Towards a Theoretically Individuated and Integrated Family Therapist

"Toward a Theoretically Individuated and Integrated Family Therapist" was published in 2003 in the Russian journal Psychotherapy. It was based on the first part of my psychology lecture in Russia in 2001. Under Communism, there was little psychotherapy. The good of society was more important than the good of the individual. Personal growth was considered anti-communist. Russians often had a hard life. Many took refuge in spiritual and superstitious believes. There is no word for “insight” in Russian.

After the fall of the Soviet Union, psychotherapy began to take off. They sought American experts on the subject.

I focused my lecture on family therapy, which I felt was a good transition from the Soviet emphasis on the social unit to the new Russian emphasis on the individual.

My hosts pointed out to me that in the audience of about 200-300 professionals and students, they were sitting together according to their schools of thought. They already had rigid boundaries around their theoretical orientations. It was similar to how child learn religion, "Our correct one and the other wrong ones."

I wanted to warn them how such egocentricity of thought has hurt the advance of the science of psychotherapy in the West. I warned that it should not be copied in Russia. I explained that we hopefully mature as individuals from our family's biases. Similarly, as therapists, we need to individuate from rigid schools of thought.

I argued for knowing how all the main theories provide interventions useful for different sorts of people and situations. However, the best theory for understanding and formulating cases was psychoanalytic. It had the best theory for a deep understanding of people.

Although some patients might be too concrete and not self-reflective enough for psychoanalytic work, it is always valuable for a therapist to use a psychoanalytic formulation.

For example, is the personality structure primitive with mainly primitive defenses such as denial, projection (putting the denied faults on to someone else), splitting (seeing things in black or white), and projective identification (provoking others to make them feel similarly disturbed)?

Alternatively, is the personality structure neurotic with mainly higher level defenses such as repression? Patients who favor repression as a defense can respond better to interpretations than those patients who favor denial. With evidence, a patient can lift the repression and grow.

After the therapist has an understanding of the patient’s dynamics, the therapist should then decide what interventions would best suit the patient. I advocate familiarity with all the major theoretical orientations and their techniques. I base the interventions on the needs of the patient and not theoretical biases.

Psychotherapists professionally mature by individuating from their theoretical family of origin. They learn to integrate concepts and techniques from most of the major schools of thought based on the needs of the family or patient. I will focus on the family unit as a pragmatic starting point, which can later lead to individual psychotherapy.

No one theory has been able to deal with the full range of psychological problems. I will offer a philosophical, theoretical and personal review of the theories of therapy. Therapists can work from their favorite core theory, and branch out from that.
I will explain why I prefer a combination of Systems theory and Object Relations theory. These theories explain both the interpersonal and intrapsychic worlds and they regulate one another. The combination allows for interventions at either the interpersonal level or intrapsychic level, depending on the degree of accessibility.

The family unit helps to develop and shape individual personality, and each personality in turn contributes to the climate and operations of the family system. Understanding this linkage can help a therapist decide on which level to direct interventions, at the family system and/or the intrapsychic system.

Sometimes the level of intervention is based on the degree of embeddedness in the system and level of psychological maturity. Children for example are strongly embedded in the family system. They benefit more from an intervention in the family system, as opposed to trying to appeal to their insights.

On the other hand, an emotionally sophisticated mother may be able to greatly benefit from the interpretive insights from individual psychotherapy that can lead to improved parenting and personal growth as well.

Sometimes I begin by working on the level of the family system, reduce the symptoms displayed by the child, and subsequently address the marital subsystem or a particular parent in individual psychotherapy. I generally work from the larger, external family system and progress to an individual's intrapsychic system whenever possible.

I no longer believe, as I did as a beginning therapist, that all psychopathology emanates from the family dynamics. That was the prevailing belief in family therapy during the 1970’s. Now I believe that it is far more complex than that. Since the 1970’s, the field of genetics has advanced tremendously. We now know that much of one’s basic temperament is biologically predisposed, and severe psychopathology, unless it is a result of severe abuse, generally has some biological basis. It was wrong to blame families for such disorders as schizophrenia, autism, and bi-polar disorders.

However, primary care givers shape the mind of the child. The family has its greatest influence on personality in the first few years of life. Research now shows that early attachment styles shape brain and psychological development. The capacity for self-soothing, affect regulation and the healthy notion of self and others are developed in the early parent-child bond.
After early childhood, the family can cause stress disorders, worsening of psychopathology, or be a source of continuing love, guidance and support.

