The mirages of the systemic clinic

“Seeing mirage after mirage, one loses one’s illusions; yet it is true that, very often, it is from hope to hope – or from mirage to mirage – that people reached America.”

“A system can only move forward through a process of discontinuous changes, since no stationary state can be identical to the previous one; the history of the system is marked, punctuated by redundancies and by differences – a dialectical interplay between morphostasis, that is, the homeostatic changes that preserve the balance or the original state, and morphogenesis, that is, the changes that make reorganization possible, and hence the evolution of a system over time.”

A Polish scientist, a navigator of the frozen seas of the Arctic, set out hoping to pull off the feat of photographing a mirage, that phenomenon of optical illusion produced by the particular interplay of changing atmospheric conditions. At the end of his voyage, he had “discovered” how the Vikings had been able to cover immeasurable distances and reach the American continent.

The mirage phenomenon studied by this scientist turned out to be this: what appears as a phantasmagorical vision, highly realistic, and which dissolves when we come closer to it, is in fact the projection of something located kilometers away. The Vikings would therefore have been guided, in their intrepid and interminable crossings, by mirages that announced the presence of a distant but very real land.

Behind those vanishing landmarks lay America.

Over these last forty-five years, the systemic paradigm developed, together with one of its most provocative applications: family therapy. The pioneers of this new approach also traveled a road punctuated by mirages, behind which there was an America. The America of the clinic, of access to new possibilities for resolving situations, relieving symptoms, creating alternatives to the traditional psychopathological view.

From the intrapsychic gaze to the relational gaze

The first landmark, or the first mirage left behind, was the intrapsychic view of an individual, isolated being whose secrets lay inside his mind. The first observation, or the first “discovery” of this new approach, was the finding that the oddities or peculiarities of an isolated individual became far more understandable, and appeared eminently adaptive, as soon as they were observed within the relational fabric of his most significant contexts, particularly that of his family. From this derives a view that is still etiological and causal, but broader and beginning to address complexity – that is, the articulated reading of the various variables at play – than the previous one: that of the homeostatic model, in which recurrent interactions were observed that changed things so that everything would stay the same. Hence Don Jackson’s model and the metaphor of the thermostat, which maintains a constant temperature by producing changes that stabilize the system. The family was then seen as a homeostatic system, and the identified patient became a kind of victim of, for example, schizophrenizing parents (a mother in particular) who made their children ill. This reading made it possible to have a more complex and richer perspective on a certain psychopathology, above all the one concerning children and adolescents in difficulty. Psychotherapy found new possibilities for action: interventions centered on the parents, or on parents and children together, obtained encouraging results, clearly superior to those obtained with individual consultants. Thus was born the systemic family clinic.

Circularity and the self-fulfilling prophecy

Another of these reference points, one of these founding beliefs, is the concept of circularity, or more precisely of circular causality: the abandonment of linear cause-effect thinking, which makes it possible to think in terms of a series of interactive behaviors that influence one another, creating a particular circuit of interactions (reciprocal and circular actions) whose reading goes beyond any beginning or end. Let us imagine two men running one behind the other in a revolving door and ask ourselves, after a brief moment, who is chasing whom, who is “causing” what to whom.

A self-fulfilling prophecy clearly evokes the transformation of an effect into a cause: I believe in an oracle, in a diagnosis, in an opinion, and I act accordingly, either accepting it or trying to reject it (and therefore believing in it), and in this way I do nothing but confirm what I have believed. “Fuel is going to run short, there will be a gasoline shortage,” announce the newspaper headlines. At once, people buy “just in case” ten times what they need and, indeed, there has been a gasoline shortage: the news (the announced effect) has “caused” that effect.

Constructivism and second-order cybernetics

Constructivism, that is, the theory of reality as constructed by the observer’s perception, allied with second-order cybernetics or the “cybernetics of observing systems,” constitute the great mirages or the great beliefs of recent decades, those that have opened new possibilities for approaching our America: the phenomenon of human suffering and human conflict.

