News of the discovery of a young woman abducted off the streets as an eleven year old by a stranger, repeatedly abused and kept prisoner for 18 years has made daily print and television news for the past fortnight. Yet another headline about violence closer to home has passed almost unnoticed. On 1st September 2009 the Adelaide Advertiser displayed the headline ‘Mum Murder, Domestic Killings Hit Alarming Levels’. The paper reported on the violent deaths of eight South Australian mothers over the past eight months and the call for ‘an official state review into domestic violence related killings’. The Domestic Violence Crisis Service Executive Officer, Gilian Cordel is reported as saying that ‘I don’t think the general public realizes how many women are murdered by their partners’. The response to the article has been minimal producing two letter to the editor and minimal additional coverage. Meanwhile, every day we are regaled with further detail of the investigation of the abductor of Jaycee Dugard.
Why is this so and what does it mean for those of us whose daily work involve those subjected to and perpetrating violence? Perhaps the story of Jaycee is, given its horror, paradoxically ‘easier’. It speaks to every parents’ fear of the unknown madman who randomly selects a child who is then spirited away. The story reads like an episode from a television crime show which ends with the captor’s release. There is no excuse, there is a villain and an innocent victim and the villain will be tried and punished. It can never happen to people we know, people like ‘Us’.
The domestic violence headline is different. This speaks of the murder of women in our community, women who we see in the supermarket with a black eye, whose children play with our children and whose husbands come to dinner. The violence, if it is seen is explained away as a single, random episode or the fault of the recipient. If the woman speaks out to friends she will often experience a pulling away as others feel uncomfortable knowing the secret, are unable to relate to the abuser and would rather not know. More disturbingly the damage is being done by one who should be most able to be trusted who has promised to love and to cherish through sickness and health and who shares a bed. We look into their lives and in many respects they look just like ours. No wonder the article does not precipitate an out flowing of interest. It is received just as the problem is in real life. With silence.
In our sex saturated world it should come as little surprise that research confirms that a satisfying sexual relationship is intricately connected to relationship satisfaction. As Timm (2009) says in her paper “Do I Really Have to Talk About Sex? Encouraging Beginning Therapists to Integrate Sexuality into Couples Therapy” ‘conventional wisdom tells us that sex is only 5% of a relationship when its going well and 95% when it is not’ perhaps because it is the physical expression of the primary emotional bond. What may be more surprising is how absent the discourse about sex is in couple and relationship therapy. Timm proposes a number of explanations for this including a lack of formal training with many courses having no requirement for specific education on the topic and neglect in supervision. Another crucial element is the self of the therapist. It is clear that the more comfortable a practitioner is to discuss sexual issues the more likely they are to include the topic in the therapeutic conversation. Messages received in the family of origin, the current quality of the practitioners’ own sexual relationship and their knowledge about sexuality all contribute to their comfort. A belief that raising the topic would embarrass clients can also act as a constraint, yet it is clear that the therapists’ ability to speak freely is liberating and normalizing for clients.
Timm offers a reassuring guide to the nervous therapist “The good news is that couples therapists do not need extensive, formal sex therapy training to address issues of sexuality in their clients’ relationships. This paper educates about the PLISSIT Model, offers specific suggestions to increase the therapist’s comfort level, provides basic questions to ask every couple, and recommends more detailed sexual history questions to use when relevant.” The paper then proceeds to fulfill all its promises explaining the PLISSIT model ( Permission Giving, Limited Information, Specific Suggestions and Intensive Therapy) a graded series of interventions which allow even the most junior and nervous therapist to offer something to their client. In addition the author provides a series of specific questions to ask when exploring a couple’s sexual relationship and an extensive bibliography of resources for both the practitioner and client. By the end all are liberated and well informed!
Timm (2009) “Do I Really Have to Talk About Sex? Encouraging Beginning Therapists to Integrate Sexuality into Couples Therapy Journal of Couple & Relationship Therapy, 8:15–33
Many of us love Christmas but those who work in the counselling and psychotherapy field know it can be a difficult time for even the most cheerful. Take yourself. There is all the pressure of celebration which begins with the school carol service ( notice it’s always the same night as a long standing professional commitment), proceeds seamlessly through Christmas get togethers and thank you’s with colleagues, the staff celebration and finally our own family and friends gatherings. That doesn’t take into account the task of Christmas shopping, which is fun but have you noticed that some people end up with multiple gifts while others seem impossible to buy for? No wonder we come to Christmas Day, ready for a break from all responsibility including our professions. we just want a holiday!
