Varvara Salavou, MSc, ECP, EFCT, Clinical Psychologist-Family Therapist, Trainer and Supervisor, Child Psychiatry Department of Athens Medical School at Children’s General Hospital “St. Sophia”
Abstract
In the present article, we review the course of the Specialist Service for Family Therapy within the Child-Psychiatry Department of the Medical School of Athens at the Children’s General Hospital “St. Sophia” over the last fifteen years (2008-2023). We describe the evolutionary phases of a therapeutic system offering family therapy for children and adolescents with a one-way mirror and a reflecting team. We discuss the past, the present and the future perspectives. We reflect upon the meanings of crisis in the present and the processes that might contribute to dealing with it. We try to learn from experience, connect with theory and raise questions about the evolutionary processes of a complex therapeutic and training function within a complex context.
Therapeutic system, reflecting team, crisis, self-organisation, group processes
Introduction
Vlassis Tomaras, former Associate Professor in Psychiatry and Couple & Family Therapist founded the Specialist Service for Families within the Children’s General Hospital «St. Sophia» whilst directing the Child Psychiatry Department of the Medical School of Athens. Initially, solely families of inpatients were referred for family therapy sessions. In 2008, the Child Psychiatry Department launched the Family Therapy Unit-Specialist Service for Families, that operated once a week for two family therapy sessions.
In order for the Specialist Service for Families to function as a therapeutic system, it was designed with the following conditions: a) co-therapy with two therapists, b) a session frequency of one session per month and a duration of therapy for an average of one year, c) a reflecting team behind a one-way mirror, d) simultaneous family therapy and training and d) in-vivo supervision[1].
In its fifteen years of operation, the Specialist Service for Families has received eighty-seven (87) referrals. Seventy (70) families completed family therapy with an average duration of one year.
The University Child Psychiatry Department is located within the Children’s General Hospital for more than forty years. When it comes to services for children and adolescents it is common to include parents both at the assessment and at the therapy phase of treatment. Within the child psychiatry field, it is common knowledge that excluding the parental subsystem from treatment will turn the child’s/adolescent’s individual therapy ineffective.
The Family Therapy Service offered two innovations in the Child-Psychiatry Department; the first was that it included the entire family system, including siblings in addition to parents and the identified patient, and sometimes even grandparents; the second was that it offered a reflective and training function from within the therapeutic system.
The therapeutic system is considered to be suitable for containing the family system at a time of crisis and especially for tackling the complexity of interactions and dynamics. Pomini & Tomaras (2015) describe how the sum of multiple attachments offers a more complex therapeutic space for the family members’ emotional relationships, both verbal and non-verbal, to take place.
The value of co-therapy
As far as co-therapy is concerned, it was first applied by Whittaker in 1944 (Ast et al., 2019). Co-therapy is considered a natural element of a systemic family therapy approach that has an experiential perspective, and it can bring along learning, explorations and change when used as yet another subsystem of the wider therapeutic system (Barnard & Miller, 1987). Amongst other things, the co-therapy dyad can act as mirroring the parental functioning, as a role model of a co-operative dyad and a useful tool for maintaining more than one points of view for the family dynamics (Berkman & Berkman, 1984; Barnard & Miller, 1987).
From a dialogical collaborative perspective, co-therapy is not about trust in the words of the co-therapist but about developing trust in the process. It is trust in the process that can be used for different understandings of the world in an open-minded atmosphere that enhances collaborative dialogue (Ast et al., 2019). Roller & Nelson (1991) mention skills complementarity, training adhesion, openness in communication, equality in participation, and respect as a few contributing factors in co-therapy efficacy. Certainly, therapists’ willingness to accept a context of collaboration, difference and reflection within their relationship is a prerequisite.
