Presentation by:
Katerina Theodoraki, Child Psychiatrist
Rozalia Giannaki, Child Psychiatrist
This is a voluminous book from EFTA’s book series. In the present book review, we will make an introduction/overview of the purpose of this publication, through the reasoning of its editors (in the 1st chapter), and we will then concentrate on reviewing the chapters authored by Greek systemic therapists.
In their introductory remarks in the 1st chapter, the three editors refer to their concern regarding the authoring and creation of manuals in general, their history, their usefulness, their contents, and the topics that they discuss.
There is a wide range of opinions concerning therapeutic manuals in our field, that ranges from them being welcome with enthusiasm for the opportunities that arise, to a profound conviction that effective systemic therapy is hindered more than it is aided if one follows any kind of manual. This book presents an overview of the present situation concerning manuals in our field, that can be utilised for a variety of purposes, for studies, for work evaluation, and for clinical teaching and training. Furthermore, they may contribute in bridging the gap between research and practice. Good manuals can demonstrate that good science, and good clinical thought and practice can inhabit the same space. The book refers to handbooks that have only been used in the setting of a single clinic, as well as manuals that have a long history of years of use (like for instance the Maudsley group manual).
This EFTA book aims at creating a flexible and novel concept of the form that manuals can take, and at offering a multitude of examples, both from Europe and beyond. One of its goals is to bring attention to the manuals that have been developed in European countries. The editors included 33 chapters in this work.
The evaluation of effectiveness, on a governmental and political level, has always been based on the DSM, which is founded on the concept of the elimination of the symptom, and follows an individual and linear model, i.e. depression has special symptoms. The objective has been to find which intervention would reduce these symptoms with the minimum possible cost. For us systemic therapists – the constructionists, the narrative therapists etc. – who deal with circular causality, it is hard to work towards resolving the symptom, if the symptom is understood as the best way possible for the family to survive in its current cycle of life. We must demonstrate that what resolves symptoms is working on the relationships. Systemic therapy manuals are complex, and cannot be created through specialised approaches, but rather through special indications of specific phases, a process that involves the entire family and the contexts in which it lives. In the 80s and the 90s, we witnessed an explosion of research in our field, regarding systems theory. Many papers were published during that time, which tended to increase mindfulness of systemic practices in mental health. Finding methods to increase research was a way to survive in the field, as was developing qualitative and quantitative methodologies, retrospective studies, and narrative transformation. To this day, even implementing these methodologies remains challenging and full of obstacles. It took us a long time to reach deep within any therapy or therapeutic approach, and see how our profession could offer help and services to the public. While systemic therapy was on top during the previous century, especially in Europe where systemic schools of thought were blooming and psychoanalysis was declining, today (after the year 2000) we have a growth of psychoanalysis and a wider use of cognitive methods.
The lack of research resulted in systemic therapy losing its relevance. We must transcend the dipole of the discussion according to which, on the one hand, we need to do research and write manuals, and on the other, any attempt of specialisation destroys the beauty and value of our work. We must move away from this dipole. A question emerges: Why isn’t the systemic model and family therapy a theory of reference for policymakers, and why don’t they introduce systemic practices in the fields of prevention, treatment and training? An answer to this question is that we still need to produce research that demonstrates the value of exactly what we do in our practice, while finding easily comprehendible a meaningful ways of describing it. In reality, a research review of family therapy papers between the years 2000 and 2009 turned up 225 results in English. That was the Stratton et al. (2015) study. However, only 23 of those met the criteria for Randomised Controlled Trials (RCTs). Therefore, while the vast majority of papers concluded that therapy was effective, the reader had no way of knowing what that therapy was, and what was found to be effective. This lack of clarity in approach jeopardised our capacity to offer the help we can in communities, and the development of our field in general.
We believe that in order to conquer the challenges of researching systemic therapy, and spreading what we do to others, whatis needed is a mixture of basic research and of manuals regarding approaches founded in processes. Deductive “evidence based” studies are based on procedural thinking, and we believe that this leads to an especially limited understanding of the system and the result of any intervention. The need to contemplate on processes as a manner of respecting, comprehending, and learning from the systems that we work with is a prerequisite for this book.
