A clear secular trend can be observed in the vast published literature on this topic from thinking based on how to promote adherence to ‘expert’ advice and interventions, to thinking about how to establish collaborative work. The issue goes beyond ‘joining’ the family as Minuchin described, essential as that is. Perhaps the best example is narrative therapy, since its basic stance is collectivist and collaborative conversations build the therapeutic encounter brick by brick.
Attention to engagement is therefore unarguably important for any psychological therapy that follows a pre-ordained structure to which the client has made no equal contribution. Beyond the obvious examples of CBT and IPT, engagement is crucial to most psychoanalytical approaches and to the systemic approach introduced in this website.
Retaining therapeutic engagement with family members throughout a long period of contact is a considerable task for several reasons:
- Intended benefits of a pre-ordained structure may not be readily apparent to them.
- Initial appreciation of it is diminished by feeling they have not been heard.
- Predicaments that brought them to the consultation are seemingly forgotten by the therapist or remain largely unresolved.
‘Why? Why could you not agree to move aside (from in front of a kitchen drawer) … when all they wanted was just to get a spoon? Why couldn’t you?’
This was the insistent question put to a fourteen-year-old late-adopted young woman and her single parent mother. She was just about the only adult outwith school to whom the young woman didn’t automatically and implacably say ‘no’, and even then she rarely agreed quickly to any of her mother’s requests. This occurred a few minutes from the start of the second session for the family, and is chosen to illustrate some of the key principles of engagement in family work described in this website.
The young woman had been referred for her irritable responding and tempers, and the question seemed to go to the heart of the matter. The path taken before that decisive step by the therapist had been established over some time, and was only possible at that moment in the second session because of an earlier contribution by the young woman’s mother.
The final steps on the path to full therapeutic engagement: these took place shortly after the second session began, when the young woman had talked of her poor relationship with her mother’s ex-husband, now reunited and living with them. She listed many complaints, which seemed largely to be about having to respond to his requests and wishes completing or assisting with household tasks.
She then went on to say that she would like to be able to say ‘yes’ to him, at which mother expressed surprise and doubt. The two helped each other to describe the problems and then her mother stated to the young woman (and for the therapists’ understanding too) that these difficulties were in fact generalised to any adult who sought her compliance. Her mother reminded her of an incident where she had refused to move away from in front of a cutlery drawer to allow someone access to it. The young woman accepted her mother’s point and so her experience became a joint story; a concrete example of an emotional difficulty which might be worked through collaboratively.
The presence of the therapists was important as mother and daughter began to discuss this. The foundations were established from the opening minutes of the first session and the full process of therapeutic engagement is described below. Staying with this moment during the second session, mother’s example was recognised as highly salient to the problem for which the young woman was referred, and constituted a timely opportunity to deepen an understanding of it. The therapists insisted that she let them know what was on her mind when ‘no’ was the only option. For example, when she refused to move aside from the cutlery drawer when an adult wanted to open it, ‘just to get a spoon!’
Quiet humour was used to persist with the question. It was, she said eventually, to prevent the adult, any adult, being ‘boss’. She was unable to explain further and then became deeply and obviously preoccupied, evidently remembering something. After seeming to struggle to find words she fell silent, shaking her head. Pressed to tell what was happening, volcanic emotions then caused her to splutter and cough; she regained control and then lapsed into silence. After acknowledging her gross discomfort, the question was repeated for a final time, conveying the importance of her response, ‘that seemed really uncomfortable. Why, why could you not agree to move aside? When all they wanted was just get a spoon’.
‘Because (she almost whispered) something might happen …’ She then added what all those in the room were now expecting: complying would mean ‘because I was weak, I hadn’t been strong enough … to stop it happening’. Suddenly she seemed child-like; her disclosure precipitated her adoptive mother to take her in her arms and the young woman allowed this, holding the therapists in her gaze.
She was then asked by the therapists what she would now like to happen. Her wish was to help her discriminate her own responding; to be able to move aside if someone wanted to open a drawer. It was no longer about her difficulty with her ‘new’ adoptive father. And to perhaps talk at another time about how she had come to her stubborn non-compliance.
The foundations of the therapeutic engagement between family and therapists had been established from the opening minutes of the first session. In all, seven steps were taken before the few minutes just described, the last steps on the path that took place in the second session.
- an initial orientation: this was setting out to mother and daughter how the consultation would proceed, including that all present would be speaking and listened to; that the therapists would summarise issues as these emerged and were understood and agreed and openness would include the family listening in to the therapists’ own discussion in the room, reflecting on it or adding to it as they wished. Finally, that a letter would be prepared afterwards for the referrer and would be a detailed summary which they would recognise as their meeting with the therapists. They would receive a copy, and if they remembered differently they might subsequently ask for it to be amended.
