The Functional Dialectic System Approach to Therapy for Individuals, Couples, and Families

THE FUNCTIONAL DIALECTIC SYSTEM APPROACH TO THERAPY FOR INDIVIDUALS, COUPLES, AND FAMILIES

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THE FUNCTIONAL DIALECTIC SYSTEM APPROACH TO THERAPY FOR INDIVIDUALS, COUPLES, AND FAMILIES

MOSHE ALMAGOR

University of Minnesota Press MINNEAPOLIS · LONDON

AAMFT Code of Ethics copyright 2001 by American Association for Marriage and Family Therapy. Reproduced with permission of American Association for Marriage and Family Therapy in the format Tradebook via Copyright Clearance Center. Copyright 2011 by the Regents of the University of Minnesota All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Published by the University of Minnesota Press 111 Third Avenue South, Suite 290 Minneapolis, MN 55401-2520 http://www.upress.umn.edu Library of Congress Cataloging-in-Publication Data Almagor, Moshe. The functional dialectic system approach to therapy for individuals, couples, and families / Moshe Almagor. p. cm. Includes bibliographical references and indexes. ISBN 978-0-8166-6955-4 (hc : alk. paper) 1. Psychotherapy. 2. Couples therapy. 3. Family psychotherapy   I. Title. [DNLM: 1. Psychotherapy—methods. 2. Family Relations. 3. Family Therapy—methods. 4. Professional–Patient Relations. 5. Systems Theory.  WM 420] RC480.5A455 2011 616.89'14—dc23 2011017084 Printed in the United States of America on acid-free paper The University of Minnesota is an equal-opportunity educator and employer. 18 17 16 15 14 13 12 11

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This book is dedicated to my late wife, Nili Gur, who surrendered to cancer on May 24, 2007. Nili’s contribution was invaluable to me. Her incisive, critical, and illuminating comments helped to shape my views immeasurably. I am eternally indebted to a loving wife, friend, and colleague. What more can a person ask for?

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Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii The Kybalion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi Part I. The System 1. System: Nature, Role, Structure, and Communication . . . . . . . . . 3 What Is the System? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 The Goal of the System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 The Individual and the System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 How Is the System Structured? . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 2. Dialectics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Dialectics as a Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Dialectics and the System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Dialectics and Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Cotherapists’ Dialectic Dialogue . . . . . . . . . . . . . . . . . . . . . . . . . 36 3. How the System Protects and Preserves Itself. . . . . . . . . . . . . . . . 37 Contract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Triangles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Emotional Distance Regulatory Mechanisms . . . . . . . . . . . . . . . 43 The Symptom. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 4. System Development and Life Cycle . . . . . . . . . . . . . . . . . . . . . . . 51 Stages in Life Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 5. How the System Changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 First- and Second-Order Change . . . . . . . . . . . . . . . . . . . . . . . . . 69 Reframing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Externalization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Part II. The Intake 6. Joining and Establishing Therapeutic Alliance . . . . . . . . . . . . . . 77 Joining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Exploration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Definition of the Focus Problem for Therapy . . . . . . . . . . . . . . . 89 Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 The Contract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Part III. Treatment Structure: The Envelope 7. The Envelope: Joining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 A New System Is Formed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Maintaining, Sustaining, and Fostering Joining . . . . . . . . . . . . 105 The Client Often Differs from the Therapist in Important Characteristics. . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Empowerment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 8. Disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Self-Disclosure: Client. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Self-Disclosure: Therapist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 9. Resistance: Impeding and Facilitating Therapy . . . . . . . . . . . . . 125 Resistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Power Struggles in Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Anger in Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 When Therapy Is Stuck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 How to Unstick Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Part IV. Treatment Process: The Dialectics of Therapy 10. Functional Dialectic System View of Symptom and Psychopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 The Artist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 The Water Bottle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 The Gas Mask . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Depression by Proxy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 The Mask of Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Part V. Selected Treatment Issues 11. Infidelity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Prevalence of Infidelity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Types of Infidelity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

How Does the System Protect Itself against Infidelity? . . . . . . . 181 The Function of Infidelity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Extramarital Affairs May Have a Positive Effect on a Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Therapy: Structure (Ground Rules) . . . . . . . . . . . . . . . . . . . . . . 186 Therapy: Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 12. Adolescent Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Functional Dialectic System View of Suicide. . . . . . . . . . . . . . . 201 Therapy: Structure and Process . . . . . . . . . . . . . . . . . . . . . . . . . 203 13. Enrichment and Facilitation of Therapy. . . . . . . . . . . . . . . . . . 217 The Dialectic Dialogue: Exercises . . . . . . . . . . . . . . . . . . . . . . . 219 Facilitating Dialectics: Family Sculpting . . . . . . . . . . . . . . . . . . 226 Part VI. Termination and Follow-Up 14. Ending Therapy and Follow-Up . . . . . . . . . . . . . . . . . . . . . . . . . 233 When Does Therapy End? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 How Does Therapy End? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 Follow-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 Saying Goodbye. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 Closing Comment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 Appendix: The American Association for Marriage and Family Therapy Code of Ethics . . . . . . . . . . . . . . . . 247 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293 Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301

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PREFACE

Therapy rests on two pillars: relationship and change. This book emphasizes the former and helps broaden the clinician’s views in facilitating the latter. Being a family therapist is not only a professional affiliation but also a state of mind and way of life. For me, it is the culmination of a long journey that began in the early 1970s. At that time I served in the army and, in the course of a military operation, was severely injured. I was hospitalized for several months, lost a limb, and sustained a severe hearing loss and other wounds. I was declared clinically dead twice and suffered enormous pain for quite a long time. I came out of this experience with a strong wish to live and to get on with my life. As a disabled veteran I had a lot of benefits, which I used to further my career and life. I entered the University of Tel-Aviv, and because I was not sure what I wanted to study, I took a double major in psychology and anthropology and sociology. I went to graduate school and earned an MA in rehabilitation psychology from Bar-Ilan University. The university had a strong psychoanalytic orientation at that time, so students were encouraged to engage in psychoanalytic psychotherapy. Consequently, I found myself lying on a rugged sofa in my analyst’s office. I had been there for more than two years trying to figure out my life. I was a good client. I was there on time, mostly, for the four one-hour sessions each week and was cooperative in the working-through process. By the end of therapy I concluded that my life was indeed miserable. Unfortunately, this view of life did not change after the termination of therapy. However, my view of psychoanalysis came to combine a sense of personal failure with a strong xi

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psychodynamic understanding of behavior that is still rooted in me. My clinical experience as a rehabilitation psychologist did not make it better. I found that my own adjustment to my disability and my psychodynamic understanding of the client were not really helpful (or maybe I was not really ready to deal with this issue). Resentful and frustrated, I took steps to become a Rogerian therapist. It took me just a short time to realize that a passive, nondirective type of therapy did not suit my active and directive nature. Further search and exploration led me to behavior therapy. I found it interesting and challenging. Working in a psychoanalytically oriented clinic, I had nobody to supervise me; I had to learn how to do it on my own. Using a wonderful book (Rimm and Masters 1979) and my wife as a subject, I practiced the technique and then tried it on my clients. Amazingly, it worked! I will never forget the client who suffered from insomnia and, after a short-term intervention, was able to sleep soundly and overcome other difficulties she was experiencing. Working in this setting, I had no one with whom to share my enthusiasm, and I felt isolated and lonely. I also felt confused. The psychodynamic beliefs regarding long and arduous working-through, analysis of transference and resistance, and the focus on the past as a source of conflicts were not in accord with the success of short-term behavioral interventions. I realized then that something was amiss, but I was not sure what it was. I felt I needed to acquire more knowledge about therapy. So when the opportunity presented itself, I moved to the United States and earned my PhD at the University of Minnesota. This was a totally new experience: a new country, different language, different culture, and a different orientation, cognitive–behavioral therapy. I felt out of place; in a highly cognitively oriented program, my psychoanalytic upbringing showed up very quickly and made me the odd man out in my class. Fortunately, I completed my clerkship and later my internship at Hennepin County Medical Center, where the senior clinical psychologists, Drs. Siegfried Stelmacher, Ada Hegion, Kenneth Hampton, and others, tolerated me as a supervisee. Their open minds and patience helped me sort out my confusion, which reached a very high level. Then, as my own little legend tells, I saw a note on the clinical program board announcing the opening of a two-year program in family therapy.

