A strange hybrid, withdrawn onto its island

Family therapy, which belongs to the conceptual territory of the social and behavioural sciences, had origins that are not very distant, nourished (and, in a certain way, begotten) by the emergence of qualitatively unprecedented lenses: communication and information theory, cybernetics, linguistics, structural anthropology, sometimes in combination with, sometimes in opposition to, the psychoanalytic paradigm. Yet, once it had taken its first steps, and still more on reaching its adolescence – and behaving accordingly –, this strange hybrid between the humanities and science that family therapy is has pursued its evolution not only as if it constituted an independent territory – something reasonably necessary during a certain period of its growth, in the development of its professional identity – but a self-feeding one, deploying an insular arrogance that guarantees battles between approaches and between schools – small territories readily breed pitched battles – as well as the impoverishment that results from its alienation from a rich multidisciplinary neighbourhood.

As for the banality of internal battles – and I cannot resist the temptation of referring the reader to an old article of mine in which I poke fun at these struggles (Sluzki, 1983) –, it is worth recalling a meta-analysis carried out more than fifteen years ago now by a team of researchers from the University of Madison, which provoked a salutary controversy when it was published (Wampold, Mondin et al., 1997; see also Messer and Wampold, 2002), and in which multiple studies comparing the therapeutic outcomes of various schools of psychotherapy were analysed cumulatively. The authors came to the conclusion that empirically “all must have prizes” (3), an indirect way of alluding to the heterogeneity of premises, methodologies and dependent variables they encountered in attempting to meta-analyse the plethora of research on psychotherapy outcomes to which they had access.

Fifteen years later, the panorama of therapies and of their effectiveness looks even more like that race with arbitrary rules to which those authors were ironically alluding in their article. An exception to this statement must be made for evaluations that take as their indicator specific symptoms such as “panic disorder with agoraphobia”, the eventual improvement being measured, for example, by variations on the Hamilton anxiety scale (for example Lueken, Straube, Konrad et al., 2013). It is worth adding that, in the majority of these studies, when the improvement produced by therapy is compared with that of people who are merely on a waiting list, the advantage of therapy is surprisingly modest.

In fact, to paraphrase in my turn the opening paragraph of the novel A Tale of Two Cities (Dickens, 1859) that I quote as an epigraph, these are the best of times and these are the worst of times in the vast field of our professional activity.

The best of times

Among the arguments in favour of “the best of times” is the fact that, even though fiefdoms governed by commercial interests remain, the great majority of family therapies – whether or not they use a systemic language to describe and prescribe themselves, whether or not they explicitly define themselves as brief in their practice – have solidified their conceptual bases and have attempted, with a certain success, to develop consensual methodologies for their practice, beyond mere intuition or a lack of self-criticism. The development of narrative-based models has contributed a great deal to this growing openness of dialogue between orientations, by softening the boundaries between the internal world and the interactional world, between the individual and society, and by softening certainty about reality in the light of constructionist premises. Moreover, family therapies – generally brief in practice – have spread substantially into many public mental health services, increasing the efficiency of service delivery without diminishing its quality.

The worst of times

Yet – the shadow of “the worst of times” is beginning to appear –, the statements of the previous paragraph still have a clearly ideological basis, since they cannot be supported by large-scale empirical evaluations that would show the comparative validity of these methodologies or the effectiveness of this delivery – with the important exception of evaluations such as those of the effectiveness of cognitive therapies for the reduction of specific symptoms (it being understood that this effectiveness has most often been compared with a waiting list, not with other forms of psychotherapy).

To the bag of “the worst of times” other factors must be added, namely:

• The reduction of social responsibility that accompanies the political shift to the right in practically the whole world over the past decade has cut the national and regional budgets devoted to public services, mental health included; so that the good news of the increase in services intended for the population of modest means is offset by serious problems of access to those services, while the rising cost of the private sector places it beyond the reach of a good part of the population.
• The economic crisis striking large sectors of the population in many countries of the Western world has reduced the demand for health services, in both the public and the private sector – rising unemployment leads many people to postpone, for economic reasons, any consultation judged non-critical, and to turn to emergency services when it is critical –, which complicates both the vicissitudes of crises and the economic vicissitudes of professionals, especially the youngest.
• In many regions of the world, a plethora of for-profit companies – I am thinking of managed care organisations –, on the pretext of avoiding excesses, have placed themselves strategically in the economy of the interface between health funds and users, reducing access for users, reducing payment for working time and bureaucratising providers, dictating the limits and the methods of treatment… and pocketing a good share of the pie along the way.
• Let us add to this the minimal emphasis that prevention programmes receive in mental health policies, as well as the blocking of any structural change, when it is not a regression towards more conservative public policies, supported by interests endowed with great economic and, consequently, political power, such as the pharmaceutical industry.
• The richness of genetic and epigenetic studies, of the neurosciences and of the work on neuroendocrine processes of these past twenty years, as well as the fascination they have aroused not only in the scientific community but in the mass media, have generated the illusion that these studies will lead to the ultimate cause of psychiatric problems and of interpersonal relations. Even though these advances will be cited below as an opening towards “the best of times”, this plethora has in fact been accompanied by a drastic reduction of the funds intended for behavioural science research in the institutions that have in the past supported the greatest number of studies in mental health, such as the NIMH.