Berkman & Berkman (1984) refer to Napier & Whitaker’s concept that co-therapy is like a «marriage» that requires commitment and a contract. Napier & Whitaker also warn co-therapists about the dangers of functioning as an individual rather than as a unit. Berkman and Berkman (1984) claim that there are three different potential sources of problems in co-therapy: a) the realistic perceptions, emotions and interactions among co-therapists, b) the «transferences» from one therapist to the other and c) the “counter-transferences” that arise from the family dynamics. The therapist’s self-reflection on his polyphonic self (Rober, 2005) as well as a supervisory relationship that favours the group reflective processes (Burck, 2018) may facilitate the therapeutic processes and help the co-therapists face these issues.
The meaning of the one-way mirror and the reflecting team
During the First Cybernetics era, the one-way mirror offered the potential for training and family therapy simultaneously. The family therapist received feedback from the reflecting team during a break, and the reflecting team members could at the same train time in family therapy sessions. The principle of a therapeutic system that could contain the family dynamics was already there.
However, the communication of the reflecting team members with the family was one-way. Through the therapist, the reflecting team members could formulate questions and transfer a message to the family that could act as a therapeutic gear for change. The members of the reflecting team could mirror invisible family dynamics, often via metaphors and sometimes via therapeutic tasks (Minuchin, 1974; Selvini-Palazzoli et al., 1980).
The dialogues between the reflecting team and the family therapist were taking place behind closed doors, without family members having access to either the dialogues or the reflecting team members. The family therapist was making circular questions, maintaining neutrality and formulating hypotheses with curiosity (Checchin, 1987).
Within the scientific evolution of the Second Cybernetics, Andersen (1987) transformed the function of the one-way mirror into two-way, by introducing a new technology of viewing and listening. The family members could now have access to the reflecting team members behind the one-way screen and could listen to their dialogues concerning the family dynamics. With this new technology of visibility, that inverted the viewing potential, a co-evolving therapeutic system was formed as well as a process of “fermentation”, with a succession of dialogues during which the participants alternate between being the “speaker” and being the “listener” (Andersen, 1992).
At the same time, Pomini & Tomaras (2015) have pointed out that more therapists in the reflecting team can better endure the emotional interactions and the mental pain expressed among the family members as well as offer a supportive context to the co-therapists. The therapist may use the alternation of position from the centre (dialogue with the family) to the periphery (dialogue with the reflecting team) aiming at continuing the dialogue with circularity, without judgement and interpretations (Andersen, 1992).
According to Andersen (1987), the more diverse the reflecting team participants are the richer and wider the understanding of the family’s cultural and social context and meanings becomes. He also underlined that the reflecting team members need to remain positive, discrete, respectful, sensitive, imaginative and free to be creative. However, Burck (2018) highlights that acknowledging the value of the reflecting team’s differences is not enough; the presence of someone that is able to connect the different points of view in a helpful manner, is also necessary, especially at times of polarity.
Additionally, Pomini & Tomaras (2015) point out that the diversity of participants widens the choices for developing a more personal therapeutic relationship and may strengthen the family’s commitment with the therapeutic context. Families embrace the reflecting team function, mostly finding it positive, supportive and an invaluable source of multiple perspectives (Chang, 2010).
EVOLUTIONARY PHASES: DEVELOPMENT AND ENTROPY
I could describe the trajectory of the Specialist Service for Families in its fifteen years course, making an effort for an experiential evaluation and reflecting a posteriori, as follows:
THE FIRST PHASE
During the first phase (2008-2016), the Specialist Service for Families was an innovation within a Child-Psychiatry Department with a very long psychoanalytic tradition, and it drew to it systemic family therapists from various training fields. The therapeutic team made use of theoretical concepts, principles and techniques stemming from both the first and second cybernetics zones. Flaskas (2012) has discussed how utilising the bridge of reflexivity one may use principles from both the first cybernetics (triangles, coalitions) and the second cybernetics (being dialogical and collaborative) as well as other scientific theories (attachment theory).
Maybe the most difficult dimension in the functioning of the Service over the first phase was co-therapy, since the members of the therapeutic team met only once per week for three hours and they were «on-loan» from various other Units of the Department. Co-therapy is based on a higher level of intimacy, trust and co-ordination between the two therapists.