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Like a truly anxious person who, when things take a turn for the worse, tends to take on more troubles, I decided to apply for this program. These turned out to be the most significant and wonderful years of my professional life. Being acquainted with system theory, I felt like I found the guiding light. The confusion cleared; the contradictions, the theoretical and philosophical incongruity of the various approaches, were finally laid to rest. I found that the system approach could easily host both the psychodynamic and cognitive–behavioral approaches. I became an avid family therapist. The system approach provided me with a general frame of reference where I could easily move from one approach to another as problems and clients required. This flexibility helped me to understand and accept the opportunity of working harmoniously with what I had previously considered competing and incompatible approaches. Upon returning to Israel, I got a job in the clinical psychology program at University of Haifa and in a public outpatient clinic that was, like all the clinics in Israel at that time, strongly psychodynamic. Being a clinical psychologist and a family therapist, I felt as I did in the old days: an outcast from mainstream, psychodynamically oriented psychotherapy. In the clinic I was part of a multidisciplinary team that specialized in children and adolescents. The team consisted of a child psychiatrist, social workers, and clinical psychologists. A routine was developed through which almost every new case was evaluated by the entire team, which allowed the various approaches to be heard respectfully. That was a wonderful period in my career. Working in a public outpatient clinic enabled me to practice and experience different techniques and to work in cotherapy with my colleagues (a daring young psychiatrist and a lovely social worker). The advent of the strategic approach allowed us to experiment with highly effective, miracle-like, paradoxical techniques. Currently I am a senior lecturer at the University of Haifa and served as the clinical psychology program director. I teach system therapy, objective personality testing, forensic psychology, and research methodology. Along with that, I have a rewarding private practice where I do therapy (individual, couple, and family), teaching, supervision, and supervisor training. My life experience has taught me a simple but a very powerful lesson. Everything that happens is for the better. You go through life and accumulate experiences of every kind and quality. Your control over life is limited

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to the point of being illusory. However, the events leave an impression; they make you smile or cry, feel content or angry, pleasant or unpleasant. They happened as a consequence of your or others’ behavior. When you let yourself feel the event deeply, you can choose what to do with it. Keeping in mind that every event may have different and conflicting meanings, you can assign whatever meaning you want to it. Future behavior will obviously depend on that meaning. You can dwell on the misery, or you can figure how to benefit from it. Both choices are present and available. If you choose the latter, you can turn almost anything into an advantageous experience. This view is highly optimistic, but the optimism does not discount the pain and suffering. It only says that you have the choice of using the hurt or injury as leverage for a change for the better. The book represents the amalgamation of my work in therapy, supervision, teaching, and research. The stimulation that emanated from these sources shaped and reinforced my philosophy of life. There are no greater teachers than my clients and students, and this book is the culmination of this journey. The functional dialectic system approach is a present-focused, optimistic approach. It believes that the person is ever changing, ever growing. The person goes through life and suffers difficulties, undergoes crises, and suffers traumas. While respecting the person’s ordeal and its significance in the person’s life, the functional dialectic system approach focuses on the interpersonal, functional, dialectic aspect of the ordeal. The approach is geared toward expanding the person’s view of self. By broadening the view of self and choices, it empowers the person to change his view of life and be able to see the more positive side of it and accept himself. THE PLAN OF THE BOOK

With the lessons I have learned through my life, work, and experience, I would like to take you on a journey. The journey is designed to show the reader the scientific and emotive bases for being optimistic in doing therapy: the theoretical foundations and their clinical application. The structure of the book follows the structure and process of therapy. The book begins with an introduction to basic system concepts that form the foundation for my understanding of behavior. A system is an organization consisting of at least two elements, whose behavior is purposeful

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and goal-oriented. It is formed with the goal of providing its members a sense of security, belonging, and identity. Behavior can be understood and meaningful in the context of a system. Once a system is formed, its existence supersedes the existence of its elements. The system develops techniques to ensure its preservation and the ability to provide for its members. The system consists of a structure and a process. The structure consists of boundaries, roles, hierarchies, emotional distance regulation, and communication. All of these will be elaborated in Part I. The system is a dynamic organization invigorated by a dialectic view of things. The principles of dialectics assert that everything includes its opposite (slave and master, dependence and independence, happiness and sadness), and there is an everlasting conflict between the opposing poles; the conflict creates pressure that leads to a change. Relating to the system from a dialectic point of view makes it a developing entity that experiences phases in a never-ending, ever-changing cycle. Dialectics changes the way we understand symptoms and the way the family functions. The system is a dynamic organization meant to provide its members with a sense of order, security, belongingness, and identity. These are basic needs that every system member’s behavior is intended to protect and preserve. Consequently, all behavior is considered functional with respect to its systemic context. I will describe how the system is structured and how it operates. I will avoid referring to specific schools in family therapy because I believe they all share the same basic philosophy and concepts. My view, in this regard, is integrative and will be presented as such. My goal is to demonstrate how system principles and concepts can be applied at the family, couple, and individual levels. After the theoretical introduction, the book continues with the therapeutic process, beginning with intake, therapy, and its ending (Parts II–VI). The most important goal of the intake session is to establish joining, or a working alliance with the client. This is the cornerstone of therapy. The second goal is to define the problem and contract for therapy. Two different but closely related aspects will be pursued with respect to therapy. The first focuses on the structural, nonspecific aspects of therapy. This includes issues related to the promotion of joining and working alliance (e.g., client diversity, empowerment, self-disclosure) and its dialectic pole,

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resistance (power struggle, anger, being stuck) and techniques that may be useful regardless of the issue or problem that is the focus of therapy. The second focuses on the understanding of symptom and psychopathology from the functional dialectic system (FDS) point of view and a number of illustrative case studies. This is followed by the application of the FDS to frequently encountered issues in therapy (infidelity, adolescence suicide, and enrichment). The underlying approach is that we need to respect the traumatic events and do not attempt to resolve or totally remove them; nevertheless, we can use them to facilitate change and growth. Finally, I discuss the end of therapy and the follow-up sessions. I make a distinction between termination, which indicates something final (e.g., death), and ending therapy, which is associated with the end of a chapter, an end that is a beginning. In FDS, ending therapy has no particular importance aside from a separation that occurs in any significant interpersonal interaction. Ending therapy means that the client is ready to continue the process on her own. Case vignettes are presented where appropriate, to illustrate the relevant issues. These cases were drawn from my practice and are presented with the permission of the people involved, with modifications to safeguard their privacy.

ACKNOWLEDGMENTS Many thanks to professors Auke Tellegen, John R. Graham, Denise BenPorath, and Shimshon R. Rubin and to Dr. Oren Gur for their help in reading and commenting on various parts of the manuscript.

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THE KYBALION The Principle of Vibration Nothing rests; everything moves; everything vibrates. The Principle of Polarity Everything is dual; everything has poles. Everything has its pair of opposites. Like and unlike are the same. Opposites are identical in nature but different in degree. Extremes meet. All truths are but half truths; all paradoxes can be reconciled. The Principle of Rhythm Everything flows, out and in. Everything has its likes. All things rise and fall. The pendulum swing manifests in everything; the measure of the swing to the right is the measure of the swing to the left. Rhythm compensates. The Principle of Cause and Effect Every cause has its effect; every effect has its cause. Everything happens according to law. Change is but a name for law not recognized. There are many lanes of causation, but nothing escapes the law.

Note: On a trip to Guatemala we came to Lago Atitlan and a small village named San Marcos. In that village there was a place called The Pyramid, a spiritual center. At its center was a billboard, and on it was this page. I was not able to trace its source, and the Internet search yielded a Web site that did not include this. The minute I saw it, I knew it was about this book. xix

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INTRODUCTION

Family therapy has gained its rightful place among the major therapeutic approaches as a viable and effective alternative. According to the system approach, the individual is not considered the focus of interest but part of a context, the social context. Glass (1971) phrases it poignantly: “Man is inescapably a social being; he becomes human only through interaction with others and the world he finds himself in. . . . To believe that the individual can achieve fulfillment as an isolated person is sheer folly” (170). For example, when an individual comes for therapy, the system therapist usually inquires about relationships with significant others involved with that person. The client may still be the identified patient (IP), but the focus is on the individual as a part of a relationship network that plays a significant role in all the parties’ lives. The roots of family therapy are grounded in clinical work. This encompasses several approaches and techniques borrowed from common usages (e.g., cognitive–behavioral therapy, psychodynamics, gestalt, social constructivism) or from socially based theories (e.g., social exchange theory). Unfortunately, the adopted theories do not always match the approaches and techniques whose theoretical and philosophical basis they were meant to furnish. We have a number of views of human behavior. Each has accumulated a large body of knowledge and quite effective applications (Lambert and Ogles 2004). The following discussion is a distillation of human processes that are pertinent to the current approach. Frank (1973) argues that the various therapeutic approaches are actually beliefs about human behavior and existence. We need to believe in our xxi