These epistemological concepts allow us to say that we are dealing with a created, invented reality; that there exists no phenomenon that can be described objectively, neither in the so-called human sciences nor in the so-called exact sciences: everything is the product of the observer’s cognitive operations, of the conceptual map that guides him and of the sociocultural context in which he is immersed. This is an observer engaged in the observed phenomenon, which he modifies by his gaze and influences by his actions, actions that tend to confirm his self-referential frame: “Tell me what you observe and what you conclude, and I will tell you which hypothesis and which theoretical framework you started from.”

The second cybernetics, that of observing systems (in contrast with first-order cybernetics, or the cybernetics of observed systems), a new mirage that includes and encompasses all of the above while going beyond it, follows the postulates of radical constructivism, in which the observer is part of the observed phenomenon. Applied to the clinic, it broadens the therapeutic system, since what is at stake is several interacting subsystems: something like an endless list of observers who observe and are, in turn, observed (for instance therapists working in pairs, observed by a team behind the one-way mirror, itself observed by the supervisor, plus a video recording of the whole process that will allow an immense professional audience to become, in its turn, new observers, who will draw new conclusions and produce unprecedented accounts of the same facts).

Under the name of subsystems we will designate all those who take part in a therapeutic process, and the therapeutic system will then be a suprasystem that will encompass all these distinct portions, identifiable but interdependent, parts of one and the same whole, where all the elements influence one another, beyond their singularities, creating a unique and irreplaceable ecosystem.

Morphostasis and morphogenesis: crisis as a favorable moment

The model, or the evolutionary view of the systemic paradigm, constitutes a new spiral, a new mirage that includes and encompasses all of the above while going beyond it. This refers back to the classical psychogenetic conception of the evolutionary stages of the process of constructing knowledge, postulated by Jean Piaget.

The homeostatic model explained stability very well, change of type 1: the change that produces changes in order not to change, in order to maintain the balance, the homeostasis of the system. The systemic clinic needed concepts capable of explaining another type of change, evolution toward new states; one then thinks of processes that are no longer homeostatic, but homeodynamic. Maruyama brings the concepts of morphostasis, to indicate what remains, what opposes change or what generates the change that maintains the balance; and of morphogenesis, to designate what is modified, the evolutionary moments, the destructuring of an organization that changes its rules and turns into another one, never to become the same again. These two tendencies coexist, interact permanently and are easily discernible in the clinic when the family says: “change us, but do not modify us.”

Crisis, the irruption of a dysfunction or of any symptomatic behavior whatsoever, will be considered, from the evolutionary point of view, in a way totally different from what a homeostatic model would say about it. It will not be held to be a symptom that tends to reinforce the homeostasis and the pathology of the system, but rather perceived as a moment of extreme instability of the system which, in the very moment of suffering and uncertainty, can give rise to new developments, open new paths, perhaps more mature on the evolutionary level, more functional and better adapted to the new circumstances of the life cycle, or to the changing conditions of the context; that is, to the growth and development of the human ecosystem. Crisis then turns out to be a favorable moment for evolution toward new potential states and, consequently, favorable to the therapeutic encounter.

The voices of Gustavo

Gustavo, 43, worked in the kitchen of a restaurant; he heard voices that spoke to him and with which he held dialogues out loud. Until then he had been treated with antipsychotics, which calmed him, but the symptom persisted. That aside, his results at work and his way of being a family man satisfied everyone. Yet this peculiarity risked making him lose his job and being hospitalized in a psychiatric institution if the classic symptom did not disappear. The family, which trusted him as a father and as a husband, was very worried: less about the symptom than about the possible hospitalization, which would have amputated from this family the member who supported it economically and who was also an affective pillar of this family system. When I received him within the crisis intervention team of the San Isidro hospital, which I coordinated at the time, I took into account two subsystems that seemed to me essential to the construction of my therapeutic scenario: a) the family subsystem and b) the psychiatric team subsystem, in particular the doctor who prescribed his treatment. To the latter I proposed teamwork in which she managed the medication, that is, “the stability” of the person, a certain “control” and a slight improvement of the situation and of the symptoms; while I, for my part, would work as if the person were not “mad” or “ill,” and as if this business of the voices were a singular construction, a particular characteristic of Gustavo’s.