We must understand that we are part of this investigation, and that we must remain humble in our conclusions that are always founded in a context of complexity, uncertainty and coevolution of the systems that we ourselves belong to. We propose that a study should only investigate three or four variables at a time. This allows the investigation of patterns, and of the manner in which the variables reflect the reciprocity within the system in practice. This means that the most important thing in a study is the question you pose. If the question concerns the symptom, i.e. whether the patient has compulsions, at the end of the interview you can make certain whether these exist or not. You are, however, unable to say anything regarding the functioning of the family, or the presence or absence of boundaries between the generations. The fact that the symptom disappears does not tell us anything regarding the functioning of the family, or regarding whether the symptom will reappear (again, there is nothing regarding the processes that preserve the symptom). We can say that the symptom is a procedural aspect of the family process.
Systemic research is a processual one, not a procedural one. If we look at the family processes, three variables are enough to profoundly increase our understanding of the system. This is the peculiarity of the systemic research. The mistake made by policymakers is precisely that; they believe that research, being based on statistical models, represents sciences and certainty. We do not need different methods than those of deductive studies, but we have different lenses and we pose different questions.
We must move towards creating manuals in a systemic manner that will assist us in achieving our goals. This book will guide us in finding the pulse of our systemic practice, by training and researching in order to communicate where we stand, and to comprehend how far we have left to go.
Next, the authors describe an outline of the book: The 1st part refers to issues and experiences that emerge when creating a manual. In the 2nd part, reference is made to research issues that are associated with the use and evaluation of manuals. The 3rd part investigates the use of manuals in clinical practice. Finally, the 4th part discusses issues pertaining to training as a basis for the development of manuals, and a setting for their implementation.
We will refer to the Greek authors that contributed to the book.
In 1997, Valeria Pomini and Vlassis Tomaras were invited by professor G. Tsiantis to participate in a European international research programme (double blind study), regarding the evaluation of psychotherapy for depression in children. Professors Tsiantis and Kolvin were the group coordinators. The authors of the paper were in charge of organising the team of family therapists. They concurred with therapists from other countries that it was an opportunity to assess the effectiveness of the psychotherapeutic approach on childhood depression, and to utilise the research as a process that could create more connections between the participating services. Thus, a network of family therapists that studied childhood depression was created. There were two themes that contributed to the development of a common ground between the different therapeutic approaches. 1) The importance of child-parent attachment and intergenerational patterns. 2) The crucial role of the therapeutic relationship and alliance that was measured with a scale that was competed by all therapists. For the two groups, the psychodynamic and the systemic, another crucial idea was the utilisation of two manuals that described the entire psychotherapeutic process. In the late 90s the discussion regarding the role and the function of manuals had not yet developed. On the one hand, everybody was aware of the need for a manual that would offer therapists that were working in different countries and had differences among them common guidelines, so that the results would be reliable and comparable. On the other hand, the therapists and supervisors were afraid of the limitations that could be imposed on the uniqueness of the therapeutic process by manual-guided therapy. The use of a manual seemed like heresy to therapists of all approaches. The utilisation of a manual requires many skills on the part of the therapists; they must observe what they are doing with the families precisely. The manual must serve as a map that will allow therapists the freedom to use their own style, and to adapt therapy to the specific therapeutic conditions. In the paper in question, the authors of the manual, David Camper and Renos Papadopoulos – who were also supervisors – encouraged the therapists to engage in a critical discussion regarding the manual, and remained open in regards to changing it so that it applied to the practice concerning different situations, during the study. Thus, practice could be incorporated into research, and research could be incorporated into practice. This implied a dynamic and circular process of connecting the theoretical and therapeutic mechanisms of change that are observed in clinical practice. Adherence to the manual was assessed by both therapists and supervisors. All sessions were videotaped, and their material is available. Thus, it is useful to investigate differences in approach and technique between countries. The supervisors were tasked with fitting everything on the “Procrustean bed”, and had to avoid diversions from the manual guidelines. All matters were discussed between the therapists and the supervisors. As a result, the authors of the paper conclude that this manual, SIFT, offers an effective therapy model for children with depression and their families that could also be used for other childhood psychological problems. The SIFT was adopted for the purposes of training in family therapy.
In his paper, Nikos Paritsis, discusses Human Systems Therapy (HTS) as a manual of sorts that uses principles of systems theory, the theory of the unconscious, the 1st and 2nd cybernetics, as well as other techniques from other schools of psychotherapy. In this paper, this therapy is discussed in detail, and the conclusion is reached that more research is necessary for its usefulness to be proven. The author mentions that this is a short method, and analyses potential reasons that may contribute to its effectiveness. The method has been utilised for a number diagnoses, from psychosis to substance abuse. The paper describes the method in specific steps that must be taken in a specific order.