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view of how our behavior, cognition, and affect are organized to provide the distressed, helpless, distraught person, who has lost his way in life, with a way of making sense of his world (Frank 1973). This belief is meant to satisfy one of the most existential and basic needs: order and predictability. The belief in order provides a person with a sense of control and security. These allow her to fend off what she fears most: uncertainty and the unknown. Our lives depend on the existence of order. Our bodily functions are governed by a circadian rhythm. We conduct our daily lives according to rhythmic and constant changes of day and night. Psychologically, this order provides us with a sense of continuity and predictability. This allows us to plan ahead, with the underlying belief that this order will be there forever. As long as we believe in that, we can conduct our lives with a sense of purpose and set goals for ourselves, based on the axiomatic assumption that things will continue to exist in an orderly manner. The need for order entails the possibility of instability. Order means predictability, which is future oriented. Unfortunately, the future is a mystery, filled with surprises, uncertainty, and random events that can change the course of life in just a fraction of a second. Stability and uncertainty are dialectic poles that govern our lives. However, we cannot live with uncertainty, so we design our lives in such way as to produce the impression or illusion of certainty. Later on, when I discuss the structure of the system, we shall see how the system helps build, sustain, and preserve order and continuity. Having set goals and purposes in life, we are able to overcome and compensate for the inaccuracies and deviations from the routine and to develop new ones as the older ones change or become incongruent with our goals. When this belief is no longer apt, we lose our sense of order and continuity, and life becomes chaotic. Chaos creates pressure for order, for restoration of our sense of stability and security. When life becomes chaotic we lose confidence and direction, and this may cause one to want to terminate one’s life or become beset by anxiety and depression. At such times we turn to those we believe have a solution: the priest, the rabbi, or the mental health professional. They are expected to provide the sufferer with hope—hope based on an understanding of her world. When the person is able to make sense of her world, she reinstates order and

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predictability, which will facilitate a search for meaning and purpose in life.1 The diverse therapeutic approaches are based on different beliefs about human behavior. The stronger the therapist’s belief in his particular view of life, the easier it is to sell it to the person who seeks help. So family therapy can be regarded as a belief system that explicates human behavior from a specific point of view. This belief system is established on two basic axioms: a person lives and functions in a social context, and there is a mutual dependency between person and context. The person and the particular context form a system. The elements of the system are intrinsically connected and related, and they share a common goal. The system is an ongoing, time-related process that develops and changes. The system’s goal is to provide its members with a sense of order, security, and belonging. Having these, the system member can develop a clear sense of identity and can organize and direct his life meaningfully. The issue of identity is vital. A person does not live independently of the world around him. A person is an inseparable part of the world. His family, friends, and community are all important factors in developing his unique identity. Most, if not all, of the theories of personality agree that the family serves as a basis for identity development (e.g., Freud, Adler, Erikson, object relations, Rogers’s client-centered, attachment). To be able to satisfy the needs for order, security, belongingness, and identity, the system must be protected. Once a system is formed, the goal becomes its preservation. In fact, the need to preserve the system is so powerful that it overrides the individual’s need to survive. As long as the system survives and appears to serve its members’ needs, the individual will be ready to sacrifice her own well-being for the survival of the system. One may be willing to sacrifice one’s social life, academic achievement, mental and physical health, and—in extreme cases—even one’s life, to sustain the system. We may ask ourselves, what makes the system so powerful? It is based on a time-tested principle: two are better than one. Human beings formed tribes that were instrumental in controlling a harsh and competitive environment. Members of the tribe were able to pool resources to ensure their survival. Belonging to the tribe enabled the person to feel secure, enjoying the tribe’s power.

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The idea of a tribe as a source of security and belonging is applied to state, community, family, firm, and so on. All these institutions are meant to satisfy these basic needs. An important question relates to the issue of system dynamics. The objective of the system is to provide the member with a sense of security, belongingness, and identity. Everything the system member does is functional for achieving these goals, and it is the best the person knows under the circumstances at the particular time. The idea that behavior is functional for attainment of one’s needs for order, security, belonging, and identity is another cornerstone of the functional dialectic system. I believe that our behavior is directed toward achieving these goals. The goal for our behavior is not necessarily apparent at all times. We may not behave the in best way possible or most effectively, but we do the math. Every behavior is the best possible under the circumstances. It is better than the alternatives we consider. We may not know all the alternative behaviors, but we tend to choose the behavior that is more likely to help us meet our needs. This is correct even if the particular behavior is harmful to us or to others. In taking a particular path, we make a choice. A question arises as to what makes the system grow, develop, change, and adjust to changing circumstances. What is the system’s source of energy? The answer I found to be satisfactory on both philosophical and practical grounds is based on a dialectic view of human behavior. The dialectic approach rests on several principles that are applicable to our point of view. The first is the idea that everything includes its opposites (black–white, master–slave, dependence–independence). Second, tension or conflict is inherent between the opposites. Third, the tension drives the given thing toward finding a position between the opposites. This position creates new dialectics. In keeping with these tenets, a conflict is not learned or acquired but is inherent in things (e.g., understanding the concept of a slave requires the concept of a master; understanding happiness means experiencing pain). The existence of a conflict creates tension (e.g., a conflict between dependence and independence). The resolution of the tension requires the person to take a stand between the two poles (“How dependent or independent am I?”). The exact point is the product of the interaction between the person and the situation. However, the new stand is also dialectic and

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leads to an opportunity for another change. Thus, change is also inherent and continuous. Dialectics can be viewed as the source for system dynamics that forces it constantly to change. Joined with the belief that an individual’s behavior is functional for the system, it will be shown how we can use dialectics to further our understanding of system functioning and to facilitate change in therapy. The dialectic view will enable us to seek a new meaning in a person’s behavior that reflects its functional value. This view enables us to look at pathology and the possibility of change from an optimistic perspective. An important and basic belief shared by system therapists is trust in a person’s ability to change. A person’s behavior depends on other members of the system, and it changes as the others’ behavior changes. When the person’s ability to change is impaired the system malfunctions, but as the person gets unstuck the system surges again. This belief is strongly embedded in the system approach and imparts a highly optimistic and positive view of the person. Experience tells us that at times this belief is the only thing that keeps therapy going. In follow-up sessions for couples who came to therapy after their marriage struck a shoal but finally made it to shore, the question I always ask is, “What do you think made the difference in therapy?” A common answer is, “The therapist’s belief in our marriage.” When the therapist loses hope, not much is left for the client. I recall a case in which a couple came for therapy, and after intake I had negative feelings about the prospects for their marriage. After a few sessions the husband left a message on my answering machine that they were not coming for the session because his wife had decided that they had no hope, hence no need for therapy. I accepted that, but fortunately I presented the case in a peer supervision group. The first question I was asked was why I had not contacted them personally. I had no good answer aside from my loss of hope in them; still, I did hurry to call them. They resumed therapy, which proved highly successful. I learned a well-known lesson: “When you give up, the client will also give up.” Therapy is designed to help the client regain hope by satisfying her needs for security, belonging, and identity, which are linked to the system of which

xxvi | INTRODUCTION

the person is a member. Viewing the individual as a part of a system, and the individual’s behavior as related and functional to this system, allows us to use the same principles when we deal with an individual, a couple, or a family in therapy. It enables us to give a new meaning to a symptom in light of its functional dialectic contextual meaning, thereby broadening the person’s perspective of her behavior. Before moving on to chapter 1, it seems appropriate to reflect on the differences between the functional dialectic system and dialectic behavior therapy because the two appear to share similar theoretical constructs. FUNCTIONAL DIALECTIC SYSTEM AND DIALECTIC BEHAVIOR THERAPY

Dialectic behavior therapy (DBT) was first introduced by Linehan (1993a, 1993b). It was embraced enthusiastically and found effective for a variety of diagnoses and therapeutic settings, mostly for borderline personality disorder but also for depression and eating disorders (Lynch et al. 2007). DBT emphasizes the dialectics of acceptance and change. The client needs to be validated for his behavior while recognizing the need to change lifethreatening behaviors in order to have a better life. Behavior is perceived as “natural responses to environmental reinforcers” (Lynch et al. 2007, 183). The individual thinks dichotomously and is unable to integrate opposing forces (Andersen 2005). Linehan argues that a client’s behavior is both functional and dysfunctional. The client is doing his best given the particular circumstances (reducing distress), but needs to recognize that his behavior is self-harming. Suicidal behavior, characteristic of borderline clients, represents both aspects. DBT is based on three basic principles (Lynch et al. 2006; Robins 2002): (1) the person is a whole, comprising different but interrelated parts that can be viewed only as a system; (2) nature consists of opposing forces that operate as thesis, antithesis, and synthesis, which lead to a new thesis and antithesis; and (3) change is continuous. These are actually the basic tenets of dialectics. DBT relies heavily on Zen Buddhism and also on use of the dialectic approach. Buddhism’s goal is to facilitate growth and evolution (Kumar 2002). According to Buddhist tradition, Siddhartha Gautama (later known as Buddha) expounded Four Noble Truths. (1) Suffering is omnipresent.