As for the family subsystem, I talked with a worried mother and daughter who were at the same time united and determined to collaborate, caught up in a solid family network that wanted to preserve itself, without amputations. Gustavo was loved, he was needed, and there was an evident willingness to help him. The family was undecided, confused, and in that state of instability proper to crisis which is favorable to systemic psychotherapeutic intervention of a clearly psychogenetic orientation: by which I mean interventions that make it possible to get out of the rut and to set out on the road toward an evolutionary situation, of individual and family growth. Let us pause for a moment to examine a few conceptual questions.

The voice of change, the voice of stability and the Rorschach

In Bradford Keeney’s terms (1985), these three elements are part of a systemic constructivist therapy belonging to the second cybernetics. The therapeutic ecosystem, which includes the therapists, the identified patient and his family, coexists, as we mentioned above, with stability factors and change factors, which the author calls “voices.”

By way of illustration, one may say that the family would say: change him, with respect to his symptom, but do not modify us, with respect to the family pattern.

The psychiatrist could represent the stability factor, or the factor of control of the symptom from the psychopathological perspective; and the crisis team, the destabilizing factor.

The Rorschach is a metaphor for that mirror of blots and ambiguous figures in which each person believes he sees something different. What was at stake here was Gustavo’s belief in those voices, which he undoubtedly heard and which interfered in his life by criticizing him and creating problems for him in his interpersonal relationships.

As coordinator of the crisis team, I chose Gustavo’s construction and I entered into it by speaking the patient’s language. Gustavo’s language was at times rambling, odd, and it generated a certain confusion in his interlocutor. Recalling the classic interventions of Milton Erickson and the concept of positive connotation coming from the MRI team in Palo Alto, so extensively developed afterward by the Milan team or school, I said to Gustavo roughly these words:

“Gustavo, your way of speaking is richer, more precise than what one might expect from a person of modest origins.” (Gustavo had only primary schooling.) “Please understand that this complex richness of yours sometimes makes it hard for us to follow you, because we do not completely grasp the reach of some of your words. I ask you, please, on behalf of the team, to speak a little more at our level; that way we will be able to exchange ideas and manage to understand you. Excuse our limitations.”

This intervention surprised Gustavo, because it implied an implicit acceptance of his singular language, and even more, praise of it. The request that followed, to “come down to our level,” flattered him; he set about expressing himself more clearly with pleasure, and he went on doing so at all times, throughout the rest of the therapeutic meetings. The “voice” of stability positioned the symptom, accepted it and, one might even say, stimulated it; on the other side, the “voice” of change humbly asked him for a small modification, valid for this context alone. This construction arose out of his map, of his Rorschach, of which we sent back to him, as in a mirror, an image of reality. All the later interventions took into account this model of transformation and acceptance, this construction that encompasses the previous construction and, at the same time, goes beyond it, on the basis of a proposal of new patterns of action that would, in the long run, reformulate his attitude toward the symptom of the voices. At another moment of the treatment, he was told this:

“You are a privileged man: the voices advise you, sometimes in a critical way, that is true, but in any case you possess something that others do not have, something that goes beyond ordinary, common thought – and with which, of course, as with any remarkable characteristic, it is difficult to live.”

Once again we enter a territory, exploring the advantages and the disadvantages of his peculiarities, stabilizing and destabilizing at the same time, accepting and modifying the Rorschach, Gustavo’s vision of the world. At a given moment, wrongly, we attempted an intervention aimed at the disappearance of the voices, based on the need of his family and of the therapeutic system. Of course, as every time we failed to take Gustavo and his map into account, we obtained no result. When we finally said to him something like:

“We understand that you are a very important person for your family, affectively and economically; that they need you as much as you need them. Your fine family, your daughters who work and study, your lifelong companion count on you and accept you beyond your particular qualities, the ones that make you different from others. We have also understood that this critical voice that guides you will be part of your life forever, and we hope that it will never abandon you. That said, we know that on buses, in public transport in general, or at work, talking to yourself out loud creates difficulties for you that could make you lose your job; and that some people, less understanding, will take fright.