We know that we are the lucky ones for Christmas can be lonely and difficult time for many of our clients. Families who have been estranged all year will yearn for reconciliation and the fantasy Christmas celebration, only to be dissappointed when the reality is experienced. Others will be experiencing the pain of family separation and seeing children for only half their usual celebration. For some, Christmas will be spent alone at a time when EVERYONE else is with loving family. No wonder this is a time when life can become too painful to bear. So, at a time when we as helpers most need a rest, our clients need support.
It is this reality that has made us reconsider our services over the Christmas, New Year break. We have decided to remain open and to offer appointments to our own clients and also to others whose usual practitioner may be unavailble. For the latter we will meet their immediate request and then redirect them back to their previous practitioner when they are again available with the offer of liason to ensure continuity of care. We may not be able to fill everyone’s stocking but even a little may help.
Paul, Michael and Wayne; three violent men whose histories are relayed by Carol Boland in her paper “Can Violent Men Change?” The stories of Paul and Wayne make chilling reading as two men from vastly different backgrounds that end up at the same psychological place where they attempt to murder their wives and children who have left them. Carol uses personality theory and in particular the theory of narcissism to explain how this could be. Paul grew up in a world where he could ‘do no wrong’ with a childhood that taught him no strategies to deal with what he perceived to be the ‘outrageous and unwarranted rejection’ of his abused wife’s decision to leave. By contrast Wayne’s childhood was dominated by abuse and humiliation and a powerful sense of shameful inadequacy with the result that he was hypersensitive to criticism and reacted violently. The humiliation implicit in his partners decision to leave him resulted in the same behavior as Paul.
By contrast she presents the case of Michael, a man who has been equally violent yet is able to engage with the therapist and not only acknowledge his violence but act to change it.
Carol makes a cogent point. Violent men can change but ‘we need to be more skilled at recognizing who they are’. Central to this is understanding the quality of their own parenting ‘particularly any information that helps us to understand what they internalized about personal responsibility and remorse’ For those who are steeped in defensive shame like Michael and Wayne it is impossible to predict whether they can respond. However initial screening to distinguish the still-reachable from the too-defended which both appeals to the man’s self-interest and rewards vulnerability and responsibility to change is crucial. In addition it is crucial that we warn the partners of violent men how they leave and be aware that a history of physical violence is no predictor. Never humiliate them, she warns, ‘if possible, simply leave when he is not around. ’She concludes by saying that anti-violence programs must be thoroughly and reliably assessed and that therapist should be unafraid to state that some men are unable or unwilling to change and that services must be provided to properly protect woman and children.
Boland, C. (2008) Can violent men change? Context: The Magazine for Family Therapy and Systemic Practice in the UK. 97: 6-9.
How are the processes of intimacy and differentiation, and the exchanges of symmetrical and complimentary communication of a couple relationship different in the gay and lesbian relationship? And if there is no difference in these aspects of the gay and lesbian couple relationship, then how is it that the external world comes to influence them, such that a therapist must be aware and sensitive to these influences and how they are reflected in the problems presented by gay and lesbian couple?
In asking these questions, Bepko and Johnson (2000) looked at gay and lesbian couples seeking couple therapy and suggest the problems can be classified as being either internal and/or external to the relationship. These authors propose that cultural and gender biases come to be reflected in both the internal and the external (contextual) problems experience by gay and lesbian couples.
The lesbian/gay couple relationship begins within a context of differentiation, where a person “comes out” to both themselves and another. Differentiation then becomes a major defining aspect of the individual and the couple relationship, difference in a culture which seeks sameness. This defining of self as separate from significant others in acted out in a relationship with another that seeks closeness and intimacy. The dilemma of maintaining separateness and closeness is a stress in the gay/lesbian relationship – great stress/trauma in all relationships deepens already present fractures between the couple.
The social and familial support all couple relationships receive can have a determining factor in how well couples are able to negotiate differences within the relationship. Having a social world allows for comparison so one can begin to decide what it is they want in a relationship. A world that highlights difference and infer pathologies, a world that compares and critiques difference, places the lesbian/gay relationship in a state of constant self critique and judgment.
For the therapist many problems that lesbian/gay couples present with may appear to be similar to those for heterosexual couples, of handling conflict around attachment, closeness and distance, sexuality, power, and differentiation. Standard tools of family therapy can be used in working with the gay/lesbian couple, such as family of origin work. A therapists’ understanding and sensitivity to the unique dilemmas experienced by the gay/lesbian couple, how the cultural predispositions bring about a struggle in the maintenance of a gay/lesbian relationship
Reviewing the literature on working with re-married, step or blended families makes for disturbing reading. Most work focuses on the complexity of such arrangements, the loss which inevitably underpins them and the grief and resentment which characterizes the experience of children unwittingly thrown into them. To discover an article which not only proposed a relatively simple way of thinking about these situations and suggestions for therapeutic change was therefore a relief.