- history-taking: this began with the young woman, and became progressively organised around the issues she was concerned about. Referred as an angry, explosive, irritable and sometimes hostile teenager, she proved to be surprisingly thoughtful and articulate. Taking responsibility for herself rather than blaming others, she agreed that the referred problems were a cause of real concern to her. She explained that she also had problems with her family relationships with a younger sister but particularly with her adoptive-father, which her mother acknowledged was a poor relationship – ‘they don’t get on’.
- the detailed letter to the referrer: this organised around the emerging story, reflecting the position the therapists had stated at the outset i.e. that the consultation belonged to the family rather than to the therapists or to the referring GP.
- how the second session began: it opened by asking the two how they felt about the summary of the consultation provided in the letter that had been sent to them – whether it reflected what sense we had all made of their situation and was accurate. The young woman agreed, including the description of her “zoning out” as a dissociative phenomenon, which had been necessary to cope with past intolerable experiences.
- how the session then proceeded: by asking the young woman to prioritise her concerns and what we should begin with. She stated: her relationship with her adoptive father.
- being honest: as the young woman began to talk, one of the two therapists recognised that he had broken the ‘rule’ the therapists had earlier stated about transparency of communication. He confessed to the young woman’s mother that after the first session he had said to his colleague that he had been very puzzled about why, given that the young woman struggled so much with relationships (she’d sought a lot of closeness to Mum as well as well as being stand-offish, and was now intolerant of having to share her mother), her mother had nevertheless introduced several challenging changes for the young woman. Firstly, by adopting another younger child and secondly, by re-introducing her ex-husband into the family after they had moved away from their home town. Her mother accepted the question, saying that each had been well thought out and were, in her opinion, “well managed” over many months. So – as Martin Buber would have hoped – she spoke boldly, holding her ground, and in doing so helped to make it an unafraid place to raise and to respond to issues as they emerged.
- generalising from a specific issue after concretising it: the young woman had listened to her mother’s quietly authoritative account, and did not disagree with it. She began to talk about her difficulties with her adoptive father in terms of her own responsibility. She then surprised her mother by saying she would like to be able to say ‘yes’ to him. In turn, her mother listened to her before putting to her daughter that these difficulties were in fact general to any adult the young woman encountered who sought some compliance from her. She then provided the recent example of the cutlery drawer to evidence this.
A gradual, step by step, incremental approach had allowed unguarded talking to become possible, because it was taking place in an imaginative and trusted space created gradually between the four present in the room: the foundation of therapeutic engagement. Its constituent elements included the emphasis on clear and open communication, being careful, being audacious, being respectful, being thoughtful, and being collaborative.
The therapists’ final question about what would she like to happen now continued the collaborative encounter, allowing her to remain in charge with her needs and communication at the centre of the two consultations. This was very different, her mother pointed out, to the traditional clinic appointments made for them previously in their home town. The mother recalled the young woman had said very little and little had been asked of her. She had also felt excluded from the young woman’s subsequent play-therapy.
The structure of the family therapy enabled the young woman to decide what she wanted to happen next, after the painful disclosure. This set the scene for the next phase in therapy, which the therapists later learnt began almost immediately. After leaving the room she talked with her mother outside about the clinic and about the hug she’d been given. Talking between them continued in the car on the way home, and then next day at home when she sought out her adoptive father.
Family therapy involves an understanding of the here-and-now and its links with the past, but unlike individual psychodynamic therapy from which it evolved, it includes the presence in the room of those with whom the referred patient/client has a significant current relationship.
This confers two advantages over individual psychodynamic therapy, demonstrated by this case. Firstly, how emerging issues can be examined. Secondly, how the referred patient/client is supported.
Both these advantages were established during the earliest years of family therapy, but the field of family therapy has greatly expanded since Integrated Family Therapy was first published in 1985. Whether in therapy or in adult learning, engagement must be needs-led.
By deciding that our revision of the 1985 publication should be web-based rather than another book, a multi-level access to the material has been provided that should allow each who use it to progress their enquiry in a way that meets their individual needs. Our aim is to ensure its relevance for social work as much as for healthcare, and to go beyond the eclectic approach required for public sector work. We hope, by the extensive use of case examples and the importance placed upon formulation, to engage readers in a coherent integration of the main theoretical models in current systemic practice. Without a coherent working model, therapeutic engagement with families will be challenging, perhaps clumsy, with a good outcome based as much on luck or on the family’s rescue of a floundering therapist – which has happened to all of us!
To maintain therapeutic engagement with the young woman and her mother in the example above, stopping rules were applied: in this case by limiting the formal assessment to maintain the consultation’s centre of gravity on the family’s focus of concern, and by making no formal summary of the developing formulation in order not to ‘trump’ mother and daughter’s manifest understanding of it. Strachey wrote about the importance of incomplete interventions for therapeutic engagement more than seventy years ago: an incomplete (psychoanalytic) interpretation allows the patient to fill in the gaps themselves, but an inexact one is liable to make the patient feel poorly understood.