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(2) Suffering is the result of an attempt to hold tightly to observable facts. (3) Suffering can be ended. (4) Ending suffering can be achieved by practicing the Eightfold Noble Plan (Kumar 2002): right vision, idea, speech, behavior, living, effort, mindfulness, and concentration (Thrangu 1993). Suffering is the result of a tendency toward essentialism. Essentialism is the idea that there is a distinct, stable self and identity that is independent of both internal physical processes and external environmental influences (Kumar 2002). The common Western view of the person is actually essentialist, in which a person is considered unique, stable, and continuous over time. The Buddhist considers this view negatively because it suggests a disconnection from others. This disconnectedness leads to dualism and polarization of thoughts, emotions, and behavior (Gyatso 1997). Therefore, the perception of self as interconnected to others and the environment is essential in Buddhism. This can be achieved only when the person reaches the state of emptiness or selflessness. Reaching this state enables the person to connect freely with the world and self. Connectedness comes from emptiness. Essentially, Buddhism perceives the world as a system in which all parts are simultaneously interconnected and interdependent in a multiplicity of ways and means to create a universal unity. These interactions entail a constant change; they negate the existence of a discrete, independent sense of self (essentialism). The belief that there exists a distinct self, separated from its context, is perceived as the source of suffering. The person who clings to the idea of being unique and different from others resists the possibility of change and consequently suffers. This systemic view is only partially shared by FDS. The notion of a system in which every element is interconnected in myriad ways is indeed central to FDS thinking. Yet FDS focuses on the systems that affect the person more directly and intimately (family, work, social-cultural). Nevertheless, the person is an integral part of the system while maintaining boundaries partially separating him from the system. The person’s behavior can be understood and be meaningful only in the context of a system. A person’s identity also develops in the context of these systems. Even though the FDS definition of a system is identical to the world view of Buddhism, the difference is striking and interesting by itself. Even though this view is vastly narrower than the one advocated by Buddhism, it is more connected and

xxviii | INTRODUCTION

accessible to the everyday life experience of a Western-born person. This also points to another difference. Even though FDS sees the person as a system member, it allows the person to develop a unique identity within the parameters of the system but underscores the interdependence between the person and the system. According to Buddhist principles, suffering is a universal phenomenon. Accepting suffering as a human condition is necessary for a feeling of compassion (Kumar 2002).2 As we recognize and accept our limitations, we become compassionate toward our selves. This enables us to be compassionate toward others. Mindfulness is a total, uninterrupted, unbiased, or nonjudgmental awareness and attitude toward the self and others (and is similar to the concept of empathy in Chinese dialectics [Andersen 2005; Wong 2006] but also similar to Rogers’s notion of empathy and unconditional positive regard [Rogers 1975]). Compassion and mindfulness are interlacing concepts. When the therapist is compassionate toward the client, he also validates the client and provides space for the client to express herself nonjudgmentally. This is also based on the Zen principle that “everything is as it should be at this moment. This is the essence of accepting the world, oneself and other people” (Robins 2002, 52). Whereas behavior therapy seeks to change the person and the environment, FDS is more in line with the Zen principle. FDS argues that whatever the person does is functional to achieving his goals and that the person is doing the best he can do under the circumstances. Dialectic construal of the world is the essence of DBT and FDS thinking. The way the world is conceived is not an “either–or,” as we are used to, but rather as an “and–both” elucidation of life. Everything is looked at from a more complex, broader, holistic view that negates the simplistic, blackand-white, linear causality perception that we tend to use in understanding the world around us. A dialectic view of behavior helps validate both the behavior and the person. The fact that behavior means also its opposite inevitably leads to a nonjudgmental view of behavior and the person. Change is the result of the tension between the two opposites and is thus inherent in dialectics. The therapeutic change results from a broader understanding and a choice the client is able to make through this new understanding.

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The inevitability of change embedded in Buddhist thinking means impermanence. Impermanence is natural but goes against the wish to see the world as stable and organized. This conflict can be resolved by accepting the impermanence; in fact, we do not have to stop the change process and accept it. This radical acceptance is a core issue in DBT (Robins, Schmidt, and Linehan 2004; Swales and Heard 2009). FDS, on the other hand, relates to people’s need to belong to a world that is stable, safe, and ordered. FDS views life as an ever-changing process. This view contributes to the FDS optimistic view. The idea of radical acceptance goes along with the Buddhist perception of the world but, so I believe, is not part of typical Western thought and thus foreign to it. I believe that in the East it may enable people to cope with and sustain a certain way of life considered by Western eyes as poor and miserable but one that is congruent with the way of life in that part of the world. Zen thinking appears dialectic. It ignores the law of contradiction. It uses instead the law of identity: “A is not A, therefore A is A.” It is the logic of the illogical (Kim 1955). This is a form of thinking closer to life. You may say that “living is dying.” In this respect the logic of the illogic of Zen is similar to Hegel’s dialectic approach.3 Even the difference between the two schools of thought is dialectic; Zen’s nothing versus Hegel’s absolute. The person’s connectedness comes from emptiness rather than from being. However, the major difference between these two schools is that the Hegelian-type approach assumes temporal synthesis between thesis and antithesis, whereas Zen has no synthesis, just the existence of the two poles (e.g., master and slave, peace and war). This difference actually makes Zen thinking more paradoxical than dialectic (Kim 1955). Moreover, it makes Hegelian dialectic thinking more practical and more therapeutically relevant because it is closer to the world in which we live and to Western thinking. I like Wong’s (2006) definition of dialectics “as a hermeneutical process that brings us closer to a better understanding by eliminating misunderstanding” (248). The DBT principles of holism, dialectics, and continuous change are translated into four broad stages of therapy. In the first stage the client is taught basic competencies such as elimination of self-harming, suicidal behaviors and reinforcement of behavioral skills such as mindfulness,

xxx | INTRODUCTION

emotional regulation, interpersonal effectiveness, distress tolerance, and self-management. The second stage focuses on emotional difficulties related to the experienced trauma. At the third stage the focus is on learning skills necessary for employment, education, and interpersonal relationships. The fourth and last stage centers on acceptance of personal struggles as an inevitable part of human behavior. Four modes of therapy (individual therapy, skill training, skill generalization, and consultation team) improve cognitive, emotional, and behavioral regulation (Linehan 1993b; Lindenboim, Comtois, and Linehan 2007; Lynch et al 2006). The differences between DBT and FDS can be summarized as follows. First, both DBT and FDS see suffering and its reduction as a product of the client–therapist relationship based on mindfulness and a broader view of the problem, its circumstances, and its meaning. Second, DBT is an approach based on dialectic principles but is essentially a cognitive–behavioral approach (Swales and Heard 2009) designed to work with specific, though significant, behaviors in order to help clients cope with their difficulties. FDS is a system-based approach that also relies heavily on dialectics, of the Hegelian-type, but focuses more on changing the therapist’s and client’s view of behavior from a system functional view, where the change in view is a major part of the healing process. Change can be achieved using any appropriate and relevant technique or approach. Third, FDS prefers to use the concept of empathy rather than mindfulness. Mindfulness is a state of mind and concerns a general view of the world, whereas empathy is better reserved for interpersonal relationships. Even though DBT relies on Zen Buddhism, it does not require the therapist to practice Zen. This is regrettable because Zen is a profound way of perceiving and being in the world, and in order to use it adequately, it seems that one needs to practice it rather than leaving it in the abstract. Nevertheless, many but not all DBT therapists practice some form of Zen Buddhism, but this is not a requirement for practicing DBT. Fourth, the FDS is a system-based approach that uses the system as a frame of reference for understanding human behavior rather than the Buddhist holistic view of the world. In this respect, the FDS view is more restricted but ideally more connected to everyday life. Fifth, in FDS the client is a partner to a dialectic view of the problem and way of thinking.

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This enables a redefinition of the problem and opens the way to the use of myriad therapeutic approaches and techniques. Finally, DBT is more individually focused and relates to the therapist–client relationship but does not include the family as a focal, systemic dialectic frame of reference for the client’s invalidation process, although it recognizes the importance of the system. Miller et al. (2002) and Oliver, Perry, and Cade (2008) propose such integration between family therapy and DBT. Still, FDS has a much broader therapeutic application and is not confined to a certain approach or technique. FDS is used mostly to change perspectives and redefine difficulties in a way that enables the use of any therapeutic technique, be it dynamic, behavioral, CBT, or other. I believe that the reader will notice and recognize the differences between the two approaches as the book unfolds. Chapter 1 focuses on the system and its structure, dynamics, development, and change.

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PART I

THE SYSTEM

Development and Change

Structure

Process

The System

1 SYSTEM: NATURE, ROLE, STRUCTURE, AND COMMUNICATION

WHAT IS THE SYSTEM?