And a quantum of self-criticism

But let us not lay all the blame on the world around us. A quantum of self-criticism is not only necessary: it is salutary.

• The effectiveness and the efficiency of the treatments we offer are, in most cases, modest at best (even if they are sometimes miraculous – in the sense that they often go beyond our predictions, and fall short of our explanations).
• Our bibliographical output – including that of the one writing these pages! – ordinarily draws very little distinction between purely conceptual assertions or causal attributions, on the one hand, and the empirical validations that would support them, on the other (4).
• Those who devote themselves to clinical practice often lack a methodological training that would allow them to conduct rigorous research (with the exception of the frequently excessive simplifications of behavioural therapies), and this lack tends to express itself as a resistance to conducting any, rather than as an effort to organise sound multidisciplinary teams (5).
• Systemic research is methodologically very complex and, frequently, long-lasting.

The skies may be clearing

The list of “the worst of times” contains in its very text the seed of a new era for family therapy: the developments of genetics, of epigenetics and of genomics, the discoveries about neuronal plasticity and, more generally, the advances of the neurosciences that are taking place in our disciplinary neighbourhood are indissolubly bound to a holistic, systemic conception of the human being-in-context, the basis of our discipline.

For this, it is necessary to review and to question the mythology of our autonomist focus, to visit some of the neighbouring areas (many of whose inhabitants may well prove as territorial and as hostile to our visit as we have been to theirs) and, flying the pacifist and integrative flag of interdiscipline, to explore areas of possible conceptual and pragmatic interpenetration in systemic research.

The question of interpenetration is complex, for it demands an effort of multidimensional integration – in which we explore the extraordinary orchestration of neurophysiological, epigenetic, neuroendocrine, evolutionary, psychosocial and socio-epidemiological processes – including, yes, family dynamics. This presupposes intertribal gatherings in which, as in the encounter ceremonies of first peoples, we exchange and become familiar with lenses and languages that are fairly discontinuous in their origins (6), all the while struggling against our temptation to define ourselves as the cause and everything else as an effect… or the reverse. To change metaphors along the way: imagine yourself listening to a symphony and asking yourself “who is following whom, are the violins following the cellos and the oboes, or is it the other way round?”. A silly question if we want to enjoy the concert, but a tempting one, and sometimes even a pertinent one for those moments of the symphony where one instrument or another takes the lead!

Allow me to conduct a guided tour of some of our neighbouring tribes and to offer, in an extremely summary and incomplete fashion, a sample of spectacular advances in some of these territories, highlighting their complementarity with our world centred on interpersonal processes. I do so in a friendly mode, avoiding territorial disputes and the temptation mentioned above of subordinating these territories to ours or, conversely, of defining the “psy” field as subordinate to neurobiological substrates (7) or to macrosocial variables.

Social epidemiology

Let us look, first of all, at the plethora of information offered by research in the field of social epidemiology, a discipline that correlates contextual data with health, illness and mortality. In this respect, multiple studies have demonstrated the impact of social attributes such as social integration, social cohesion, social capital, interpersonal support, working conditions, unemployment, retirement, discrimination (of gender, race, sexual orientation, other attributes) and political oppression – measured in isolation or in multilevel studies – on the health, the capacity to recover from illness and the survival of individuals. And this association is in part mediated by the personal social network, in particular the family (Berkman and Kawachi, 2000; Kawachi and Berkman, 2003; Cohen, Underwood and Gottlieb, 2000; Sluzki, 1996; and others). And some of the mechanisms of this mediation are being explored in an integrative manner (see for example Uvnas-Moberg, 1997), including the salutogenic effect of affectionate relationships (for example Holt-Lunstad, Birmingham and Light, 2008; Floyd, Boren, Hannawa et al., 2009; Grewen, Girdler, Amico et al., 2005).