One of the basic criteria for accepting a referral was that the child/adolescent presented a mental health issue. We required a stable therapeutic relationship with a child-psychiatrist or child-psychotherapist in parallel to family therapy. We followed the principle of multiple approaches and multi-level addressing of mental health needs of the child/adolescent and their family.
Moreover, it is worth noting that in many cases there was very close collaboration between the Specialist Service for Psychoanalytic Psychotherapy for Children and Adolescents and the Specialist Services for Family Therapy of the Child-Psychiatry Department. The idea was to join forces and address as many therapeutic needs as possible.
Within the first phase, the Stavros Niarchos Foundation funded two family projects concerning mental health. The first one was for families with a child suffering from cystic fibrosis (with fourteen families participating) and the second one was multi-family therapy for adolescents with eating disorders (with nine families participating)[2].
During the first phase of the Service, the therapeutic team members shared a great enthusiasm and disregarded of all the difficulties that such an endevour entailed. Charalabaki (2017) has discussed that one needs to be unsuspecting in order to become a psychotherapist within the Public Sector, but one cannot escape an oscillation between the emotional position of a «special assignment» and the emotional position of «deep disrepute». However difficult, a stable in vivo supervision[3] helped the Service establish a stable therapeutic and reflective functioning. In addition, supervision contributed towards a sense of coherence amongst team members, despite the different training background and the different professional fields outside the Service.
THE SECOND PHASE
During its second phase between 2016 and 2020, the Service for Families was transferred to a building away from the Hospital, within the community, and operated on a daily basis for three families at a time, and a reflecting team of trained and trainee family therapists. We designed review and reflection group meetings every six months. Furthermore, we launched in-group training for special issues like the complexity of co-therapy and family therapy for families with an addicted member. We started using an internal email for more systematic and coherent communication among the therapeutic team members.
We ensured our participation in the Child-Department’s weekly scientific meetings and discussed the systemic family therapy experience in the Auditorium (Lecture Theatre). We aimed at participating in real inter-disciplinary dialogues, sometimes in rather heated dialogues, with different therapeutic approaches, and also at creating a space for systemic family therapy inside the Department - something that has not been considered self-explanatory over the previous years.
During the second phase, we collaborated for three years with the training programme in Family Counselling of the Greek University Institute for Mental Health[4] and hosted trainee family counsellors. Some of the therapeutic team members regularly attended conferences in child psychiatry and systemic family therapy both in Greece and Europe.
During this phase, the therapeutic and training work was fertile. We faced obstacles - often with the therapeutic system not even possessing the appropriate sound system tools[5], with patience, inventiveness and stoicism.
THE THIRD –PRESENT-PHASE
In its third phase, from 2020 until today, the Service for Families is in recession, since the therapeutic team found it hard to make a transition to the post-covid era. During the pandemic, it was impossible to function with many people in the same room and with an in-vivo reflecting team. Part of the difficulty concerned the real danger of meeting together in a small space, and another part was connected to the fears that emerged during that time in all human systems when getting together with others. The Service for Families did not have the technical equipment at the time to support online family therapy sessions.
Moreover, in the present phase the Child-Psychiatry Department is understaffed, an internal crisis that creates yet another obstacle in borrowing therapists from other Units in order to function as a Service. Last, but not least, when being community based, it is hard to get therapists that are Hospital based on-loan.
Presently, systemic family therapy is offered within three different Units of the Department: a) the Unit for Eating Disorders for adolescents with eating disorders, b) the Inpatient Unit, especially for adolescents with suicidality, borderline elements, eating disorders and gender dysphoria and c) the Service for Pervasive Developmental Disorders, for children and adolescents within the autistic spectrum. During this phase, the challenge for the family therapist is to manage to create a dialogue with the family maintaining both a strong therapeutic alliance, and autonomy from the dialogues within the inter-disciplinary team of each Unit (Rivett et al., 1997).