The system approach has its origins in fields such as engineering and mathematics. Theoreticians became aware that biological and mechanical structures did not exist in a vacuum but were related, and this led to the idea of a system. Oxford Student’s Dictionary for Hebrew Speakers (1993) defines a system as “a group of related things or parts working together” (782), so a system consists of at least two elements. These can be of diverse origins, such as chemical, physical, sociological, or psychological ones, to name but a few. Once formed, a system produces a whole, which is more than its parts and is the product of the interactions between its elements. System members need not and usually do not share the properties of the whole. The saying “The whole is greater than the sum of its parts” applies nicely to the concept of a system. It also implies that when a part of a system is seen outside it or when the system changes its characteristics (e.g., loss of parts, disintegration), the properties of the elements also change. A system can be a subsystem of a larger one, or it can subordinate other systems. A person can be a subsystem of a couple, which can be a subsystem of a family, which itself can be a subsystem of an extended family, a tribe, and so on. A member of one system can concurrently be a member of another system or systems (e.g., a family and work organization). Being a member of different systems can entail adopting different behavioral patterns suited to each system. 3

4 | SYSTEM

Once formed, a system begins to evolve. Its members evince a continuous, goal-oriented interaction, with implications for issues of causality and responsibility. Weiner (1991) uses a machine metaphor to describe the person and lists the following properties of machines: 1. They have a part (a structure). 2. There is a desired end or function. 3. The whole functions as a unit of mutually interacting parts to reach this end. 4. The behaviors are involuntary, or without volition. . . . 5. The behaviors are performed without conscious awareness. 6. The reactions are necessary or predetermined to a set of circumstances or activating stimuli. 7. The actions are fixed and routine. 8. Forces and energy are transmitted. The forces may be in balance or in equilibrium, where no tendency to change is present, or out of balance, promoting a tendency toward change. (p. 922) Weiner (1991) maintains that the machine metaphor can apply in psychoanalysis, drive theory, ethological theory, field theory, and Gestalt theory. For the present discussion, the machine metaphor accords well with the idea of a system: it consists of mutually dependent elements, and a change in one of its elements will cause a change in others. This principle is directly associated with our change of view of causality from linear to circular. Our habitual way of examining our own behavior and others’ tends to be linear. We believe that for every effect there is a cause and that the cause always leads to an effect. Whenever something unexpected or unusual happens to us, the immediate question is, “Why?” We seek the cause responsible for the event. Finding the cause allows us to ascribe responsibility to it. Being able to explain why something happens allows us the illusion of understanding what led up to the event. Then we can attribute responsibility to the self or to others. The search for an understanding serves our need for an orderly

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and predictable world. Western science is guided by this linear approach. Statistical analyses are based on the presumption of cause and effect (x predicts y). This linear relationship means that responsibility is also linear; that is, for any event, somebody or something must be bear responsibility for it. The mutual dependency axiom directs us to a different understanding of causality. Mutual dependency is the simultaneous mutual effect of system elements. When I do something, it affects another person and me. My behavior takes into account my wish and my anticipation of the other person’s reaction to this wish, which is based on his perception and expectations concerning my reaction. My next reaction will be based on my perception and expectations of the other person’s current and future behavior. A causal loop is formed. This interaction describes a typical web of interrelated behaviors; the end result is that all partners to this loop share responsibility for its consequences. Because the behavior of every system member simultaneously depends on the other members’ behavior, we cannot posit a linear, one-way causality but must impute a shared, circular causality. This view represents a shift from the usual cause-and-effect thinking. The circular causality view means that every member of the system shares responsibility and contributes to the system. This view is often challenged on grounds of socially correct beliefs. For example, domestic abuse is ostensibly an obvious case of an aggressor and a victim, so responsibility for the abuse seems clear. But is it? To answer this particular question we need to distinguish between behavior and responsibility. Abuse is a socially condemned and forbidden behavior. The aggressive person has crossed a line and should be brought to account and punished for this transgression. However, therapeutically we would like to help the person or the couple understand and change their behavioral pattern, so we need to understand how the system, the relationship, within which this behavior took place operates. Applying the mutual dependency principle, we scrutinize each participant’s contribution to the events that sparked the behavior, and in this way we might be able to construe the abusive behavior as a consequence of feelings of frustration and helplessness in face of provocation. One possible explanation is a power struggle between the spouses.

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Accordingly, abusive or other undesirable behavior can be understood as the product of an interaction between system elements. This understanding can prove more useful in attempts to change maladaptive behavioral patterns than a linear, one-way view of behavior. A couple was referred for therapy by a social welfare agency. The husband, Michael, a superintendent, age fifty-four, was removed from his house by court order following a complaint by his wife of physical abuse. The wife, Joyce, age fifty-two, is a homemaker. The couple has a son, twenty-five, unemployed, living at home, and abusing drugs and alcohol. Michael and Joyce have been married for more than thirty years. Their marital history was unremarkable until several years ago, when their son lost his job as a truck driver, divorced his wife, and came back home. Michael and Joyce did not know how to deal with their son and were divided as to the way to handle the situation. Michael wanted their son to be out of the house, but Joyce wanted him to stay in the house until he got back on his feet. The disagreement turned into verbal fights and, when the situation escalated, into physical abuse. Following Joyce’s complaint to the police department, Michael was charged and brought to trial. The judge put Michael on probation and referred the couple for therapy. Early in therapy, it became very clear that the spouses really liked and loved each other, but it was also clear that their conflict resolution skills were poor. Typically when they had a disagreement, Michael had the last word. That was acceptable to Joyce but not to the son, who did not accept Michael’s authority. The frustrated Michael turned to Joyce and accused her of spoiling their son. Feeling helpless and frightened for their son and herself, Joyce became passive and quiet. This angered Michael, and an ensuing cycle began wherein Joyce’s growing helplessness reinforced Michael’s growing frustration to the point of physical abuse. At the onset of therapy it was made very clear to Michael that regardless of how he felt, physical abuse was an unacceptable response for which he had been punished. However, the stimulus–response cycle was clear, and the couple’s disappointment, helplessness, and frustration in face of their son’s return were also clear. The focus of therapy was to help the couple deal with their son through improved communication and joint agreement. When this

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was achieved they were able to jointly face their son and demand that he take care of himself. This was successfully achieved, and in the process of therapy the couple learned how to solve their differences in ways other than physical fighting. The interaction web between system members is purposeful, functional, and goal oriented. In the next section we shall see what goals these interactions serve. THE GOAL OF THE SYSTEM

The ultimate goal of a human system is to provide its members with a sense of security and belonging. Satisfaction of these needs is associated with a perception of constancy, predictability, and identity. It should be noted that the need for stability embeds a lack of stability; in other words, we need to ensure stability because we are afraid of instability. Instability means unpredictability, a lack of control over life. Unforeseen events can change the course of our lives in ways that are beyond our control. The people who worked at World Trade Center in New York had no idea that their lives were going to end at a precise time on September 11, 2001. The endurance, steadiness, and durability of the system are a buffer against randomness and uncertainty. In order to provide these essentials, the secondary goal of the system is self-preservation. Human beings are parts of social units: family, extended family, tribe, nation, and so on. These units provide the individual with physical, emotional, and economic protection. Every member of the unit has to contribute to it in return for its protection. The individual belongs to the unit and draws her identity from it. A bargain is struck wherein the individual is asked to contribute to the unit in return for its protection and the right (or destiny) to be a part of it. The unit outlives the individual, so it provides her with a sense of constancy and roots that serve as a basis for her identity. The system shapes its members’ behavior through social norms. The individual who wants to benefit from being a member must subordinate her belief system, behavior, and expression of feelings to the norms of the system. To be able to satisfy its members’ needs, the system needs to preserve itself over time. Therefore, it must outlive the individual. People behave accordingly at every level of the system, from sacrificing one’s life for the

8 | SYSTEM

nation or a tribe in war to sacrificing the individual family member’s welfare and even life in order to preserve the family. Two important effects result. First, the focus shifts from the individual to the system. The primary influential agent is the system, which shapes and dictates the norms for its members. Obviously, a change in the individual can change the system, but it takes more effort and energy than changing the individual through a system change. This issue affects the relationship between the individual and the system. Second, the system uses certain means to preserve itself. We will discuss this point later in the chapter. THE INDIVIDUAL AND THE SYSTEM

An individual’s behavior can be understood in the context of the systems to which he belongs. One is likely to be a member of several systems simultaneously. Each wields rules and expectations regarding one’s beliefs, social perception, emotional expression, and behavior. Should the individual deviate, consequences will follow to ensure future compliance. These consequences are usually associated with the denial of basic needs by the system. One can be cast out, losing one’s tribal or community support, freedom, and membership in that system. Every transgression (e.g., inappropriate sexual behavior, abusive behavior, aggression, or deviant political views) can be grounds for punishment. Traditional personality theories focus on the individual and attempt to understand his behavior on the assumption that this depends on his perception of the situation. However, orthodox system believers, taking an approach similar to Skinner’s black box, think that knowledge of the individual member of the system does not contribute to understanding how the system works or even to a better prediction of that individual’s behavior. Because the system is more than its parts, they claim, understanding the individual member has no bearing on how it operates. In my opinion, this is a narrow-minded view of the interaction between the individual and the system. The system forms a frame that circumscribes the individual (through rules, behavior, and expectations). To a certain degree, one chooses which system one wants to be a part of. Within its bounds one is free to develop one’s own interests. One can negotiate the rules and the right of expression with the system, and the outcome of this give-and-take may change the