The extraordinary richness of the data that flow from this type of research opens paths and generates interdisciplinary questions that concern us, such as, for example:

• How does this mediation take place?
• How is it that one family operates as a neutraliser of the negative effects of the environment while another succumbs to them?
• And what health policies can be proposed in order to increase the mediating effect?

And so many others.

Epigenetic research

Let us now mention, jumping to another neighbourhood, epigenetic research (that is, the modification of genetic effects by the environment); more precisely, the reciprocal impact between genetic inclination and family environment. Certain studies lodged at this interface constitute a model of explorations that attempt to decipher the weight of the genetic and of the environmental (and for a thorough exploration of the potential impact of genomic studies on world health, see the WHO Advisory Committee on Health Research, 2002). Particularly worth mentioning are the studies on siblings that explore the variables bearing both on the resemblance and on the differences between brothers and sisters (Reiss, 2000), as well as those centred on children at high risk of an inclination towards schizophrenia (children of a mother with a diagnosis of schizophrenia, which statistically multiplies the probability tenfold), adopted and raised by families with no specific pathology in their ancestry: it was found there that the genetic inclination is expressed only in “high-risk” adopted children adopted by families whose interaction places them at the extreme of traits of interactional rigidity or chaos (Tienari, Wynne and Wahlberg, 2006; Wahlberg, Wynne, Hakko et al., 2004; Wynne, Tienari, Nieminen et al., 2006; Wynne, Tienari, Sorri et al., 2007; Sluzki, 2007a and 2007b). Also deserving to be included in this sector is the research on monozygotic twins (Segal, 2012) separated at birth and raised by different families – twins with astonishing resemblances and equally astonishing differences, the product of the difference of the family context of upbringing.

This research gives an idea of investigative strategies applicable to so many other fields of behaviour, an amalgam of what is inherited (as inclination) and of what is incorporated in the family social world, and then in the extra-familial one.

Endocrine studies

Let us now briefly visit endocrine studies, neighbours in certain respects hardly novel, since hormones appear frequently in our metaphors when not in our existence (see on this subject, for example, the important panoramic contribution of Wolkowitz and Rothschild, 2003). Yet, beyond metaphor and traditional endocrinology, research that correlates endocrine fluctuations and social conduct in one direction or the other is still only in its beginnings.

Take for example research showing that oestradiol levels in women make it possible to predict a greater attraction to the features of men who display characters of masculinity associated with testosterone when these women are close to ovulation, rather than at any other moment of the menstrual cycle. This suggests not only that women have a different interest in mating at different moments of their menstrual cycle – information perhaps already known, given its pragmatic expression in the lives of many people – but that there is also a fluctuation in the traits that appear most attractive to them. For their part, men with higher testosterone have more success with women (measured by the number of different women per month) than those with lower testosterone – which may accord with more attractive physical traits, or else indicate that the former are more insistent in their courtship and better at detecting women in ovulation (Peters, Simmons and Rhodes, 2008; Roney and Simmons, 2008). In fact, it is currently argued that the kiss is not only an act of communion of interest, of love or of intention, nor only a stimulant of pelvic circulation activated by pheromones: it is also a vehicle for the exchange of information about the state of health (by way, for example, of halitosis), but also about the dominance of the hormones in circulation (see for example Floyd, Boren, Hannawa et al., 2009). And, to add a level of interlocking, everything indicates that the development of empathy at the early stages of romantic love is facilitated or hindered by cumulative variables in the alleles of the genes linked to oxytocin receptors (see for example Schneiderman, Kanat-Maymon, Ebstein et al., 2013).

If this research establishes a certain directionality, these are studies that do not explore the reverse directionality, nor the processes of interaction between directionalities; all of that remains open to exploration, including, for example, the possibility of studying the hormonal changes generated by therapeutic interventions with couples.

As for the manner in which hormonal architecture contributes to regulating parental behaviour, the puzzle of hormonal combinations becomes somewhat clearer when one studies the variable balance between the impulses of mating and the impulses of feeding and care, and aggression as between its antagonistic and its protective side. It has been found, for example, that testosterone levels have a modulating effect on the balance between the procreative impulse (of sexual mating) and that of care for babies. In women, testosterone is higher in single women than in married women and, although it is lower still at the moment of childbirth, it rises as their babies grow, in particular beyond the age of three (Barrett, Tran, Thurston et al., 2013). For their part, testosterone decreases in partnered men whose companion has just had a baby, and more still if they provide care to that baby (Gettler, McDade, Feranil et al., 2011). Yet circulating testosterone increases with the baby’s crying – entirely in keeping with a reaction of defensive aggression (van Anders, 2013). But the hormonal effect is more complex, for other hormones come into play. It is known, for example, that prolactin is higher in women who have just given birth, this hormone stimulating the mammary glands. Now it turns out that men, for their part, have a higher prolactin level when they are in a stable partnership than when they are not, and higher still in those who have young children (Gettler, McDade, Feranil et al., 2012; van Anders, 2013; van Anders, Goldey and Kuo, 2011) (6).