In chapter 23, Virginia Ioannidou and Christina Lagogianni present a basic model of couples crisis therapy that they also propose as a manual for couples therapy. Initially, they focus on the description of their work with couples that usually seek a therapeutic session during a crisis, like for instance during a transitional period, when the development and evolution of the couple is required. On their therapeutic path, the members of the couple initially negotiate the sense of security, then they develop curiosity regarding both their relationship with the therapist and between themselves, and finally, they express the willingness to change.
As therapy progresses, the therapist intervenes in regulating the tension in the communication of the members, he reinforces the cultivation of mutual emotional regulation, he highlights and comprehends their experience, and he then contains it in their therapeutic relationship. Ultimately, the therapists, through their own resonance with the experience of the members of the couple, invite them to explore new perspectives.
By analysing the basic model of understanding the crisis between a couple, the authors focus on working with dysfunctional communication patterns that hinder the couple’s smooth transition, on the unprocessed issues that pertain to the history of the couple’s emotional life or that of its members personally, and on the absence of common plans or even individual expectations. Special emphasis is placed on the organisation of aspects of adult life, and on the transition to a next phase of the cycle of life.
Finally, they describe the developmental course of the relationship of the couple in five phases (those of enmeshment, resistance, differentiation, reconciliation, and reconnection in a more mature manner).
In conclusion, this is a useful manual that presents the basic principles of couples therapy, with the goal of organising the multitude of information of the initial phase of therapy, of providing guidance in processing complex issues and in ending therapy, and of evaluating the cooperation alongside the couple.
In chapter 30, the three authors, K. Charalabaki, K. Thanopoulou and A. Kati, present a family therapy training programme that is organised in the Greek public sector, as well as the layout - in a form of a manual - of the experiential learning process through the personal and professional evolution of the participants.
First, the theoretical framework of the family therapy training programme is presented. This is founded in the principles of the organisation of living human systems. Namely self-organization (rejection of the commercialisation of mental care and mental health training, maintaining common principles in cooperation), self-correction (a combination of theory and personal experience and growth), and goal orientation (introduction of systemic principles and practice in public services of community psychiatry).
The development of the compound model of systemic experience includes the theory, as well as the experience in the systemic approach of family therapy, training through watching family therapy sessions through a one-way mirror or on DVD, the construction of the genogram of each member of the trainee group, and supervision of clinical cases that the trainees encounter at their own workplace.
The trainee group is characterised as non-therapeutic, and rather functions as a safe transitional space for the processing of the experiential learning for the trainees and for its reflections on the group members. The continuation of supervision and individual therapy is of utmost importance for the formation of the therapist. The trainees should be aware of the manner in which they relate to others, the manner in which they relate to their internal world and should be able to reflect on themselves. I consider their study as useful and beneficial, as they have discovered many points that could comprise the guidelines for the organisation and functioning of other systemic training programmes as well.
In chapter 31, authors A. Androutsou, T. Bafiti, and G. Kallaritis present the development of a therapeutic plan into a manual of an enriched model of systemic therapy entitled “From mind to culture”.
They initially refer to their theoretical positions concerning the benefits of multiplicity and of the usefulness of the combination of the four approaches.
The enriched model of systemic therapy includes the theory of attachment, basic principles of narrative psychotherapy, and findings from interpersonal neurobiology.
Next, the authors discuss clinical cases, they propose guiding questions that lead to the trainees’ personal development, and finally, they focus on the role of the therapist. Trainees follow personal long-term therapy as a part of their training (a combination of individual, family, and group sessions).
In the intervention plan manual, every therapeutic approach guides clinical attention to a different aspect of the therapeutic process.
The enriched model of systemic therapy can be implemented in individual, couples, family or group therapy, whether it be short-term or long-term, for the treatment of a variety of symptoms or problems.
We view the incorporation of three other therapeutic approaches into systemic therapy as pioneering, and as an attempt to demonstrate and respond to the complexity of macro-micro-systems, in which modern man is contained and interacts.
In conclusion, this book poses several considerations regarding the relationship of research and therapy, and the manner in which the one affects the other, and how they both co-evolve in a dynamic fashion. We would say that, initially, I too viewed it with scepticism, but then ended up with a much better idea of how useful research is for our work. Maybe the question that every therapist asks himself when leaving the consulting room “what have I just done?” is a macro-research integrated into therapy.