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system and the individual’s behavior (social change). Because the existence of the system is paramount to the individual’s basic needs, it must be more powerful than him. Otherwise, it runs the risk of obliteration. The system’s power is based on its control of resources such as financial goods, physical assets, physical strength, and emotional energy. Because these resources are limited, there is competition between family members over their allocation. This competition turns the system into a fundamental source of influence. This influence can be manifested even in individual differences in the expression of personality traits. Downey (2001) posits the resource dilution model, arguing that parental resources are limited and become diluted as the number of siblings increases. This finite amount of resources might be the source of sibling competitiveness. Family size is considered one of the factors contributing to differences in personality and intellectual development between siblings (Eysenck and Cookson 1970; Kuho and Hauser 1997; Post and Pong 1998). Children search for their niche in the family (Sulloway 1996) in order to maximize their share of the available resources. They want to be different from one another. Whether birth order affects a child’s personality has been investigated in numerous studies. Generally, the firstborn child appears to be more achievement oriented and to have a greater need for acceptance than children born later (Philips, Long, and Bedeian 1990). The lastborn tends to be more socially oriented and gregarious (Phillips et al. 1988), and middleborns seem willing to compromise and to be noncompetitive (Kidwel 1982). This research area is controversial (Michalski and Shackelford 2002; Wichman, Rodgers, and MacCallum 2006; Zajonc and Sulloway 2007). Zajonc (2001) argues that birth order and family size “are conditions that afford, mediate, or prevent an array of diverse outcomes” (495). Stansbury and Coll (1998) found that age spacing, socioeconomic status, parenting style, and gender were among the variables affecting differences in siblings’ personalities. In a recently completed study of twins, Guttman-Baumgold (2010) studied similarity in psychological needs between monozygotic twins, dizygotic twins, and nontwin siblings. She found that, on a self-report questionnaire, the twins were very similar to each other. However, when the issue of access to parental resources was assessed in relation to their similarity, the monozygotic twins viewed themselves as different from their twins.

10 | SYSTEM

The idea that belonging to a system is an essential part of our existence is consistent with our need for identity and uniqueness. Two forces operate simultaneously. The first is the system, which sets expectations, values, norms, beliefs, attitudes, and rules of behavior. The second is the individual member, who has to find a place for himself or herself within the system while considering the needs of its other members and the rules and expectations it sets. The individual need for identity and uniqueness is bound by the system, as is seen clearly in children. They compete for their parents’ attention and resources. A child must find a place in a system that enables her to enjoy its support and resources but also to develop her unique identity within it. For example, if an older child excels academically, the next child usually finds another avenue that makes her special in the family (e.g., sports, art). The child after that must find yet another niche (e.g., become an academic failure or take an oppositional stand). Another example of the search for identity is an adolescent girl who uses drugs or manifests antisocial behavior to test her parents’ ability to contain her. Should the child succeed (i.e., the family is unable to contain her), the system can suffer a mortal blow. Should the child fail (the family is able to contain her), the system will be strengthened. This struggle shapes the adolescent’s behavior and personality and affects the other family members. The question of one’s capacity to choose the system one wants to be part of is controversial. The choice is likely to depend on one’s past choices or on those made for one by other factors (e.g., parents, financial considerations, work, or schooling alternatives). These past decisions include which kindergarten or grade school the child attended. Most of these choices are made at a developmentally critical period when the child has no control of them, yet these choices affect the child’s current and future choices. The basic need for belonging, consistency, and identity runs counter to the idea of free choice. Belonging to a certain system requires acceptance of its norms and limitations. Consequently, even if the person seems free to choose the system he wants to be a part of, personal choice is limited and influenced by the system or systems he was part of before his current choice. This discussion leads us to the conclusion that one’s personality is the product of an interaction between one’s trait predispositions and the demands of the particular systems one is a part of. The supremacy of the need to belong assigns the system a decisive role in the person’s life.

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A twelve-year-old girl was referred to therapy by her school counselor after she had shown a sudden and marked deterioration in academic achievement and uncharacteristic social withdrawal. The family has two more children: an older sister, eighteen, who just left home, and a younger boy, aged six. It became clear early in therapy that the parents were experiencing marital discord, expressed in arguments and disagreement over how to discipline the kids. The adolescent girl argued vehemently from the start that she was not the problem and that her parents had to deal with their own difficulties before turning on her. While acknowledging their problems, the parents said that they could live with them if their daughter improved her behavior. Therapy ended after two sessions because the girl refused to participate and the parents refused to come as a couple. The story did not end at this point. Eight years later the girl, now a twentyyear-old woman, sought individual therapy from the same therapist. Asked why she returned to the same therapist, she said that she did not recall the specifics of the earlier intervention, but she remembered that the therapist had said something about her strength and caring for the family, which she liked. Reviewing her history since then, the young woman reported being anorexic, with two hospitalizations (one in a psychiatric ward) and a severe physical deterioration that landed her in critical condition in the hospital. She expressed a wish to be rid of her family and able to live on her own. She said she could not leave home because of the responsibility she felt for her younger brother (who was about to leave home for military service). This story tells us about the child’s need for support and belonging, the price she was willing to pay, and how the process of negotiation with the system had shaped her in terms of behavior, health, career (or lack thereof), personality, and interpersonal relations. However, when an external, independent force (e.g., a layoff or accident) affects the individual family member, the results affect the system as a whole. If an individual has cancer, the whole family has cancer. The individual’s illness affects all family members and affects the way the system is organized and functions.

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HOW IS THE SYSTEM STRUCTURED?

For a system to meet its basic needs, it must have a solid, durable, changeless structure. The existence of such a structure, an external skeleton, provides strength and protection for the soft tissues; it allows change, growth, and development to take place. Systems can be open or closed. An open system interacts with and reacts to the environment by exchanging information. A closed system is one whose boundaries are fairly rigid, and its communication with the outside world is limited. Social systems, including family systems, tend to be open. They interact and exchange information internally and externally with the environment. A system can limit or expand its interaction with the outside world under certain conditions. The most important is the existence of an external threat to the system. Then the system will attempt to restrict interaction with the outside world in order to minimize the threat and protect itself, for example, when physical or sexual abuse is present in the family. In this case there will be an attempt to conceal the abuse by limiting the interaction of family members with friends and others so that the secret is kept in the family. Boundaries

As the system evolves, it needs to differentiate itself from the outside world and within itself. To this end the system develops boundaries that regulate the internal and external flow of information. Three general types of boundaries can be identified, ranging from very close to very distant relationships (Minuchin 1974). The terms characterizing these boundaries are borrowed from biology. First, there is the enmeshed or permeable type, depicted as an uninterrupted flow of information between the system elements. There is no restriction and no differentiation between the sharers of this type of boundary. These people may be considered to be in symbiotic interaction. The invasive relationship between mother and daughter in a case of anorexia nervosa is likely to be described as an enmeshed boundary. Second, there is the disengaged or impermeable type of boundary, which severely restricts the flow of information. It is exemplified by two

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people who live together under the same roof but conduct their lives independently of one another. Third, there is the intermediate or semipermeable boundary, which allows a partial flow of information between the members. The flow can be selective, by which the person shares some pieces of information with others but withholds information that he wants to keep private. Therapists should be aware of a common mistake in assigning values to the different boundary types. Intuitively, and with some supporting empirical research,1 one might think that the enmeshed and disengaged types are likely to be negatively valued because the former does not allow the development of a unique, individualized identity and the latter blocks communication. Apparently, these types do not necessarily mean that these families are not functional; many function well enough under these conditions. Note that the negative appraisal of these families draws from our seeing only the dysfunctional ones in therapy. These families, couples, or individuals may be more likely to exhibit extreme types of boundaries. This does not mean that the type of boundary is causally connected to the problem. The formation of any type of boundary can be one of the means the system uses to preserve itself. Either it needs to control its members better to avoid breakdown of the system, or there is a need for separation (disengaged boundaries) in order to maintain individual independence for the same reason. (For example, in the case of an anorexic young woman, her symbiotic relationship with her mother can be viewed as a way to prevent the breakdown of the parents’ marriage by allowing the mother a replacement for a close, intimate relationship and allowing distancing of the father. The price, of course, is the loss of a separate identity for the daughter.) Hierarchy

The family system usually expands as the number of members increases. Children are added. The dyadic relations become more complex, and a new form of life management is needed. Hierarchical organization based on well-defined roles is a functional structure that uses system resources efficiently. Minuchin (1974) maintained that hierarchical relations based on power are essential for an adequately functioning family. Haley (1976) argued for the importance of hierarchical relations in the family and found that inadequate hierarchies stood behind most family problems.