Psychology seems most effective in dealing with the sequeli of psychological trauma. Perhaps the most damaging of traumas is from our own family. When the very family that should be the source of protection and love traumatizes a child, the damage cuts to the core of personality. Development is altered, and the capacity for healthy relationships is compromised. Interpersonal treatment can help the trauma that came from interpersonal causes, better than medication. Therapeutic relationships can best help to heal the repetition of bad intimacies that was a result of an unhealthy childhood relationship.

However, our field has been slowed down by having competing schools of thought trying to advance their superiority over other theories. Many therapists are often stuck in their early loyalties to a theoretical orientation.

If you wish to be a master of your profession, then grow beyond the assumptions and allegiances of your professional childhood. We help patients to individuate from their families of origin. Therapists also can benefit from individuating as well.
Studying the art of any practice involves some degree of identification and imitation of our teachers and gurus who served as our professional parental figures (Gordon, 1995). However, I often hear colleagues idealize their gurus while devaluing other schools of thought. This primitive splitting into idealized and devalued schools of thought represents a defensive insecurity and a lack of professional maturity.

I sought out and studied with some of the great proponents of the major’s schools of family and individual psychotherapy. Although I have my preferences, I can say that I have grown as a therapist because of my ability to understand, respect and integrate the various schools of thought.

All our schools of thought are derived from long traditions in epistemological assumptions, and not scientific facts (Lana, 1991). These assumptions permeate academia and our present day beliefs. The assumptions of Behaviorism and Cognitive therapy are that the whole of personality is the sum of learned behaviors. There is no dynamic unconscious, or innate tendency. The best area of study is the observable behaviors or thoughts.

Yet the mechanistic assumptions that are implicit in behaviorism, go back to the 17th century's British school of Empiricism. The Empiricist John Locke wrote that the mind is a passive blank slate, written on by the external environment. This philosophical view helped create a psychology of a concrete and simplistic model of the mind. This assumption is seen in the work of Pavlov and Skinner.

Psychologists mainly tested the Behavioral model in animal lab research, and then generalized to the complexities of human personalities and relationships with often-poor results.

Behaviors are seen as the atoms of psychology, and that the sum of behaviors is equal to the whole of the person. Since the theory is based on a physics model rather than a biological model (as is Systems and Psychoanalytic theories), it developed no theory of resistance. This is significant, since symptoms often serve a function, and families and individuals are often reluctant to relinquish them.

From the opposite end of epistemological assumptions is the Enlightenment philosopher Immanuel Kant. Kant proposed a dynamic mind with innate structures and tendencies. The proper study of psychology therefore begins with understanding the innate structures of the mind and how the mind actively processes experience.
Darwin’s theory of evolution gave us a structured brain that evolved from lower life forms, and took along with it a primitive inheritance. Darwin argued that mammals evolved behaviors and emotions for their survival value.

Freud then posited a structured mind with both primitive (Id), and anti-primitive, i.e. cooperative value-oriented structure (Superego), and a reality oriented structure (Ego) to deal with the inherent conflict between the Id and Superego and the demands of external reality. In this model of the mind, the whole is more than the sum of the parts, since there are conflicting and dynamics interactions among the various parts of personality.

Freud considered innate character and the interpersonal-emotional world of the child. These forces are within the context of a dynamic unconscious mind with its defenses and its ability to encapsulate conflicts with symptom formation.
Freud derived his theories from case studies of mainly introspective, intelligent patients suffering from psychoneuroses. It remains the most sophisticated theory for understanding personality, symptoms and defenses. The treatment however is not effective with concrete individuals who have poor self-reflective abilities.

When we view these different assumptions ranging from the mind as a blank slate to a structured organizing mind, we can put a corresponding continuum of psychotherapeutic theories ranging from Behaviorism to Psychoanalysis.
Systems theory represents a middle ground. It is ahistorical and its focus is on overt behaviors and not insight, as is Behaviorism. However, similar to Psychoanalytic assumptions, Systems theory has a concept of the whole as more than the sum of the parts and with a biosocial model of resistance, boundary and homeostasis.

Locke		Kant
Pavlov		Darwin
Skinner		Freud
Behaviorism	Systems	Psychoanalytic

These distinct schools of therapies based on philosophical assumptions, and particular patient populations (or animals), are often not generalizable to the wide range of human conditions.

Each school contributes valuable techniques and understanding of psychology, but none has fulfilled its original promise to be either fully explanatory or successful.

They can be unified under an encompassing theory that includes levels of systems, from the social systems to the intrapsychic system, from the level of overt behaviors to unconscious dynamics.

