Collaboration and the Role of the Larger System

Many patients have more people than just their families involved with their problems: they have schools, social service agencies, attorneys, doctors, and other health professionals. The possibilities are limitless. The goal of the family therapist is to determine the players who have a major effect on the problem and whether those people need to be involved in the treatment.

In the situation with Jorge and Maria, the geneticist was a major player. With the couple’s permission, it was important for the therapist to communicate with him.

Therapist: Dr. Reed, thank you for referring Maria and Jorge. They sure are concerned about the possibility of passing on Maria’s disorder to a future child.

Dr. Reed: I know. They seem to want certainty that I can’t provide.

Therapist: Jorge keeps talking about odds. I know you geneticists think in terms of risk. I wonder if you could speak to them in terms of odds. This seems to be the language with which Jorge discusses the problem.

Dr. Reed: I appreciate that suggestion. Certainly it is not working to offer them one more genetic test that is highly unlikely to be positive. Let me review the data and see what I might offer them in the way of an explanation in terms they’ll understand.

The next therapy session occurred right after their meeting with the geneticist. Jorge was elated: “He told us we are likely to have no greater than normal odds of having a baby with Maria’s disorder. In fact, he said we’d be more likely to have a baby with cystic fibrosis . . . and amniocentesis can test for that!” Maria just smiled. After the session, the therapist e-mailed her geneticist collaborator, telling him the couple seemed to be doing very well with the news. Dr. Reed wrote back: “I gave them the same talk over and over, and could see it was not being helpful. Once you got involved, I decided to try something different. I’m glad that we succeeded.” Sometimes making a change in one part of the system will create a reverberating change in another. Though it was not planned as such, the family therapist’s approach to this couple helped the geneticist to see them and then treat them differently.

FAMILY THERAPIST–PATIENT RELATIONSHIPS

In family therapy, the relationship between family members is primary, not the relationship between the therapist and the patient or family. In psychoanalysis or psychodynamic psychotherapy, the transference of the patient’s introject of a parental figure onto the therapist becomes the grist for interpretation and exploration. In family therapy, it is the actual relationships that are the focus of treatment. Behavior therapists may talk with patients about how significant others reward progress or unwittingly reinforce symptoms. In family therapy, those positive and negative reinforcements are available for view in the therapy room directly. Because of this, the intimacy in the room is typically between family members rather than with the therapist.

Part of the challenge for the family therapist is developing what Ivan Boszormenyi-Nagy (1973) termed multilateral partiality, or alliances with all members of the family. This term refers to the need for the family therapist to form strong relationships of trust and fairness with each member of the family, without taking sides and inadvertently forming a coalition with one member of the family against another (a professional version of an intergenerational coalition). This can be difficult when, for example, an adolescent is appealing and a parent appears to be too harsh. However, forming a warm bond with the adolescent while remaining cool with the parent only inflames the problem. Instead, the therapist is charged with finding something in each family member to connect with, recognizing that this kind of neutrality (or better said, multipartial alliance) is part of the healing aspects of most family therapy.² With multiple patients, there are inevitably multiple agendas. In the case of Jorge and Maria, the therapist worked to understand both party’s positions—Jorge’s worrying and Maria’s advocacy for the relationship. By describing both positions respectfully, the therapist joined successfully with both members of the couple without siding with one against the other.