14 | SYSTEM

The traditional family hierarchy requires the parents to be the heads of the family because they are more experienced in life and have moral, economic, and physical power over the children. Should this order be disrupted, as the children gain power over the parents, the family system is likely to become dysfunctional. The child becomes responsible for the family. Nobody has prepared her for it, nor has she acquired the necessary skills. The child’s childhood is taken away when she has to shoulder the adults’ duties. Such children are known as parental children (Lackie 1983; Mika, Bergner, and Baum 1987). Being a parental child can be adaptive if it is temporary and parents keep their leading role, as in the case of an illness or a disability (Boszormenyi-Nagy and Krasner 1986; Minuchin and Fishman 1981). But when the parents abandon their authority and transfer their duties to the child, the hierarchy turns upside down and the family becomes dysfunctional. The hierarchy operates through the roles that system members assume and the rules that govern family members’ behavior. Roles

The family system is a social organization meant to provide its members with security and order. To furnish these and to function well, the system must distribute responsibility for its various functions. Labor and responsibility are distributed as roles assigned to or undertaken by each member of the system. A role is a set of shared expectations about how members of a group should behave (Aronson, Wilson, and Akert 2005). Role theory (Biddle 1979, 1986; Heiss 1981; Turner 1990) proposes that for most of their lives people are members of groups and organizations (which we may call systems). Each member has a distinct position or role, namely a set of functions he or she performs for the system (a definition similar to the one given earlier). When applied to a group, these expectations are formalized as norms. Roles, then, relate to expectations about the behavior of a person occupying a certain position in the group. People tend to be conformists; they adhere to norms and try to meet expectations. Consequently, they merit the system’s protection and security. Meeting expectations also means that they behave and perform in accordance with their role in the system. The roles are means the system uses to ensure its ability to fulfill its commitments to its members and to preserve

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itself. They also provide an evaluative frame for the individual that helps shape each member’s identity. People are members of more than one system simultaneously (e.g., family, work, friends, and social groups). Some systems can be rigid and fixed (e.g., family), others more flexible (e.g., work). These systems are not necessarily compatible in terms of the roles the person occupies. A person can take up different and conflicting roles in different systems (e.g., work and family) or even within the same system (a father to his children is also a child to his parents). The different and conflicting roles allow the person to present different aspects of the self in different systems, a possibility that can have a compensatory effect (having authority at work while relinquishing it at home) or an intensifying effect (being esteemed in one system and denigrated in another for the same personality or behavioral characteristics). These differences may exacerbate or relieve tensions and consequently may cause change or sustain stability in the system. In an optimally functioning system, the roles are clear and fixed. Each role has its own characteristics and expected behaviors (which also determine boundaries). However, the role must be differentiated from the person who fills it. For example, a family system can have the complementary roles of an emotional and an instrumental parent. The wife is stereotypically expected to be the emotional spouse, the husband the instrumental one. Stereotypically, the husband is expected to provide financially for the family and to be physically strong, the disciplinarian, and distant emotionally. The wife is expected to stay at home and to be more caring and emotional. However, in a well-functioning family the man does not necessarily take on the role of the husband or the woman that of the wife. Often men are caring and emotional, and women are more instrumental and practical. Those who assume the different roles can change. This dynamic, situationally dependent change increases the system’s adaptive ability (Jackson, in Nichols and Schwartz 2004). Jackson proposes another type of relationship, which is symmetrical, in which the partners take on both roles. This type is based on similarity and equality between the spouses (two career people who share life together). The symmetrical type does not preclude the complementary one in that spouses can be symmetrical in some aspects and complementary in others. Role conflict, in which a person simultaneously holds contradictory roles, may exist (e.g., being a parent at home and a child when visiting the

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grandparents). Even if the roles are clearly defined, confusion is always possible, although it does not necessarily indicate difficulties in functioning. The outcome of role conflicts is determined by how the system resolves them and uses them for its development. The clarity of role definition contributes to the establishment of clear boundaries. Several roles exist in a family. Parents

Being a parent means being responsible for your children in all aspects of life: physical, emotional, behavioral, educational, and financial. The parent is a model for the child. The parent needs to be mature, responsible, law abiding, caring, and watchful, overseeing the child’s welfare. Being a parent is a psychological and a legal role. Until the 1800s children were deemed their parents’ property; today society has taken on the role of protecting children from abuse. It keeps a close watch on parents and limits their authority over their children. Husband and Wife

These roles differ from the parental role. Whereas the parents are both committed to their children, the husband and wife are committed to each other. The spousal role traditionally takes two forms. One is instrumental, and whoever fills it is expected to be more practical and rational. The other is emotional, and the person holding it is responsible for emotional expression and is allowed to be more impulsive and irrational in the relationship. The former role is stereotypically assigned to the husband, the latter to the wife. However, there is no reason why either spouse cannot take on either role in different situations. A functional system is characterized by its ability to shift roles in response to situational demands. If one spouse becomes highly emotional, the other helps by being more rational and practical, balancing the other’s reaction. When the roles become fixed and each spouse undertakes a particular unbending role, the system may be inflexible in responding to a changing situation and is likely to become dysfunctional. Children

Toman (1961) studied the roles children play in the family and their personality characteristics. The roles are usually related to birth order. The

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eldest child is expected to be the mature, responsible one who looks after the others. Other studies have found that the eldest child tends to be high on achievement motivation (Berland 1974; Zajonc and Markus 1975) and have higher intelligence (Belmont 1977). In his meta-analytic study Sulloway (1996) found that eldest children tended to be higher on the Conscientiousness scale of the Big Five personality traits (those high on this dimension tend to be more cautious, dependable, and organized) but also higher on the Neuroticism scale (anxiety, emotional instability). The sandwiched child, the one between the first and the third, is expected to feel deprived and neglected (Toman 1961). Forer (1977) found that this child was likely to be friendly but with a strong sense of not fitting in. The eldest child was there before him and has won status in the family. The youngest child usually enjoys more attention. This leaves the middle child feeling deprived, and he might exploit these feelings to gain status in the family (“You owe me, I’m deprived”). The third role is that of the youngest or last child, or of the only child. This is usually the spoiled and childish one. These children have the highest rate of mental disorders (Forer 1976) and the highest empathic ability among siblings (Belmont 1977). Sulloway (1996) found that youngest children were higher on the Openness and Agreeableness scales of the Big Five. Studies in behavior genetics (Plomin and Daniels 1987) have demonstrated repeatedly that the family environment contributes more to sibling differentiation than similarity in terms of personality characteristics. A similar finding was reported by Ahern et al. (1982), who found low between-sibling correlations on personality traits. Twin studies (Loehlin 1982) reported similar findings. Sulloway (1996) argued that the reason for these differences is the children’s struggle for the limited attention resources of their parents. Each child is actually born to a different family from that of her predecessors and needs to find herself a niche not already occupied by older siblings. The eldest child keeps her position by identifying with parental authority and conformity, whereas the younger siblings need to find other positions and may become more open to nonconservative ideas and experience. Paulhus et al. (1999) found similar personality patterns when they studied withinfamily personality differences between siblings. Studies on the relationship between birth order and personality characteristics are controversial. For example, Trebitch (2004) recently studied

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differences between siblings using the Big Five and Big Seven personality dimensions and failed to confirm earlier findings. Clearly, however, siblings differ markedly in personality characteristics. Also, certain roles, such as the eldest, the youngest, and the sandwiched child, are common in families. Grandparents

The role of the grandparent can be most enjoyable. The grandparent is stereotypically expected to be kind, generous, patient, and unconditionally giving. Grandchildren tend to view their grandparents positively, showing them affection and respect (Kennedy 1990). They perceive that their grandparents have a strong influence on their lives and that their relationship is independent of their parents, who support but do not dominate it (Kennedy 1990). Grandparents enjoy their grandchildren without taking parental responsibility for them. However, when they do assume the caregiver role, they tend to have poorer mental and physical health than noncaregivers (Strawbridge et al. 1997). Grandparents have more free time than parents. They are expected to help their children in taking care of their grandchildren. They can do it by sharing time or money or by giving advice based on their own life experience. However, the grandparents’ ability to assume that role depends on their relationship with the children and their own mental and physical health (Whitbeck, Hoyt, and Tyler 2001). When grandparents grow old, there is always the risk that they will develop ailments (e.g., physical, mental, or financial) that put more responsibility on their children. We will elaborate more on this in the section on the family life cycle. More roles typical of the system exist, such as the scapegoat and the problem (i.e., the identified patient). These roles are discussed at the appropriate points in the book. In sum, roles have a stabilizing effect on the system. If the situation is steady (e.g., if people do not move or change jobs, spouses, or living conditions), the established and fixed roles keep the system functional and stable. But when the situation changes, the existence of firm, inflexible roles can impair the system’s functioning.