If one breaks out of the narrow “school of thought”, then a wide range of knowledge is available to understand and treat a wide range of psychological problems.

I started my psychology training with Behaviorists. I began to break from my strict Behaviorism roots by working with cognitions.
In New York, I received supervision from Albert Ellis in Rational Emotive Therapy. Ellis was one of the early proponents of Cognitive therapy. He felt that most of personality is inherent and unchangeable, but what were changeable were irrational thoughts that could produce symptoms.

This lead to a simple theory of psychopathology based on wrong thinking leading to psychological symptoms. Change the thinking, and the symptoms will disappear.

The Cognitive Therapy model is from both lab research with human subjects and short-term case studies. It also assumes that only observable thoughts (a form of behavior) are the only or main legitimate area of study. There is really no theory of personality, development, resistance or unconscious dynamics.

The interventions are helpful for most everyone. Most people feel better just knowing that they can control their irrational thoughts. Just persuade a client to remember that they need not be perfect, or need to have others approval or need to be in control, and tensions may be temporality reduced.

The theory does not seem to consider that these irrational thoughts may be a symptom of a deeper emotional trauma that needs emotion detoxification and the internalization of a healthy smoothing intimacy. This can only come from the context of a long-term therapeutic relationship.

Recent brain research shows that the science behind Cognitive-behavior therapy (CBT) is weak (Panksepp, 1998, 2004). All mammals have similar affects that evolved since these emotions had survival value. These sub-cortical affect centers of the brain are not due to cognitions. Ironically, CBT therapists argue that they have the most scientifically based treatment. Even if their theoretical assumptions are weak and not backed by science, the technique is helpful.

In the 1970s, family therapy promised to become the great psychological panacea, and Philadelphia became the Mecca of family theory. I was fortunate to be a psychology graduate student in Philadelphia at that time at Temple University. To the south of me, I had the workshops at the Philadelphia Child Guidance with Jay Haley, Salvador Manuchin, Carl Whitaker, Harry Aponte and Lynn Hoffman.

On the north side of Temple University, there was the Eastern Pennsylvania Psychiatric Institute (EPPI) where Ivan Boszormenyi-Nagy, Jim Framo, David Rubenstein, Geraldine Spark, and Gerald Zuck were developing their theories and offering conferences and weekly lectures in family therapy.

Philadelphia Child Guidance emphasized cure by changing the family structure and system. EPPI emphasized object relations theory in the context of the family system. I was geographically and philosophically in the middle of these two competing schools of thought.

As with Cognitive-Behaviorists, many systems-oriented therapists seemed to have an ax to grind when it came to psychodynamics, making it seem as though their ideas were in part a defense against the idea that there was an unconscious out of their control. Interestingly, it is the most controlling therapies that deny that there is an unconscious that is out of conscious control.

It makes one wonder about the motivation of therapists who solve psychological problems with more ideas of behavioral control than emotional empathy.

After my Ph.D. I studied with Peggy Papp at the Ackerman Institute in New York City. Papp taught me how to apply many of the quasi-hypnotic techniques of Milton Erickson to short-term work with couples. These techniques cleverly were able to deal with the problems of resistance that eluded the Cognitive-Behaviorists.

I discovered in my work with Peggy Pap that my talent for formulating paradoxical interventions was based on my understanding of a paradoxical unconscious. That is, I would tell a husband that was hostile and controlling, that he should continue that behavior since it was his compromise between his wish to be loved and his fear of it.

Generally, the paradox of describing and prescribing the symptom was enough to disrupt the behaviors. However, if it was also a valid interpretation of an unconscious conflict, it could also produce an emotional insight that helped bring about more lasting change.

I noticed that the other supervisees who formulated paradoxes that were not also valid interpretations of a self-defeating unconscious, tended to have less results with their families.

The use of paradoxical communication grew out of Communications theory, which considered that meta-communications regulated a system. However, before that, there was simple Communication theory that involved teaching patients how to communicate more clearly and constructively.

The educative level of Communications theory helps most families and couples learn on a conscious level how to better relate. This remains, regardless of theoretical bias, one of the most important therapeutic interventions that is, teaching people how to speak clearly and constructively. It helps most people, most of the time. However, it is too superficial for families who resist positive change.

Dysfunctional families may use confusing and harmful communications to maintain their family system in a rigid homeostasis. Such families will resist such straightforward prescriptive interventions. Communication theory then evolved to deal with resistances, by moving to the level of (unconscious) metacommunications that define roles, alliances, power, and boundaries.
Symptoms may be reduced by changing the communications with relabling, reframing, and paradoxical directives.