Let us introduce two or three questions here, to stimulate the imagination of potential researchers:

• Might there be differences in this hormonal dance in couples of parents who get on well, compared with those whose relationship is conflictual?
• And would it be possible to detect corrective changes of the reciprocal imbalance in the course of a successful therapeutic process?

Hormonal fluctuations operate, this has already been documented, on terrains that have been oriented by earlier emotional experiences. In fact, the close correlation between negative experiences in childhood, duration of breastfeeding in women, postpartum depression and hormonal variations has been well documented. What very recent studies have added is that this association is moderated, or perhaps mediated, by the presence of a polymorphism of a specific nucleotide, that is, by a specific genetic inclination (Jonas, Mileva-Seitz, Girard et al., 2013).

It would be worth assessing the genetic load – in terms of inclinations – in patients who have responded to therapy, compared with those who remain impervious to such changes in specific life contexts.

The biology of mind

Let us turn now to some of the many recent studies on what Eric Kandel has called, in a recent book of extreme importance (Kandel, 2005), the “biology of mind”. For two hundred years, a great many studies have been published associating specific traits of behaviour with cerebral structures – from the rise of phrenology in the 19^th century, with its cerebral maps specifying an area for each emotion, each virtue and each vice, through to the more recent mappings of cerebral locations by functional MRI. It is worth stressing that many current neurobiological studies – leaving aside those that analyse the effect of specific brain lesions on human behaviour – aspire to specify neither cause and effect nor subordination (beyond the studies of specific brain lesions that determine processing areas, such as the occipital area where vision is processed or Broca’s area where part of language is processed): they establish only a correlation. Yet certain recent research on neuroplasticity makes it possible to establish an interesting directionality.

In this connection, it is worth recalling the already famous studies conducted by functional magnetic resonance imaging with London taxi drivers (Maguire, Woollett and Spiers, 2006; Woollett and Maguire, 2011). The first study in the series compared taxi drivers with bus drivers of that city. These two samples were chosen because obtaining a taxi driver’s licence in London requires undergoing a rigorous training, lasting three to four years, in the course of which the candidates must memorise in detail the extremely complex layout of the streets, lanes and shortcuts of that capital – a city which, owing to its existence since very remote times, constitutes the antithesis of a reasonable urban layout. In this study, the control sample was made up of bus drivers of that same city, who, although equally exposed to the tensions and the irritating experiences of urban traffic, follow only a few fixed routes and have only minimal memorisation demands. On these functional MRIs, the taxi drivers present an increase in cortical thickness – a structural increase of grey matter – in the posterior middle part of the hippocampus, compared with those of the control sample, once the other variables have been made homogeneous. Moreover, this volume increases as their experience increases. This comparison made it possible to rule out as a variable the stress of driving on public roads – comparable in both samples – and to establish that the research made it possible, in all probability, to designate the neurofunctional location of complex spatial representations. A second study compared the functional MRIs of taxi drivers before and after their training and, once again, the more advanced the training, the greater the thickness of grey matter in these specific brain areas.

This research provides evidence of immense importance about neuroplasticity and allows us to glimpse the viability of structural changes through experience – which indicates that experience modifies the connectivity of the brain areas associated with it in one way or another.

Moreover, very recent studies of the same orientation (Heim, Mayberg, Mletzko et al., 2013) have produced results that are not only fascinating in themselves, but directly relevant to our professional practice. When the functional MRI of adult women who suffered repeated or traumatic sexual abuse in childhood is compared with that of women without this history, the former show a reduction of the thickness of grey matter in the zones that correspond to the somatosensory representation of the genital areas on the cerebral cortex. Given the greater frequency of sexual dysfunctions in women who were victims of sexual abuse during childhood, these studies provide a further illustration of neuroplasticity in the course of development as a function of experience, in the form of a kind of cortical adaptation which, I would say interpretatively, protects the little girl from the sensory processing of the experiences of abuse, by modifying the cortical representation in a very specific way. This same defensive adaptation has the drawback of translating, in adulthood, into a far higher prevalence of sexual dysfunctions – anorgasmia, dyspareunia, promiscuity. And the specificity is such that, when this sample is compared with another, made up of women who were victims of emotional but not sexual abuse during childhood, the latter present no reduction of thickness – that is, of the number and the complexity of the connections – in that area, but in other brain areas that are considered to be associated with self-evaluation and self-perception.

