If a little knowledge is dangerous, where is the man who has so much as to be out of danger?
—Thomas Henry Huxley (Collected Essays, Volume 3)
On the pre-scientific level we hate the very idea that we might be mistaken, so we cling dogmatically to our conjectures, for as long as possible … we then perish with our false theories … (but) on a scientific level, we try to let our false theories die in our stead.
Like all dreamers, I mistook disenchantment for truth.
—Jean-Paul Sartre (Les Mots, 1964)
Certainty of view is unwelcome in the field of family therapy. Anyone offering it is treated with suspicion, their propositions considered unsafe. That has come to include ‘expert’ categorisation within medicine, where psychiatry’s strong disposition away from dimensional processes has been a formidable obstacle to a wider social care acceptance of current concepts and language used in mental health services. The protean symptoms and signs of Huntington’s chorea, or the nineteenth century discovery of insanity caused by syphilis, are considered rare exceptions to a rule that the biological determinants of most distress, disturbance and troubling behaviour are relatively minor.
Yet the legal and benefit systems of most countries require categories, including for billing, payments and for governance. Families might welcome a diagnosis being made (“now at last we know what we’re dealing with”). Nor would any professional have difficulty recognising a colleague’s description of “a tired Mum” or “semi-detached Dad”, their immediate concerns likely to be organised around such observations.
Our position is that such observations are useful starting points, as long as they do not diminish curiosity and render the person less open to understand what lies beneath such presentations. Families too sometimes offer these: “I think I am the problem”, as Mr Smith stated to Sal Minuchin.
New ways of looking at things to replace unsafe certainty: support for the value of uncertainty came recently from an unexpected quarter with the radical change in position of the US’s National Institute of Mental Health (NIMH) towards diagnostic categories. It has funded billions of dollars for mental health research, but will no longer accept any research proposal couched in the language of current DSM-categories, about which it is now “agnostic”. This has been to the consternation of the many who over years laboured to revise it in its new form, DSM-5.
The reason for this is to assist “a new way forward for clinical diagnosis”, derived from psychobiological findings that current diagnoses may obscure, preventing new theory building to which neuroscience and epigenetics are expected to make a major contribution. NIMH has introduced a new framework based on dimensions. Instead of being abandoned on the periphery of theory-building investigations, social systems such as attachment and the perception of self and others, are firmly present.
“Each individual at risk for or suffering from a mental illness presents a unique set of characteristics, whether they are genetic, environmental, experiential, developmental or a combination of these factors”. NIMH’s mission statement anticipates “an environment in which mental health care adopts a personalised approach”. Their eventual aim, to replace current diagnoses by new ones that offer “precision (i.e. tailored) medicine”, obviously differs from systemic therapies, but we can think of no better way of describing the importance of two core features of our approach. These are the integration of models at a conceptual level, and how these can be combined at a practical level in the formulation that, following assessment, provides an explanatory model for the unique circumstances each family bring to their service contact.
Blending old wine with the new in twenty-first century bottles: both integration and formulation were at the heart of the approach described in the first edition of Integrated Family Therapy, but it had not anticipated gene-environment studies or epigenetics (which NIMH considers will re-shape psychiatric thinking), nor social constructionism, which forms the basis of much recent systemic thinking and practice.
However, the book did strongly endorse a collaborative approach with every family, albeit that ‘co-constructed’ ideas were never mentioned. The individually-developed formulations it advocated would not have been possible without the active engagement with families referred to in the first edition of Integrated Family Therapy as ‘orientation’. During their training at McMaster, the book’s authors had observed that before taking a history from a family, most experienced practitioners first ensured there was a shared understanding between them and the family of all the expectations being brought to the consultation. Similarly, before engaging in any therapeutic work, these practitioners established a collaborative ‘contract’ with their families based on issues derived from a formulation agreed between them. The authors took care to point out that this approach was very different from the strategic approaches to family therapy then being advocated.
In ‘What Are We Integrating?’, the website provides an account of how these earlier concepts can be combined with post-modern developments in an integrated way. The problems being brought by families can now be viewed in an ‘and/and’ way, rather than ‘either/or’. From this standpoint any major findings from epigenetics and neuro-developmental psychology may offer yet more competing explanatory models.
A ‘right first time’ approach requires conceptual integration: the authors of the first edition of Integrated Family Therapy wrote for a wide audience, particularly for those working within the public sector of social work and health-care where the heterogeneity of tasks require a diverse range of skills. Its authors recognised that assessment skills were vital in public sector work. Not just because these are expected at a managerial or cultural level in this sector, but also because no single model of therapy can be considered sufficient to effectively meet the needs of most families referred to a service. We believe, as they did, that a therapist must be able to draw upon a diversity of models to understand family-based issues, and use these selectively in working through with each of their families to an effective resolution of their particular needs.
The current emphasis upon a ‘right first time’ approach, where most families’ problems can be resolved without onward referral, makes a good assessment even more essential. The first edition of Integrated Family Therapy described formulation-driven therapy, and a wide range of therapy techniques, from ‘experiential’ to ‘cognitive’, so that any stuckness in therapy would direct experienced therapists to re-consider their formulation. That in turn might prompt a re-examination of the initial assessment: whether it had been sufficiently comprehensive, and if so, what factors might have been responsible.
Integrated Family Therapy: A Paramodern Position: the text on this website constitutes an evolution of the central ideas contained in the first edition of the book, by bringing in new findings from the neurosciences and epigenetics as well as reflecting our understanding and acceptance of post-modern ideas as these have come to shape family therapy since the first edition. Two levels of its four-level framework now seem particularly dated: the terminology describing ‘surface action’ and the certainty of description of ‘dysfunctional transactional patterns’. The original account of formulation has been considerably expanded by the contribution of contemporary psychoanalytic thinking about the mind, as well as deepened to embrace possible individual differences in brain function.
Under the influence of post-modern ideas, the central place of task-setting in a therapist’s toolkit has now been replaced by a far greater emphasis upon communication. This had previously been subsumed as one of four domains of ‘micro-executive skills’. Change is now considered to come from co-constructed ideas rather than solely from an ‘expert’ therapist at work.
Changes in relationship-behaviour are still important, 300 years after Alexander Pope said that “expression is the dress of thought” (Pope, 1711). In contemporary family therapy, we recognise the importance of ‘behavioural activation’ of changes in thinking style, observed when family members try new ways of relating during a session, develop their genogram, or agree on between-session tasks.
We hope those familiar with the first edition will not be disappointed, and those new to it appreciate the ground it had established to allow this new edition to be successful.
Pope, Alexander (1711). An Essay on Criticism. Public Domain.
Sartre, J. -P. (1964). Les Mots. Paris: Georges Braziller.