At this point of my theoretical continuum from Behaviorism to Psychoanalysis, is Systems theory that is not mechanistically based, but works like a biological system, which includes complex interacting levels of behaviors, not all of which are either conscious or have to do with learning.

Systems theory assumes that people are trying to maintain a homeostasis, not just responding to reinforcements. It assumes that biological systems resist invasions of its boundaries and operations.

Gregory Bateson, John Weakland, Jay Haley, Don Jackson and Virginia Satir eventually saw meta-communications within a family system as a main cause of psychopathology. Double binds, confused communications, and mystifications could drive someone to psychopathology, even schizophrenia. These theories were largely based on observing families of schizophrenics who often had poor communications. They assumed a cause and effect relationship, without seriously considering that the members of the family of a schizophrenic may share some degree of loosening of thought. In addition, many families have poor communications, but do not produce a schizophrenic child.

It would seem to me that hostility, scapegoating and negligence are more powerful in traumatizing a child than unclear speech. Based on these assumptions, relabling schizophrenia, as say “idiosyncratic confusion” was supposed to help this disorder. This theory however provides for powerful interventions to circumvent resistances and to help change patterns of communications that can produce damage to self-esteem and independence.

Eventually, while theorists such as Jay Haley focused on communication within a system, Salvador Minuchin focused more on the structure of the system. Systems theory does not view humans as simply made up of atoms of behaviors, as in the case of Cognitive-Behavioral theory, and simple communications theory.

The family system is a biosocial unit that tries to maintain a homeostasis, unless it is programmed to become open to change. The system has levels of power, boundaries, tasks or operations it needs to perform, such as who does what jobs, how tensions are resolved, or how to manage changes in roles, membership and alliances.

Psychopathology of an individual is based on the maturity of the family system. It assumes that such severe psychopathologies are usually a result of a family system with weak intergenerational boundaries, weak executive functioning, unhealthy alliances (such as an over protective mother), the system’s need for a sick patient to perhaps maintain or balance the personalities of the parents, or take the focus from their marriage.

Salvador Minuchin based his theory from a population of acting out boys from the New York slums. These boys’ families were disorganized and impoverished. Minuchin assumed that if their families became better structured, the children who were embedded in the structure of the family would become less symptomatic.

His techniques are often helpful for children of concrete beleaguered parents who often have little psychological resources available for their children. I have found much of what he advocates to be much less effective with insightful adults.
Many of Minuchin’s devotees have attempted to apply his theory, based on poor disorganized families, to insightful middle and upper middle class families with poor results. These patients often complain that they felt unheard and manipulated.

However, Minuchin made it possible to make significant progress in the lives of children, who could not be reached by techniques that involved theories of learning or insight. His techniques often help children get out of the role of the symptom bearer of the family with short-term treatment. Today, Minuchin adds a psychodynamic component to his theory by going into the parent's childhood. This allows for deeper work.

I felt that Cognitive-Behavioral therapy and Systems therapies did not go far enough. I then went for psychoanalytic training. This also necessitated my own psychoanalysis. My analysis contributed more to my abilities as a therapist than all the other educational and training experiences.

The subjective relational emphasis within psychoanalysis is Object Relations theory. However, before I outline Object Relations, since it is a derivation of Psychoanalytic theory, I shall briefly first review psychoanalytic assumptions. Freud held a concept of a structured and dynamic mind that was both selfish (Id), and socialized (Super Ego). This gave us a model of a mind in conflict with itself from the start, with the child both dependent on the adaptations of the Ego, and the quality of the parenting to help reduce conflicts and move through the stages of maturation. Recently, research on infant attachment supports Object Relations assumptions.

The force to procreate and to protect is innate. The child is born with affects and drives that had survival value. The child needs the family to help tame these primitive forces. The child practices and needs to master issues of aggression and sexuality throughout development.

Rejecting, conflicted or seductive parents interfere with normal psychosexual development, and the child traumatized by the family develops sexual and aggressive conflicts and fixations. The trauma is symbolically repeated in the symptoms. Later psychoanalytic theories added the importance of traumas with attachment and empathic failures. When the patient unconsciously repeats the trauma in the therapeutic relationship, empathic interpretations help the person work through the emotional past rather than repeat it.

This not only produces symptom reduction, but personal growth as well. Psychoanalytic theory is excellent at explaining many of the mysteries of human conflicts, defenses and symptoms. It takes into account instinct, temperament, development, and family dynamics in the etiology of psychopathology.