This research provides empirical evidence of the neuroplasticity of the brain, shedding light on neurofunctional processes that associate traumatic experiences of childhood with dysfunctions of adult life, a frequent presupposition of our professional activity.

Given this evidence, among much else, questions deserve to be explored: does therapeutic work with patients who suffered sexual abuse or emotional abuse in childhood – work that frequently includes an activation of the connections between those experiences and their hitherto blocked emotional correlates – show itself in an increase of the volume of grey matter, an enrichment of the neuronal connections, in these zones? And, if that occurs:

• Does it correlate stably with therapeutic success, or is it only the evidence of a kind of re-traumatisation?
• In more general terms, what are the neurofunctional correlates, if there are any, of successful therapeutic processes?
• Can therapeutic success be “measured” at the neurofunctional level?

Mirror neurons

Let us move on to a brief discussion of a line of research that is already incorporated into the rhetoric of our professional field. I mean the discovery, led by researchers of the University of Parma (Rizzolatti and Craighero, 2004; Gallese and Sinigaglia, 2011; see also an update in Hunter, Hurley and Taber, 2013), of mirror neurons, a functional system that seems to replicate not only the actions of the other – and, consequently, learning by imitation – but the meaning of the actions, allowing the construction of the mental map of the other, that is, of intersubjectivity. The studies conducted with people diagnosed as autistic and, to a lesser degree, with Asperger’s, show a marked deficiency of this functional system. Yet all of them display emotional empathic reactions, frequently with animals. Here a differentiation proposed by interdisciplinary researchers of the University of Haifa (Shamay-Tsoory, Aharon-Peretz and Perry, 2009; Shamay-Tsoory, 2011) comes to our aid; they seem to have demonstrated the existence of two independent neuro-systems, corresponding to the distinction between the two modalities of empathy known as emotional empathy and cognitive empathy; the first is linked to the mirror neuron system, with an anatomical substrate and a phylogenetic age older than the second. The studies conducted with patients carrying focal brain lesions in various areas tend to confirm this supposition.

These fascinating studies on the mirror neuron system have been popularised in the “psy” world in an extraordinary manner and used frequently in hypothetical associations, as if mentioning them adorned us in more credible or more scientific finery, with this complication that they have often contributed to the mistaken supposition that neurofunctional substrates are “the underlying processes”, that is, the “true bases”. Beyond that, the interdisciplinary exploration that is beginning around these processes opens unheard-of doors of extreme richness.

Not losing sight of the orchestra

The systemic interlocking between macrosocial, interpersonal, genetic and neuroendocrine processes is profound, and the partial advances at any one of their interfaces move forward our understanding of this articulation between levels of analysis. This perspective nevertheless obliges us to develop and to maintain a systemic lens of extreme complexity, since each level of process affects the others and is affected by them, in a harmonic concert, both in its balance and in its imbalance, even if, at key moments, one or another of these levels may acquire a dominance over the others. Our responsibility as professionals is not to lose sight of the orchestra even when we turn our attention to one instrument.

This statement holds whether we centre our main activity on clinical work, on institutional activism or on research – itself an artificial distinction since, as clinicians, we must be permanent researchers, on models as much as on interfaces and on effectiveness, and must push our institutions (even when they are reduced to an isolated private practice) in directions of social responsibility – and it holds just as much if our emphasis bears on institutional responsibility or on research.

Shutting ourselves inside our disciplinary shell and interacting only with those who speak our language and operate with our premises perhaps offers us the possibility of maintaining ourselves as thinking beings, but we run the risk of inhabiting nothing but a confirmatory, solipsistic cosmogony.

We family therapists and brief therapists are no longer the youngest child in the family of the behavioural sciences, the baby who can afford the luxury of being the centre of attention and the star of the show. If our central activity is clinical practice – as is the case for the majority of family therapists –, this requires that we maintain or that we develop a critical practice, politically committed and up to date, which explores the grey areas of our work with the same warm curiosity with which we explore the ambiguous, problematic, excluded or oppressed areas of our patients’ narratives; a practice that catches our theories of action and our other clinical intuitions by the tail and transforms them into clear questions, capable of being translated into rigorous research, articulated with that of neighbouring disciplines. We must also open the dialogue with our neighbours and organise transdisciplinary projects that widen the systemic optic beyond the usual confines of our “family” field.

A curious, self-critical practice, open to transdisciplinary dialogue (and politically committed, an argument not discussed in this article but of equal importance), assures us a professional life more complicated than the one offered to us by the illusion that the map of our territory would be the map of the universe – but assuredly full of fascinating challenges.