Training in systemic family therapy elements is taking place with co-therapy wherever possible for the Department’s registrars and trainee clinical psychologists, without necessarily the use of a one-way mirror and the reflecting team. The absence of a one-way mirror and of the reflecting team does not equal abolishing a systemic way of thinking. For as long as the therapist can maintain contact with his inner dialogue and his polyphonic self (Rober, 2005) from within a therapeutic position of Not-Knowing (Anderson & Goolishian, 1992) and in the context of dialogue with the wider system, the therapist can be systemic enough in family therapy.
The current crisis could have a double meaning: it could either mean the pathological breakdown of a previous balance, or it may mirror the painful enactment of a need for a more mature balance (Onnis, 1990). One needs to reflect upon the factors that made it difficult for the Service for Families to maintain its functioning within the previous phase, and the requirements for reaching a new vital functioning balance in the future.
PERSPECTIVES FOR A NEW PHASE
One of the dimensions that may need better looking after in the future, for a better way of functioning of the Service for Families, is that of the group processes[6]. Even with the focus rightfully remaining on the therapeutic work with families, the therapeutic and reflecting team members need to also remain open to the exploration of the group dynamics (Clarke & Rowan, 2009). These authors suggest that looking after the group processes is beneficial both for the therapeutic work as well as the group relations and it is a challenge.
Post-modern theories have emphasized «collaboration» amongst the therapeutic team members, downplaying, however, the importance of hierarchy and power relationships among its members (Clarke & Rowan, 2009). The question comes up of whether the members of a team operating within a hierarchical institution can maturely reflect upon their own group processes without the support of an external supervisor.
Whilst trying to review her training and supervisory role, Burck (2018) observes that one of the most demanding needs of an in vivo supervision group is the need to act in the here-and-now. This sense of emergency makes the team members’ interactions far more intense, and thus different scientific perspectives are rendered more difficult to handle. Moreover, she indicated that a sense of belonging within a therapeutic and reflecting team requires a sense of connectedness. Ultimately, Burck (2018) points out that connectedness is shaped when team members have a strong desire to be part of the group, as well as an interest to help build the group’s structure, finding correlations between the individual narratives and the narratives of the group. Otherwise, it is not a group but rather a loose gathering of people.
An external supervisor may enhance the sense of connectedness among the members of a reflecting team and may function in an integrative way, accommodating different points of view that arise during therapeutic work with families. There is a danger, of course, of idealising the supervisor, as someone that can manage to strike a balance in maintaining both the group’s coherence and the group’s scientific differences (Clarke & Rowan, 2009). Judging from experience, the years of continuous in-vivo supervision were positive for the scientific containment of both the family work and the group dynamics.
As far as group dynamics are concerned, Bateson, already in 1973, in his book Steps to an Ecology of Mind had underlined the unconscious processes that rule human systems, stating: “no living system can function consciously for issues that can be resolved at an unconscious level” (p. 152). Within the same decade, Bion (in Pines, 1987) underlined that the therapeutic work finds obstacles when unconscious needs, desires and conflicts amongst family members remain unprocessed. It then becomes impossible for the group members to learn from experience in the «here-and-now».
Reflection
Very important questions emerge for the way a Service for Families may function. Could it be thought of as a luxury in the context of a public hospital? Is it about the private madness of only a few select staff members? Does it offer a scientific update in the child psychiatry field? Is family therapy in the context of a therapeutic system (one-way mirror and reflecting team) more effective that simple parental counselling that does not require such investment of time and human resources?
The functioning of a therapeutic system with the aforementioned mentioned design within the public sector requires stable personal commitment, constant emotional availability and a large amount of energy investment to materialise. Is there a space for therapy with the preconditions described above within a Greek public hospital? Which staff members have the desire (and the courage) for emotional availability at such a level?
Family therapy with preconditions of a therapeutic system requires passion in order to flourish. Passion is defined on the hand as great love, energy, and decisiveness for accomplishing a desire/aim, and on the other hand may refer to a misfortune, with physical and mental suffering (Wiktionary).