In Freudian theory, the emphasis starts with our primitive drives. Object relations theory shifts the emphasis from innate drives to internalized parts of the self and others who are associated with aggression, sexuality, dependency, and love. Fairbairn (1952) felt that we are essentially social animals, not so much propelled by drives, but attracted to needed love objects.
These internal parts are made up of various aspects of the self and the external object (meaning mothering figure for the most part, and later other family members).

These objects are not simple internalizations of real people, but subjective representations of them as perceived by the child’s temperament, needs and developmental stage.

The locus of pathology is housed in the internal world of bad objects and a compromised self. These internal objects seek out others to enact and repeat past traumas, or to repeat successful love depending on one’s first loves in the family of origin. Individuals with family traumas have internal bad objects that gyroscopically pick, provoke or distort current intimates to repeat the past (Gordon, 1998, Kernberg, 1995, Stierlin, 1970, Willi, 1982).

This theory is able to explain better than all others resistance and repetition. Why do people complain about their symptoms, yet are intent on maintaining them and resisting change for the better? Object relations theory helps us appreciate that symptoms help maintain the homeostasis of the internal object system.

A symptom is a compromise between the demands of the real world and the internal world of good and bad objects. It may be better for a person to have a lot of aggression in intimacy. It may represent the internalized need to punish the symbolic parent. Without such aggression, the person may feel extremely anxious, empty or lacking passion.
Guntrip (1969) describes an “in and out program” for intimacy. The person may both wish intimacy and fear it, so therefore develops a pattern of moving in and out of intimacy.

When a primary love object frustrates and injures a child, later a dramatic and conflicted intimacy provides moments of familiarity and the safety from feared commitment. The person may need to attach to a drama, fetish, fantasy, a third party (child, lover, or substance), work or an illness in order to regulate intimacy.

The self becomes split off into many parts as an attempt to give to the external loved object, and yet retain some degree of true self. The person feels confused about one’s own healthy needs and the toxic needs of the bad internal objects. These internal bad objects become an internal saboteur that purposely seeks and maintains poor relationships.

Other theories do not begin to explain such self-defeating relationships, resistance to change, nor do they offer any enduring solution. Object Relations therapy is aimed at the deep level of identity to which all relationships are subjected.

Although Object Relations theory represents the best combination of attachment and family context, temperament, development and innate factors, its main draw back is that the theory is too complex for most therapists.

The application of analytic theories demands the most amount of training, often involving a personal analysis. It is intellectually and emotionally challenging. It is not a therapy for the masses.
Object Relations theory has perhaps the best explanatory value of all the major theories of interpersonal behavior. It is the most sophisticated theory for understanding both pathological personality structure (such as Kernberg’s work with Borderline Personality disorder 1976, 1980, 1985, 1989), and both mature and pathological love relationships.

However, its application is often limited to insightful psychologically minded people. There is nothing more powerful in helping a person grow, than a well-timed, accurate interpretation of a self-defeating unconscious pattern in the context of being a good emotional container for the patient.

At this point of my professional life, I respect and work with all these theories. I hope not to have offended any of you in my trying to break old stereotypes in my over simplified survey.

However, let me return to my point, to grow as a field and as therapists, we must give up our over identifications with schools of thought. I have found value in all of them, but none of them has been enough. After all my training in the various schools of therapy, and over 25 years of day to day practice, I have come to value most the combined approach of Systems and Object Relations theories. This combination has the best explanatory value in understanding the complexities of human problems and intimacy.

Although I may use behavioral desensitization, cognitive therapy clarifications, and education in constructive and clear communications to deal with specific symptoms, I always use psychoanalytic formulations to help me understand the full depth of a person.

Religions and political parties are often stuck in their dogmas and splitting the world into true and false believers. Psychotherapists cannot afford such thinking. We are applied scientists. Scientist cannot be out to prove something, but only to discover with an open mind.

Our theories are guides in our thinking. We can integrate theories that range from external behaviors, internal conscious thoughts, a complex interpersonal system, to the internal dynamic unconscious system. All are interconnected. Therapists should not choose a theory based on assumptions and old loyalties. The choice needs to be on what is the most effective and practical. Patients with limited emotional resources may be helped on a behavioral level, while other patients can be helped on a deeper level, and achieve more personal growth. Most therapists feel comfortable with ways of thinking that fit their own personalities. My best advice is after you have mastered at least one theory, to grow to respect other theories and techniques to add to your core modality. Your only identity should be the best therapist that you can be, and your only loyalty should be to helping patients.