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Systemic Therapy with Individuals

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Until recently systemic therapy has been identified with family therapy. This no longer applies; the systemic approach and its techniques can now be used with profit in therapy with individuals. This book introduces and describes the first adaptation of the systemic model in the individual context.Boscoli and Bertrando describe the work they are doing with individual clients in Milan. Locating themselves clearly within the tradition of the Milan approach and more recent social constructionist and narrative influences, and articulating continually a broad systemic framework emphasizing meaning problems in context and relationship, they introduce a range of ideas taken from psychoanalysis, strategic therapy, Gestalt therapy and narrative work. They describe the therapy as Brief/Long-term therapy and introduce new interviewing techniques, such as connecting the past, present and future in a way that releases clients and helps them construct new narratives for the future; inviting the patient to speak to the therapist as an absent family member; and working with the client to monitor their own therapy.The book is written with a freshness that suggests Boscolo and Bertrando are describing "work in progress", and the reader is privy to the authors' own thoughts and reactions as they comment on the process of their therapy cases. This is a demystifying book, for it allows the reader to understand why one particular technique was preferred over another.

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5 Chapters

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1. An evolving theory

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WHAT WE HAVE LEARNED FROM SYSTEMIC FAMILY THERAPY

Our current model of systemic therapy, that which gives us inspiration in our work with individuals, was developed through a series of experiences in research, consultation, and therapy with families and couples. From 1971 to 1975, we used the strategic-systemic approach of the Mental Research Institute (MRI) of Palo Alto. In the following ten years, we worked with the Milan Systemic Approach, based mainly on Bateson’s cybernetic epistemology. After 1985, the model was particularly influenced, first, by constructivism and second-order cybernetics and, later, by constructionism, narra-tivism, and hermeneutics. All of these theoretical contributions inevitably left their mark on our current model, which, for this reason, we would define not only as a systemic model, but also as an epigenetic one (see p. 28, n. 12).

Due to a series of particular and fortunate circumstances that came to pass at the beginning of the 1970s, the senior author had the privilege of working for about ten years in two very different situations under the same roof. The first was that of a psychoanalyst’s private office. In this room, three days a week, he conducted long-term Freudian analyses as well as face-to-face psychodynamic therapies, with sessions once or twice a week and lasting from one to three years. The second was the work environment of the so-called Milan Approach team (Selvini Palazzoli, Boscolo, Cecchin, and Prata). This team did research on and therapy with families and couples in three rooms: the therapy room, in which the members of the family or the couple and the therapist sat; the observation room, separated from the therapy room by a one-way mirror; and the discussion room, where the whole team would confer at the end of each session to formulate a systemic hypothesis and create a possible intervention to communicate to the family (Boscolo et al., 1987).

 

2. Working systemically

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Working systemically

This chapter deals with the methodological, operational (i.e. indications, diagnosis, goals, duration), ethical, and philosophical issues of individual systemic therapy.

INDICATIONS

In the early 1970s, at our Centre (Selvini Palazzoli et al., 1978a), the original Milan team used to draw a clear distinction between family therapy and individual therapy, and chose to do family therapy with all clients referred. There were only a very few exceptions. For example, if during family therapy some family members did not want to continue therapy, the team would eventually decide to go on working with one individual, who usually happened to be the person who had made the request for therapy or, sometimes, the identified patient. Nonetheless, the meetings with the one client alone were still defined as family therapy sessions, in order to avoid transferring the label of “patient” from the family to the individual.

At that time, the indications for individual therapy as such came down to only two. The first was when the client did not want to come with his family and put this condition as the sine qua non for initiating therapy. The second was when the client could not bring his family members or spouse, either because they refused to participate or because they were unable to for organizational, logistic, or financial reasons. Nonetheless, this was an uncommon situation, since our Centre was known as a private institution that specialized in family and couple therapy, and therefore the clients were referred and motivated by other professional to come as a family or as a couple. The clinical context was different for our trainees; at their workplace, they often had to make compromises, especially if they worked for public health agencies in which psychotherapy was traditionally done with individual clients rather than families.

 

3. Therapeutic process

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In the present chapter we address all those aspects pertaining to the process of individual systemic therapy. The different principles employed since the 1970s in conducting the session (hypothesis, circularity, and circular questions) are fully dealt with first. We then turn our attention to the stages of therapy (from the initial evaluation to the final session) and conclude by discussing in depth the recent, stimulating contributions concerning some linguistic aspects (semantic, rhetorical, and hermeneutic) of therapeutic dialogue.

DIALOGUE

As indicated in Chapter 1, the development in the past few years of narrative and social constructivism has witnessed the increasingly widespread use of the term “conversation” to define the complex of linguistic exchanges between therapist and client. Most of the authors who identify themselves with these ideas attribute the effects of therapy to the conversation itself, with no special reference to the therapist’s hypotheses, typology, or theories. We have already expressed our interest and appreciation for these ideas—but also our criticisms. Hence, we keep to the well-known and experimented term of therapeutic “dialogue”1 and illustrate here some of its aspects.

 

4. Therapy with a predominantly strategic-systemic approach

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TERESA S.: FORTUNE’S TRICKS!

At the beginning of the 1980s, a man telephoned our Centre to make an urgent appointment for his wife, Teresa, who had suffered for two years from every possible phobia. When he was given the appointment, he said that it was impossible for his wife to come to the Centre because of her overwhelming phobias, and that Dr. Boscolo (the doctor whom Teresa’s psychiatrist had recommended) would have to go to their house, which was 20 kilometres from Milan. The secretary finally convinced the man that Dr. Boscolo did not make house calls, and so he agreed to bring his wife to the Centre. On the day of her appointment, the client was brought there by ambulance, because she was afraid to travel in a car without medical supervision! Because of her fear of lifts, she had to be accompanied by her husband and a nurse up the stairs. At the beginning of the session, she seemed extremely apprehensive, almost to the point of having a panic attack. The most evident phobia was agoraphobia, which had kept her prisoner in her home for more than two years, since pharmacological and psychological interventions had had no effect. However, even at home she was full of fear: fear of germs and all sorts of illnesses, as well as fear of her own aggressiveness. For example, she was afraid that she might take a knife and stab her only son. As a precaution, she made him move in with his maternal aunt and the aunt’s husband, who lived two floors below in the same building.

 

5. Systemic therapy cases

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GIULIANA T: LIFE AS CONTROL

Here we present, practically in its entirety, the first of nineteen therapy sessions that this client attended at our Centre. Giuliana was a tall, slender, and pretty 26-year-old woman. She worked as a translator in the public relations department of a company. She had been sent to the Centre by a doctor who had diagnosed her as having chronic anorexia-bulimia. She came to the first session wearing a close-fitting dress that accentuated her curves, and during the session she moved with a vaguely seductive demeanour. After the formal introductions, she began to describe her symptoms.

GIULIANA: I’ve suffered from bulimia for many years. The first time I had it—it was a particularly nasty form of anorexia-bulimia—was when I was sixteen. It ran its course in about a year. Then I had the problem again when I was eighteen or nineteen. That time it lasted for a number of months. It always began with a diet, a very strict, low-calorie diet, of course. Afterwards, when I had lost a fair amount of weight, I began to have hunger attacks, actual bulimic attacks, and I vomited. And also this time the bulimia went away by itself. Finally, when I was twenty-three, it arose again, and I’ve had it from that time on. It began with anorexia. I went very quickly from my usual 52 to 54 kilos to 44 or 45 …

 

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