Assessment
Initial assessment must evaluate for the presence of any safety issues. For example, if significant depression is part of the presenting picture, I routinely assess for suicidal ideation, and, if present, evaluate the lethality of the threat. Symptoms may require a medical evaluation to rule out serious physical problems. Elder abuse, child abuse, neglect, and domestic violence must be addressed if relevant in initial assessment protocols.
From a life cycle perspective, I want to “. . . track family patterns over time, noting particularly those transitions at which families tend to be more vulnerable because of the necessary readjustments in relationships. . . . Problems are most likely to appear when there is an interruption or dislocation in the family life cycle, whether because an untimely death, a chronic illness, a divorce, or a migration forces family members to separate or because a family is unable to launch a child or tolerate the entry of a new in-law grandchild” (McGoldrick, 1995, p. 31). It is important to be aware of the typical triangles and issues at each stage of family life (McGoldrick & Carter, 2001).
From the perspective of my model of practice at http://www.Cunninghamtherapy.com, which is heavily informed by Bowen Family Systems Therapy, outcome is viewed very differently from other theories. A small change in one person may significantly change his/her life course, and such a small change cannot be implemented without therapy that may last several years. Also, a small change in one person may not be reflected in the family system for three or more generations. Kerr and Bowen (1988) state that “The more generations of a family included in an assessment, the greater will be the divergence in functioning. . . Given sufficient generations, every family will produce people from the extreme of remarkably high functioning to schizophrenia” (p. 221). Kerr and Bowen clarify that “. . . the most extreme forms of manic-depression, alcoholism, and obsessive-compulsive neurosis, for example, develop over the course of at least several generations. . . . Most distinctions between diagnostic categories may eventually be discarded in favor of a continuum ranging from mild occasional depression to chronic psychosis. . . so saying that the intensity of symptoms is generations deep does not necessarily mean that the actual symptoms have been present in preceding generations. It means that basic levels of differentiation are generations deep” (p. 241).
It is important to understand that all people diagnosed with a specific disorder are not the same emotionally (Kerr & Bowen, 1988). As Kerr and Bowen explain, “There may be an inherited predispositon (genetic or otherwise) to [a disease like] manic-depression, but all people who have such symptoms are not equally adaptive. Those with low levels of differentiation have lives that are usually unstable in most aspects. . . those with higher levels of differentiation may have only one or two [episodes] in a lifetime. . . . The age of onset, severity and impairment of life functioning associated with all psychiatric diagnoses can be understood in the context of the multigenerational emotional process” (pp. 240-41). Some instances involve a combination of markedly impaired adaptiveness and fairly minimal life stress and produce a psychosis. In other instances, a combination of strong adaptiveness and extreme life stress can precipitate a psychosis. Kerr and Bowen explain that “Whether the potential for psychosis is actually part of everyone is difficult to determine. . . because there are so many other ways people manage anxiety. For example, there may be learned or genetically based psychological as well as biological tendencies that determine that a given individual will, when under stress, develop serious physical or social symptoms rather than emotional ones. This does not mean that the potential for psychosis is absent. . . . It just means he manages his anxiety, even when under extreme stress, in a different way” (p. 240).
The Bowen therapist is concerned with assessing intensity in relationship. Papero (1990) describes an intense interaction as “. . . one in which strong feeling states are produced and very rapidly transmitted among the participants to the exchange. . . . Intense anxiety is a strong fear of real or imagined events. The more intense an interaction, the greater the likelihood that individuals involved will behave automatically, that is in response to the emotional system with the intellectual system being overriden” (p. 41). Such automatic behavior is viewed as reactivity.
Since Bowen family systems is based in natural systems rather than cybernetic systems, the focus in not on homeostasis so much as it is focused on reciprocity. Thus, if one person’s functioning declines, another person’s functioning may rise. As such, it is possible, for example, that one sibling’s success may predict another sibling’s failure. Similarly, if an overfunctioning spouse decreases his/her functioning, the underfunctioning spouse should improve.