The loss of your job and above all people’s fear could end in a hospitalization that would have disastrous consequences for you and for your family. We believe it would be intelligent of you to avoid speaking with your “voice” on buses, at work or in any public place, in order to spare your family a terrible amputation. It is clear that if you persist in this behavior in public places – and not in the intimacy of your home, where you can enjoy your privileged characteristic – you could be locked up, no longer for madness, but for stupidity and irresponsibility. Now you understand perfectly the consequences of your acts and you know what it is right for you to do, for the good of your family.”

This intervention constituted the essential reformulation as far as Gustavo was concerned. The work with the family consisted in preparing it to live with Gustavo’s voice, since beyond that he was an affectionate father and husband, concerned for the well-being of his family. The family accepted this proposal and committed itself to supporting Gustavo and neither stimulating nor discouraging his inner dialogue so long as it took place within the home.

A long follow-up of this consultant and his family was carried out. He resumed his activities and never again had inner dialogues that compromised him in public places. Moreover, both he and his family reported, in the follow-up interviews, that he was talking to himself less and less, including within the home.

The team had instructions to congratulate him on his responsible and intelligent attitude toward his family, while regretting that he was, as a consequence, losing that remarkable quality. The psychiatrist confirmed the progressive disappearance of the symptom, gradually reducing the medication. From hope to hope, from construction to construction, Gustavo, his family, the psychiatrist and the crisis team arrived at some possible America.

One version among others

Various readings could be made of cases like this one: each adherent of a model, of a school, of a particular technique could describe this treatment by underlining certain points, foregrounding certain interventions rather than others and arriving at different conclusions, all of them assuredly plausible. What follows is therefore only one possible version, self-referential, of the one writing these lines, and one that claims only to reflect a form of approach, based on the vast constructivist paradigm and on second-order cybernetics, which underlines the ethical and aesthetic responsibility of its author. That said, one may observe in this case the importance of constructing the psychotherapeutic scene starting from the construction of the identified patient and his family, as well as from that of the psychiatric subsystem that referred the patient. It was only with the articulation of the multiplicity of views and the interrelation of the different subsystems, including the crisis team and all those taking part, directly or indirectly, that it was possible to construct a plausible scenography, in which all could coexist and support the negotiated and consented solutions that were gradually arrived at.

The therapist can never place himself as an external agent, since he belongs to the therapeutic system and is always part of the ecosystem in which he operates. The reality “out there” is unknowable as such, because it is the product of cognitive operations that take up external elements, which are in turn modified, shaped and reconstructed by those same operations.

Bateson says that wisdom is an awareness of the way in which all the circuits of the system fit together, adjust to one another and are connected. This means deciding that the family did not “cause” the individual’s problem, nor the other way around. No element takes precedence over another (in the last instance, the only thing that comes first, within this framework, is communication) and none controls another.

Multidirectional partiality and neutrality

Faced with the inevitable struggles or power games that unfold on the psychotherapeutic stage, the therapeutic attitude that facilitates a constructivist action is the one inaugurated by the concept of multidirectional partiality of the psychoanalyst Boszormenyi-Nagy (1966): the psychotherapist’s attitude allows him to empathize with each of the family members, to acknowledge their merits and to take sides according to those merits. The concept is later taken up by Harry Goolishian and broadened by that of neutrality, described by Mara Selvini Palazzoli and her team (1980).