Patricia Papernow (1987) proposes the concept of middle ground, “an area of shared experience, shared values and easy co-operative functioning, created over time.” A re-coupled family begins as a collection of already established “mini-families”, each with a different culture, history and rhythm of easily completed interactive cycles. The thickest middle ground exists between parents and their children who share memories, patterns of conflict, play and mutual nourishment which may extend into the wider family system. While in first time families the couple relationship may be the easiest place to retreat for comfort, understanding and problem-solving, in the re-married family the easier understanding may reside between parents and their children.
Working to thicken the middle ground between the new couple is one way to conceptualize the task of therapy. Seeing the adults alone and inviting in other immediate and extended family member is a way to begin the process by giving them an opportunity to relate without the competition and demands of children. An early step is to lower anxiety which has been precipitated by the awareness of painful differences which cannot be explored due to silence out of fear of conflict or escalating out of control disputes. A therapeutic conversation can allow each person to speak and hear of the very different experience of being in the family. Providing normalizing information, empathizing and supporting can all reduce anxiety.
The act of ‘thickening the middle ground’ is achieved by prescription of shared family rituals, invention of a sense of shared history, planning and negotiating major family gatherings and the establishment of sanctuary time for the couple away from children. Learning to satisfactorily complete a cycle of problem definition, attention to each person’s experience and the achievement of a mutually satisfactory resolution is also crucial. The authors conclude with a positive note “Those who succeed in bridging the chasm exude a sense of vitality and mastery which is rare in first time marriages.”
It’s the first bit of good press I’ve encountered for the beleaguered step-family!
Papernow, P. (1987) “Thickening the “Middle Ground”: Dilemmas and Vulnerabilities of Re-married Couples” Psychotherapy 24, 3S pp630- 639
Q. What do Cinderella, Hansel and Gretel and Snow White have in common?
A. They all had perfect mothers, ugly step-mothers and pathetic fathers.
This is the fate of stepfamilies and given this bad press it is little wonder that while the divorce rate in first time marriages stands at 45- 50% for step-families it is a disturbing 65% to 70%. Some statistics place it even higher with 76 % of second marriages failing within five years, 87 % of third marriages failing and 93 % of fourth marriages ending in divorce within five years.
Given this, it is surprising that most adults entering a step, reconstituted, blended, instant, re-married or synergistic family do so with such naïve optimism. John S. Vischer in his paper “Step-Families : A Work in Progress” writes of his own entry into such a family “ We were so starry eyed it never occurred to us that the children weren’t as thrilled about everything that was going on as we were….We thought everything would go smoothly after a brief period. We thought our children would be automatically happy because we were happy”
In understanding the difficulties faced by these families Vischer turns to the idea of basis human needs; the need to be cared about, accepted and loved, to maintain secure attachments to special individuals, to belong to a group and not be a stranger and to have personal autonomy and control. By definition, he suggests, at least initially, the structure of step-families prevents these needs being met. Based on this understanding he then makes suggestions for guidelines to help the new family’s integration.
The paper finishes on a positive note with the statement “With your help there can be a multitude of healthy step-families for the 21st century!”
In preparing for Maurizio Andolfi’s visit to Adelaide in late March, I was fascinated to encounter his view of the recent fate of family therapy. The very last paragraph of his paper, “A 35 Year Long Personal - Professional Journey”, a work in preparation for possible publication in the Australian and New Zealand Journal of Family Therapy, is entitled “Why Family Therapy Lost its Mission in Social Community Realities?” In the 70’s and 80’s he contends, family therapy developed as a search for “concrete resources and answers in social contexts” which were directly connected to “people’s problems and realities”. For Andolfi, this is not an abstraction for in the early 1970’s as a resident in New York City and Fellow in Social and Community Psychiatry at the Albert Einstein College of Medicine, he worked in the South Bronx with highly disadvantaged families from diverse ethnic groups. This experience was reinforced by his work in South Philadelphia with Salvador Minuchin and Jay Haley. He goes on to suggest that the appropriation of family therapy by tertiary institutions and mental health agencies cost its “marginal perspective” and delivered a place in the mainstream. It has also negated “the pioneering spirit and capacity to speak out against the psychiatric establishment and the institutional bureaucracy”. These changes are reinforced by what he perceives to be an “increased individualism” and resultant consumerism of the last decades. These changes have impacted on therapy which has adapted its interventions from “social and community tools” to “became mostly a service for individual wealthy and lonely clients” and less accessible and used by families.