It is worth pointing out that in order for structural change and continuity to take place, the members of the therapeutic team need to change the way they used to participate in the old formulation of the Service for Families, much like within the Second Cybernetics era, the therapist needs to make use of the effects of his own interactions with the therapeutic system in order to change the way he participates (Keeney & Keeney, 2012) and bring about change. Sakkas (1994) has described that a unified training and therapeutic system needs to be a springboard for emotional change within its members. In the same way that we learn to change our emotional position within the therapeutic system as therapists (Bertrando & Arcelloni, 2014), we need to dare an emotional re-positioning in a new phase of the Service for Families.
From the point of view of an evolutionary process and according to Prigogine’s theory (Onnis, 1990), a crisis - even during pain and uncertainty - may lead to bifurcation that means at least two new possibilities, unknown at the time of crisis. This process confirms the system’s ability for self-organisation. The route that this bifurcation will take depends on three factors: a) the system’s elements that will encounter the external environment in a random way, b) the general governing rules of the system, and c) the very special/unique characteristics of each member of the system. Thus, in the evolutionary perspective of the Service for Families, the general rules of the wider context (National Health System and Medical School of Athens), the unique elements of the therapeutic teams’ members. as well as the way they meet together. will be at interplay.
Can there be self-organization and change within a hierarchical institution with strong homeostatic mechanisms? Some Family Services achieve it. According to Maturana (1999) the organization of a system needs to remain stable but its structure need to be flexible. Which elements do we need to retain from the old organisation in the new structural scheme in order to achieve change?
Furthermore, as per the developmental psychoanalytic perspective and attachment theory, the basic foundation for self-organization is reflecting functioning[7] (Fonagy & Target, 1997). Reflective functioning is about understanding the apparent and non-apparent mental states of the self and others as well as their intentions (Fonagy et al., 1991). This capacity is built over time through the interaction with an emotionally available and accessible caretaker that mirrors to the baby its own mental state. As a consequence, the baby can internalise the capacity to reflect, and organises an autonomous self (Fonagy & Target, 1997).
One can easily think that external supervision may function in the role of the caretaker that can cultivate, over time, the reflective capacity of the team members. Then, they can self-organise. According to Winnicott (1956) via holding, the mother safeguards the baby’s sense of being alive and existing in a continuity-of-being, which is what eventually leads the baby to self-integration.
From the point of view of attachment, according to Byng-Hall (208), the family members experience emotional safety when they demonstrate increased emotional awareness. The term emotional awareness refers to «the capacity to show sensitivity to how each family member may experience the situation at steak and the expectations that each one has about the role of the others, as well as being informed about how his own emotions and how his immediate behaviour may affect others» (Byng-Hall, 2008, p. 135).
Interactional awareness is based upon family members’ empathy and reflective capacity. It is impossible to try and increase the family members’ interactional awareness without taking care of increasing the therapeutic team members’ interactional awareness.
Whilst going through transformation, it seems that interactional awareness processes are necessary in order to safely offer family therapy. The Round Table of HESTAFTA in the context of the 13th Panhellenic Child-Psychiatry Conference has been an opportunity for scientific refuelling, networking and a sense of encouragement.
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[1] This design followed the model of Service for Couple and Family that was established by V. Tomaras and V. Pomini in 1988 within the First Psychiatric Department of Athens Medical School in Aeginiteio Hospital.
[2] V. Tomaras acted as the Supervisor for both family therapy projects
[3] V. Tomaras kept coming for seven years for in-vivo supervision of the Service for Families, with no financial compensation.
[4] The Head Trainers for this programme are R. Gournellis, Professor of Psychiatry, 2nd Psychiatric Department of Athens Medical School in Aiginiteio and Attikon Hospitals, and V. Pomini, Clinical Psychologist and Systemic Psychotherapist.
[5] During a period that the sound system malfunctioned and could not be repaired, we used a baby monitor instead.
[6] This dimension emerged through my supervision meetings with D. Sakkas, Psychiatrist-Couple, Family and Group Therapist, Director of the Athenian Institute of Anthropos.
[7] Maturana had also underlined the value of reflective capacity in the field of biology.