The idea of neutrality is distinguished from multidirectional partiality as a contribution of the systemic therapy model: besides the empathic attitude toward all the members of the family, the systemic family therapist will choose to show no predilection for any of the consultants in particular, but will show interest in and validate each of them individually, as well as all of them as a whole. This way of acting has as its object to ensure the maintenance of a metaposition with regard to the family interaction and, moreover, it helps therapists not to impose their own values on the family. The constructivist systemic therapist must therefore train himself to recognize his own point of view as a therapist. From this perspective, it is fundamental to validate all opinions, to respect each family member’s feeling of self-esteem, bearing in mind that the therapist’s punctuation will influence the reading of the situation to be resolved.

The family will have to be neither judged nor blamed; at most one will seek to increase its capacity to take responsibility for its actions and their consequences…

How is a psychotherapy constructed?

It begins with a gathering of data that bears on communicational actions – who does what, when, where and with whom – and also on beliefs, values, the vision of the world, the construction of the world; or, in the broadest sense of the term, on the language – understood as a linguistic system – that predominates and that constructs the “reality,” or the account of reality, expressed by the consultants. This original linguistic system, this initial “official” account, will be transformed, on the basis of the therapist’s questions and interventions, into a new account: a co-construction, a script similar to the previous one but definitively different, which the therapist, or the therapeutic team, and the consultants or patients will construct together, within a framework of second cybernetics, that is, that of an engaged observer who is part of the therapeutic ecosystem, which includes him and influences him. At each meeting a new linguistic field would be created, arising from the interaction between the therapist and the person or persons consulting; the direction of this encounter will be given by the school or the model the therapist represents: it may head toward an objective, toward a minimal goal, toward a structural change, toward the search for a new family hierarchy, or simply toward the construction of alternative realities or new linguistic constructions, new accounts or new versions of the same facts, based on the earlier constructions but endowed with new evolutionary possibilities.

These new constructions, or therapeutic fictions, require a historical reconstruction – the possibility of seeing the history we have lived, the facts, the associated feelings and above all the conclusions or consequences that were drawn from them, from another angle, with a broader vision and above all with a reformulation of the earlier conclusions – a reconstruction that makes it possible to create a different vision of the present context and to glimpse a future full of hope.

The “graduate”

The case of Graciela B. illustrates, to my mind, the typical story of a “career” of failures, with, as a consequence, a training in various psychotherapies, hospitalizations, and a diploma in madness and failure awarded by “the best establishments.”

“The graduate,” this 50-year-old consultant, and her family, are facing a new crisis, one more moment of madness and failure (with running away from home and a possible suicide attempt on the railway tracks); and the decision, the sentence or the definitive diagnosis falls to a team of last resort – a sort of Supreme Court of Justice: I am speaking of the crisis intervention team of the San Isidro hospital, which I coordinated at the time – which would determine, through its diagnosis and through the actions that would follow from it, the direction of the evolution of the illness: toward a worsening, a chronification or an improvement, in the best Hippocratic tradition.

The infallibility of hindsight – that fact of being able to make past events say whatever one wants – allows us to set out in search of the exceptional fact, or of the “unique outcomes” in the words of the Australian family therapist Michael White: a fact that marks a landmark, a favorable, mitigating, positive circumstance, a success, and starting from which the account becomes a search for similar facts, which little by little reassemble the puzzle and turn it into a story where the successes or the achievements counterbalance the failures, giving rise to new readings. If the alternative account is accepted, it is possible that the cognitive structures of this person and of her significant others will be modified and will push toward the carrying out of new actions. The new account, marked by success, far removed from psychopathological diagnostic labels, moves toward psychogenesis, toward the construction of instances that go beyond the situation and create favorable environments. The exceptional fact does not need to be spectacular or particularly striking: it is enough that it be significant for the person and for her context, and that it be named and described insistently by the therapist, to the point of calling into question the validity of the earlier belief or sentence, in which everything she said or did was used against her. From that moment on, this person, with the support of her family which also believed in this positive reconstruction, managed to dilute the symptom-actions and to bring out more and more the success-actions, the asymptomatic moments, and everything that made her recover her role as leading actress and regain confidence in her possibilities. Before finishing, I would like to give a few examples of interventions in this case, which seem to me to shed light on what has just been said:

(During the first part of the initial interview, the patient, while she listened to her long psychiatric “curriculum vitae,” her career of failures – rather like a defendant listening, overwhelmed, to the reading of his criminal record – remained silent, curled up on her chair; and when she was spoken to, she gave a start and let out a cry that confirmed her historical role.)