Kerr and Bowen (1988) state, “It is the basic level of differentiation that is largely determined by the degree of emotional separation a person achieves from his family of origin. . . basic level is fairly well established by the time a child reaches adolescence and usually remains fixed for life, although unusual life experiences or a structured effort to increase basic level at a point later in life can lead to some change in it” (p.98). A given sibling will have a slightly greater or lesser amount of differentiation than his/her parents.
As opposed to basic differentiation, functional differentiation is dependent on the relationship process. As such, people with very different basic levels can, under favorable circumstances, have similar functional levels (Kerr & Bowen, 1988). Related to functional differentiation is the concept of pseudo-self, which refers to “. . . knowledge and beliefs acquired from others that are incorporated by the intellect and are negotiable in relationships with others. Pseudo-self is created by emotional pressure and can be modified by emotional pressure” (Kerr & Bowen, 1988).
Kerr and Bowen (1988) explain, “Assessment of the basic level of differentiation of a multigenerational family is one component of the assessment of basic level of differentiation of an individual. A second component is the impression about the individual’s awareness of the self in relationship. Change can occur when people apply their will to their own self-differentiation rather than trying to will others to change. In this way, one can change one’s position in his/her family system.
Bowen (1978) did not consider the interpretation of transference as the way to change. Instead, Bowen thought that “. . . the therapist should try to stay out of the transference as much as possible by functioning in a detriangled manner that kept it fulminating within the family in front of him” (Friedman, 1991, p. 154). I agree, and coach clients to resolve transference directly with family members, especially within their primary triangles. In clients’ one-to-one meetings with siblings and parents, the effort is to develop an adult-to-adult relationship with each individual family member. By taking problems back to their original sources, the client is on a direct route to altering the etiological factors giving rise to current problems. Through revisiting one’s position, especially in his/her primary triangle, and by reviewing childhood distortions, the client’s perceptions become more realistic. In this way, family cutoffs can be repaired and fused positions can be shifted, which diminishes family anxiety. It is in this context that the client can change from a focus on others to a focus on self-in-relation.
Bowen (Kerr & Bowen, 1988) believed that the process of change takes time. Change is not equated with symptom relief or even feeling better, but with an increase in the level of differentiation of the family. Long-term therapy increases the depth with which the client addresses multigenerational processes (Friedman, 1991), and this requires a commitment to therapy that may last several years. Change occurs outside of therapy, as the Bowen coach sends clients back to work with their families of origin.
To affect change in the system, I work with the person most motivated to change, who often is the overfunctioner. The goal of the work with this person is to develop a differentiated leader, one who can lead the family in a way that will have a positive effect on all members.
Horizontal and vertical stressors challenge the system in varying degrees, depending on the level of differentiation in the individual and in the family. By raising levels of differentiation, more flexible and adaptive responses to change can increase Bowen, 1978).
Marked upward or downward changes in differentiation from one generation to the next are uncommon. Each sibling may have a little bit more or a little bit less differentiation than may his/her parents. Children that are focused upon more heavily are not as differentiated as those left freer to grow and develop (Kerr & Bowen, 1988). Thus, the position of each sibling in his/her family of origin may be more or less fortunate, leading to small but varying differentiation in lines of the family. Much as it takes several variables all lined up correctly to spawn a hurricane, so it is with negative outcomes in the human being and his/her family system. If only one variable is changed, it can prevent the storm that might otherwise have occurred.
Bowen (1978) bypassed the marital fusion of the nuclear family in favor of focusing on at least three generations of the extended family (Titelman, 1987). Bowen (1978) concluded that “. . . families in which the focus is on the differentiation of self in the families of origin automatically make as much or more progress in working out the relationship system with spouses and children as families seen in formal family therapy in which there is a principal focus on the interdependence in the marriage” (p. 545).
I believe that people are doing the best they can with the tools that they have at any given time. I also view the principles of psychic determinism (Freud, 1924; Brenner, 1973) and evolution as complementary. One thing follows naturally from another. To attend to the evolving process between people while at the same time analyzing the evolving process within people is the heart and soul of my theory of change.
To learn more about my model of practice and pick up some free tips just by visiting the web site, visit me at http://www.Cunninghamtherapy.com or call 619 9906203 for a complimentary phone consultation!