antonio is about to set out on a long journey through life and he is taking a backpack with him. Try to find two or three important things of your own, which you have managed to cultivate and of which you are proud, to give to Antonio; he will put them in the backpack and, when he needs them, on the long road of life, he will take them out and make them his own.

Let us see, for example, an aspect of your character that has served you in your life and with which you are satisfied.”

Laura then, taking Antonio’s hands with great determination and looking intensely into his eyes, says to him: “I give you my enthusiasm, because in life it has allowed me to overcome difficulties and to take new paths.”

(The therapist takes a sheet of paper, divides it down the middle and carefully notes what Laura says: on one side the concept, on the other its explanation.)

“I give you my trust in women, because balance and collaboration between the sexes have always seemed right to me.

I give you my love of children, because it has always guided my behavior.”

The therapist says: “Very good, Laura, let us go over these three things again.” He repeats the concepts and has Laura repeat them, trying to define them in a single word, or in a few words, to explain the reason for those words.

Once the concepts have been repeated, the therapist asks Antonio, who is moved and is looking at his mother with misty eyes, to leave something of himself with his mother before setting out on the long journey, something he thinks his mother might be pleased to take with her.

Antonio then speaks to his mother in a moved voice, saying to her:

“I leave you my protection, which will always be there.

I leave you a different sensitivity, even though we both have a similar creativity.

And, lastly, my capacity to observe and to sense the person in front of me, a door onto the world.”

The therapist reads back what Antonio has said and has him repeat it. After which, he asks them both to embrace without words, resting their head on each other’s shoulder. This is what they do, in a long embrace that ends with a kiss. Cristiano watches, moved and silent, what has passed between them, and prepares to sit down facing Antonio.

The therapist says to him: “Now, Cristiano, it is your turn. Sit facing Antonio and, like Laura, choose two or three things with which you are satisfied in order to give them to him, for his long road through life.”

The words chosen and the metaphors used for this exercise awaken deep emotions in all the participants, which helps to create a very warm and engaged atmosphere.

The father chooses his words with care, helped by the therapist to define the concepts clearly.

“I give you my sense of intellectual freedom, which has allowed me not to let myself be conditioned by anything or anyone.

I give you my doubt, because in life it has allowed me to analyze things better.

And I give you my courage to spend myself without counting the cost in life, to get to the bottom of things.”

Antonio, deeply moved, takes his father’s hands and, trembling, brings them to his face, holding them there, in a highly significant silence.

Then he says: “I leave you a new space in which to lower your guard and enjoy yourself without a care!

I leave you my way of experiencing time, letting it flow gently.”

Once this is finished, the therapist has him repeat the concepts, after which he asks them both to embrace, without words, resting their head on each other’s shoulder. This is what they do, in a long and moving embrace. Laura looks on in silence, her eyes misty. Then the therapist concludes: “These moments you have lived through with intense emotion, let them flow within you, without asking yourselves for explanations and enjoying these sensations.”

About a month and a half after the backpack experience, Antonio comes to the session, after the holidays. He is much more relaxed and smiling, and says that he had a very good time in the countryside with his family and his grandfather. After that, he went to the seaside with his friends and had a lot of fun. “I was withdrawn into myself. I have got past very complex aspects of self-observation that were leading me to cruelty and fragmentation. Lately, there has been a recovery.”

The therapist: “And how are your family?” “It seems to me that they are well. Things have improved appreciably. The relationship with them has become more relaxed, there is more acceptance. After the backpack session, I needed two days to recover. I needed to work through those things that had never been said before. It was like a comma, which made me change the subject. It was very violent. I loved and I hated that moment. I realized that I am a delicate person, not a strong one, but a very emotional one. What impressed me most was a reflection of love in my father’s eyes. I saw him in a way I had never seen him before.”

The backpack experience, carried out at that moment of the therapeutic journey, has a synergistic effect that shortens the sometimes very painful passage through this phase of the family life cycle, since it involves all the participants in the relationship and makes it possible to experience from the positive side the intense emotions linked to these experiences of differentiation.

The parents feel that they can fulfill their duty and have permission to show their feelings, without restraint. It is without any doubt a very important rite of investiture for the child, who needs a confirmation of his parents’ approval for his growth.

It also helps the parents to rethink their life less in terms of the child and to confront the empty-nest phase, a very difficult moment for the couple since, in our Mediterranean culture, the couple lives almost exclusively on parenthood and much less in terms of an intimacy that has to be built and taught.

The backpack is a therapeutic experience that facilitates differentiation and, at the same time, a test that shows us the evolution of the parental relationship and the capacity for mental functioning of the child and the parents. On their capacity for symbolization (only once, in dozens of attempts, did it happen to me that the parents put into their son’s backpack some salami and various cold cuts!) and on their capacity to accept this reciprocal farewell may depend the future evolution of their relationship and of the child’s existential project.

The usefulness of a failed expansion

It is truly very rare for relatives to refuse to take part, whereas it may be more frequent for the expanded session to end up being a disappointing experience, in particular when the therapist does not manage to handle adequately family situations that are emotionally very cold or intensely conflictual. For example, the relatives remain centered on their own needs, are incapable of taking the point of view of their son, their daughter or their brother; in fact, they go on pinning him to that role, often of a sacrificial kind, that they have attributed to him from the beginning. Such a painful session is very important, in particular so that the therapist may understand the extreme limitation of that family’s resources and the need to accompany the patient in working through this mourning, to help him to defend himself better and to be content with a few “crumbs”, without expecting anything more.

However, in this field too what Cirillo (2005) maintained for abusive families holds good: let us not bet straight away on irrecoverability – winning would be as easy as it would be dangerous!

Teamwork, frequency of sessions

This therapeutic model requires excellent credibility and great self-assurance. One of us, Alfredo Canevaro, the inventor of these techniques and the one who has experimented with them, has been able to apply them while always working alone. Another author, Matteo Selvini, has more often tried out this model working as a team with the one-way mirror (and, sometimes, with a colleague conducting the family sessions). In general, we recommend teamwork, especially in the case of therapists still at the beginning of their career or with little experience of family sessions. In this context, co-therapy – the two therapists in the same room, even if with distinct roles (more active / less active) – seems to us more appropriate than the one-way mirror.

The question of the frequency of sessions remains to be explored further. Canevaro has worked very well with sessions every fortnight, or even every three weeks. However, with patients who are suffering a great deal, beginning with weekly sessions is usually useful and necessary. With more stable people, even more widely spaced frequencies work well.

Conclusions

With this article, we would like to counter the myth according to which individual therapy must be done only with the individual.

The experience of family therapy provides important lessons for enriching the individual setting through the creation of an ad hoc technique that gives pride of place to the family of origin as a therapeutic resource.

Through the promotion of the emotional encounter, it can encourage reconciliation with significant figures, facilitating the search for an autonomous and original existential project in every patient.

We shall thus move toward an integrative scenario, in which the “natural selection” of the great ideas in the history of individual psychotherapy will be able to draw on these new techniques in order to invent and improve ever more effective psychotherapies.