“I see (addressing the patient’s husband and children) that Mrs. Graciela needs rest, and we are going to respect that. I would like to tell you that, in the account of Graciela’s life, I have heard several things said by her lifelong companion and by her daughters who love her so much: in other words, very important opinions.” (Pause.)

“Many of these facts speak of a person who raised her sons and daughters with a great deal of love, who helped her husband both through the hard work of the home and by going out to work to support the family economy, and who, for this and for many other things besides, is greatly appreciated by those very people who are here, worried about her. There is no doubt that this is a person who has given everything for others.

I have rarely heard such a moving account, or such a clear description of the important role that a wife and mother fulfills within a family; a family that is moreover very united, very supportive.”

The intervention foregrounds, arbitrarily (as does every psychotherapeutic intervention), all the elements linked to successes, which are very positively connoted; and what I hear, or what I select in order to underline it, is the account of a person who has fulfilled her tasks and her role efficiently and affectionately.

It is worth making clear that this unexpected reading of an account that rather abounded in psychopathological facts arose, or was induced, through a few questions of the type: “What was she like as a mother?”, “What did she do before she had these problems?”, which meant that, for the first time, Graciela raised her head and looked at me with a certain attention, at once curious and astonished. This, in broad strokes, is what the construction of a story consists of, based on the exceptional facts in the life of a person marked by certain circumstances and above all by diagnostic labels that have anchored and defined the course of her life and that of her family. All the interventions of the following sessions, in which Graciela took part in an increasingly lively way, followed the line of positive historical reconstruction. When one of the members asked what behavior to adopt regarding this or that subject concerning Graciela – for example, the husband asked whether he could have sexual relations with his wife, and the answer was: if the two of you agree, I do not see why not – the answers respected the vision of this new script, which suggested that Graciela should be treated and regarded as in the days when she had no psychological problems. The family always showed itself very willing and very cooperative in this respect.

The meaning of symptoms

Graciela often asked questions about certain symptoms, about gaps in her memory or things of that kind, and she asked whether this implied an illness or an aftereffect of it. Faced with this type of question, I remember the following intervention:

“While I am thinking about the question of your memory, I recall that at the beginning of today’s interview several members of the team and I myself discussed in front of you the date and the number of the room assigned to you for the next session (depending on the day, the time and the place of consultation changed). In the middle of our discussion, you kindly enlightened us, telling us the exact time and place where the next session was to be held. Despite our doubts, once we had checked the information that we did not remember, on account of some gap in our memory, we found that you were right. The next time we have a doubt about this, we will consult you again.” (What followed was laughter shared between the team and Graciela; then, after a short pause, I brought up a certain difficulty in finding things in her kitchen, a question that worried her at times, because she had been told one day that she suffered from confusional states.)

“From what your family tell me, you manage very well as a housewife, especially now that you are feeling better. That is a relief to them, because they count on you a great deal. Speaking of domestic matters: today, while we were preparing the room before your session, one of the most experienced members of the team, in charge of bringing the microphone, made a mistake and brought a stapler. I suppose we are going to have to treat him for this confusional matter we are talking about.”

The use of humor to dissolve certain psychopathological preoccupations and to encourage discreetly the very significant changes that we knew were taking place – namely her household tasks, her wish to go back to work in a job, her affective exchanges and the reduction of the psychiatric medication by the psychiatrist who had referred Graciela to us – turns out to be useful, because it creates a climate of natural conversation in an atmosphere of cheerfulness and unconcern. I believe that these interventions, both in their content and in their tone, clearly illustrate the concepts set out here, which confirmed the patient’s favorable evolution…