What also flows from these changes is “an increase in conformist ideas and language” and the development of theories and models “where real people are missing”. Its time, he suggests, to return to “simple, concrete language in order to embrace everyone instead of using complex and abstract concepts with very impressive labels”.
How could anyone disagree, but do we really want to open up the gates, to back away from our increasing passion for accreditation, specialized vocabularies and sanitized practice? You never know who might want to join!
Still going strong after 35 years must be an achievement in any occupation but to be ‘alive and kicking’ as a therapist is surely impressive. Maurizio Andolfi, Full Professor in the Department of Psychology at the University of Rome who trained as a child psychiatrist in Rome and at the Ackerman Family Institute and Philadelphia Child Guidance Clinic in America, can make just such a claim. And you just have to ask “How does he do it?”The answer may lie in his recent paper, prepared for possible publication in the Australian and New Zealand Journal of Family Therapy, “A 35 Year Long Personal - Professional Journey”. In this he elucidates his intergenerational approach to marital therapy with its emphasis on actively including both family of origin, parents and siblings, and children in the presence of each spouse. He regards the generations on either side of the troubled couple as a valuable resource, the previous generation available to help discover new relational pathways and children to ‘enhance information gathering, creativity, flexibility and playfulness”.
But wait, there is more. Andolfi has also presided over a thirteen year outcome research project into the evaluation of family therapy treatments. This has involved one hundred and fifty families and explored outcomes in three situations; where therapy last less than three sessions, where therapy concludes after several sessions without a satisfactory conclusion and where therapy concludes with a positive outcome.
There are also the “International Practicum” he has held in Rome from 1981 to 2006 and his own world travels which have kept the elixir alive. Working with seasoned therapist, the Rome experience encourages practitioners to identify their own “professional handicap’ or charecterological limitation to their work. In identifying and addressing this, the trainee is encouraged to explore and discover new ways of using themselves.
Finally, and in Andolfi’s own words there is his history of “cultural marginality”. “I learned how to stay at the edge of the scientific discourse without needing to follow the mainstream mode of rules and models, without giving up to common sense and to the “lessons of the road”, the knowledge which comes from real people in their social contexts and not only academic knowledge ex cathedra.”
Nothing is a exhilarating as working with a couple whose distress has brought them to the point of despair and annihilation of the relationship and feeling instrumental in its recovery. Equally the pain of encountering the impossibility of influencing the course of events and presiding over the demise of a relationship is equally compelling. Our experience of our own efficacy is highly subjective and it is important to look to the literature of outcome studies to satisfactorily address the question “Does it work?”
As late as (1998) Werry was sadly reflecting that “family therapy has many of the hall marks of a religion with several competing sects led by feuding charismatic prophets each claiming to have a premium on the truth, but with few of the attributes of a profession rooted in ethics and skepticism”. However by 2003 Sprenkle (2003) was able to say that in reviewing the literature “Werry’s blanket indictment of the field is no longer valid”. Johnson and Lebow (2000) cited research studies which pointed to the efficacy of both Behavioral Marital Therapy and Emotionally Focused Therapy. While the former produced an effect size of .95, meaning those who undertook this treatment had higher scores on outcome measures than 83% of treated couples; questions remained as to the long term benefits of the approach. By contrast Emotionally Focused Therapy, which is based on attachment theory, produced an effect size of 1.3 with no evidence of relapse at two year follow-up. When the two approaches were compared EFT was more effective than behavioral exchange and skill building interventions. By 2005 Stratton, writing for the Association of Family Therapy in Britain concluded that while the efficacy research is ‘generally positive’ there remains a need to replicate treatments shown to be effective by specialists who are often the originators of an approach in more realistic field conditions. This challenge is been met. Wright et.al 2007 paper. “The Clinical Representativeness of Couple Therapy Outcome Research reported that where pretherapy training was less intensive, treatment less structured and therapists more experienced larger effect size was noted.
So, it seems we can say ‘Yes’ to our original question. However there are as many questions generated as are answered and perhaps it is time we all began to consider our contribution to providing answers to these new and provocative questions.
Johnson ,S & Lebow,J.(2000) The “Coming of Age” of Couple Therapy:A Decade Review Journal of Marital and Family Therapy Vol 26:23-38
Sprenkle,D.H.(2003)Effectiveness Research in Marriage and Family Therapy:Introduction Journal of Marital and Family Therapy Vol 29:85-96
Stratton,P. (2005) Report On The Evidence Base of Systemic Family Therapy Association for Family Therapy
Werry,J.S. (1989) Family Therapy: Professional Endeavor or Successful Religion? Journal of Family Therapy,11:377-382
Wright,J. et al (2007) The Clinical Representativeness of Couple Therapy Outcome Research Family Process 46:301-316