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Rules

Rules are cognitive and affective behavioral conventions shared by family members and governing their attitudes, emotional expressions, and behaviors within the system and toward others. The goal of these rules is to ensure the preservation of the system. Rules describe behavioral regularity (Jackson 1965). Through them behavior is controlled, so only certain behaviors are allowed to be manifested. These rules can also be viewed as metacognitions; they regulate the cognitive system, attitudes, beliefs, and behaviors of the family. A rule stating “In our family we do not talk about feelings” can give rise to an ideology that explains why it is important to avoid talking about feelings (“We shouldn’t upset anyone”) and behavioral patterns intended to prevent emotional outbursts. The goal of the rules is to preserve the structure of the family and thus to ensure that family members are able to enjoy the security of the family system. Narratives

As a person goes through life, he accumulates an infinite number of memories. These are stored in memory and can be recalled or remembered as needed. Some of these memories are repressed, but most are available with some degree of effort. Our recollection of these memories is not random but selective. We tend to recall relevant memories for a particular situation and time. When we have a certain feeling or find ourselves in a certain situation, we are likely to recall events, people, behaviors, and other elements that are relevant to that situation. Our selection is guided by our cognitive system. Beliefs and attitudes determine how we perceive the stimuli that flow from the situation. For example, if we suspect that our spouse is not loyal, we are likely to interpret any unusual behavior by him or her (even affectionate behavior) as an indication of disloyalty. The ability to selectively choose our memories enables us to recreate and reconstruct our past in a way that is functional for our current situation. The goal of these stories, or the edited history, is to maintain a sense of consistency and coherency in our life, even if the current situation is unpleasant. The reconstructed stories are functional for the individual but also for the system. The rebellious teenager who misbehaves at school and

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has a history of aggressive and disruptive behavior might want to divert attention from the marital difficulties experienced by her parents. The need to preserve the family system at all costs is manifested in pressure to create pseudo-mutuality (Wynne et al. 1958). Pseudo-mutuality is a facade of unity that masks conflicts and threatening secrets (e.g., incest) that, when exposed, endanger the system’s integrity. The family creates the impression of normal and conforming functioning in order to preserve itself (Wynne 1984). Closer inquiry into the family produces a tightening of boundaries, and the family increases its isolation to defend itself. Ferreira (1963) and Stierlin (1977) use the term family myths to define means of distorting reality as a way to preserve the integrity of the family system. In light of this information, the family narrative can be seen as one of the numerous mechanisms and means used by the system to preserve itself. We should keep in mind that the need to preserve the system rests on more basic needs of belonging and security. The story a person constructs and edits serves a dual purpose. First, it is told by the person and for the person, in an attempt to make sense of her own world. Second, it is a means of communicating with the external world. The narrative perspective is discussed further later in the book because it represents a major innovation in family therapy (Nichols and Schwartz 2004). Once people join together, a system is formed of roles and boundaries and is hierarchically organized. The system also writes its own story, which helps keep the elements together. For the system to function efficiently, the various elements need to communicate. Communication is an exchange of information that relates to every aspect of the system’s functioning (Watzlawick, Beavin, and Jackson 1967). COMMUNICATION

Communication is an exchange or transfer of information intended to bring about a certain behavioral, cognitive, or emotional consequence, which may occur in the present or in the future. As long as the communication is clear and similarly understood by the involved parties, the relationship is likely to be open and the behavior predictable, thereby adding to the person’s sense of security. When communication is unclear, uncertainty flourishes, creating mistrust and disintegration of the relationship.

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Communication can be articulated on two levels: verbal and nonverbal. The verbal level is the intentional spoken transfer of information; the nonverbal is concomitant behavioral signs and indications (such as body language). Verbal communication is usually believed to be under voluntary control (except perhaps for “slips of the tongue”), whereas nonverbal communication is not (Skynner 1976). The distinction between voluntary and nonvoluntary control has led people to confuse them with fakeable and nonfakeable behavior, with nonverbal behavior deemed to be “truer” than verbal. So when a woman tells her husband that she loves him and then behaves in a way that contradicts what she has said (e.g., forgets their anniversary), he will tend to believe the nonverbal behavior and disbelieve the verbal. This belief is misguided because communication occurs on both levels, each of which is meaningful. We seek consistency in our communication. Congruency between these two levels indicates consistency to us, which we interpret, not necessarily rightly, to be valid. When we detect inconsistency we feel anxious and distrustful. The contradiction compels us to look for a resolution. If we ask the person to clarify the conflicting messages we might find that there is a reason for this inconsistency (“I love you, but right now I’m angry with you”). The inconsistency between the two levels is also part of the communication that calls for clarification. There are two types of confusing communication. The first is the double message type, whereby a person sends contradictory messages to other people. The recipient of this communication is likely to feel confused or to interpret the message as he likes. This is a common problem in communication, which can be solved by asking the sender to clarify the message. Obviously, this can be accomplished only when the relationship between the sender and the recipient is sound. Otherwise, the communication is likely to be problematic. The second type of problematic communication was called double bind by Bateson et al. (1956). These researchers discovered a pattern of communication between people in a significant relationship when two contrary messages are sent simultaneously, without the recipient being able to verify them. They assumed that when this type of communication is repeated over a period of time (a mother tells her child “I love you” and pushes him away from her), it can lead to confusion and eventually to the development of schizophrenia in some cases. Although the effect of the

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double-bind theory has long been proved negligible (e.g., Khouri 1977), it is still a powerful communication flaw. Feedback Mechanisms

A system is a process operating along a time dimension. The interactions between system members take the form of feedback loops, which are of two types: negative and positive feedback. Negative feedback is a mechanism that maintains a fairly constant level of functioning (e.g., a thermostat). This state of relative stability can be called homeostasis or equilibrium. Freud argued that this is the desired state, wherein a person is free of anxiety and tension. Negative feedback is a maintenance mechanism that helps preserve an existing state, not necessarily a desired one. We see the operation of negative feedback in cases of severe pathology (e.g., high-level anxiety or psychotic paranoid disorder). Thinking becomes disturbed, guided by black-and-white thought processes designed to keep the world as simple as possible, and it does not admit change. A person caught in this type of thinking cannot see or contemplate the intricacies of situations and cannot adapt cognitively or emotionally to new situations and stresses. The negative feedback mechanism operates in order to maintain stability. However, stability does not signify the absence of change; it means only that change is limited. This gives the individual time for reflection, regrouping, evaluation, reenergizing, and preparation for the next stage. Positive feedback is a mechanism producing a change. It means communication that leads to change. The direction of the change, progression or regression, is not really relevant. Communication can be viewed as an exchange of information that is intended to produce a change. A behavior leads to a response that can lead to a change in the initial behavior, which can lead to change in response, and so on. Guiding a convoy to a certain goal, the leader has to adjust the pace to that of the slower-moving vehicles, and these have to adjust their speed to the leader’s in order to preserve the convoy’s integrity. A simple conversation between two people, in the course of which their perceptions, attitudes, feelings, and behaviors change, is a good example of positive feedback. Feedback loops are powerful mechanisms that must operate along a time dimension. A family meeting over dinner where family plans for vacation are discussed is another example of a positive feedback mechanism. One member makes a suggestion that

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reminds another member of another place. This stimulates discussion about how they will spend their time together. This discussion might end with a decision not to go on vacation together. This conclusion is very different from the initial wish to go together on vacation and reflects the process of change that occurred in that meeting. Modes of Communication

People tend to exchange information using different modes acquired through modeling and education. Each person has her own primary style, which can be characterized as intellectual, emotional, or kinesthetic. An intellectual person often says “I think . . .,” “I assume . . .,” “I believe . . .,” and the like, suggesting that thinking is the major player in her verbal expression. An emotional person uses emotional expressions on the verbal and behavioral levels (e.g., saying “I feel . . .,” crying). A kinesthetic person is likely to use behavioral and somatic expressions, such as “My heart beats faster” or “The blood drained from my face.” When people using different modes try to transmit their feelings, they can appear to be speaking different languages. The result could well be resentment, frustration, helplessness, and greater emotional distance. Imagine an emotionally oriented person hearing from his intellectually oriented partner, “I think I’m in love with you.” Only if the person is able to recognize the different mode and interpret it correctly will the interaction be productive. The reason for this difficulty is an underlying assumption that the emotional and kinesthetic modes are less under voluntary control than the intellectual mode, so they manifest the “true” expression of feelings and attitudes. This is incorrect. A person might say “I love you” but display incongruent accompanying body language. This can happen when the person holds back feelings, is afraid of the other’s reaction, or is ambivalent. Both messages can be genuine, and the incongruity should be clarified between the partners in that communication. Clinical psychologists of different orientations can be indoctrinated into believing that one mode is superior to the others (e.g., a dynamically oriented therapist can be led to believe that the emotional mode is superior and that the use of an intellectual mode can act, at times, as a defense against emotional expression). Different people are likely to use different modes of communication, and this use should be respected. People can change

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their mode of communication depending on the situation. In a scientific presentation, the emotional mode is inappropriate; in describing feelings about an issue, an intellectual mode might be out of place. The ability to shift from one communication style to another according to the situation is typical of a well-adjusted person. The types of feedback mechanisms and communication modes tell us how communication is made. They do not tell us what motivates communication or what energy source is used for communication.

2 DIALECTICS

Pervin (2003) divides theories of personality in reference to a person’s behavioral motivation process into three categories: t


t


t


Pleasure or hedonic motives, emphasizing the pursuit of pleasure and avoidance of pain. Psychoanalytic theory (Freud 1964) ascribes its dynamics to instinctual forces (Rapaport and Gill 1959). These are reduced to Eros (the sexual instinct or libido) and Thanatos (the destructive instinct). The two instincts operate together and against each other, and they influence everything we do. The energy emanating from the instincts, or psychic energy, is used to achieve instinctual goals, namely maximization of pleasure, through cathexis, which is balanced by anti-cathexis, or ego defenses. Drive theorists (Hull 1943, 1951) consider the needs that serve as psychological energy drivers of behavior. Kurt Lewin (1935) proposes that the source of energy is tension created by the goal object and the psychological distance from that goal. G. A. Kelly (1955) distinguishes two models of tension reduction: push and pull theories of motivation. According to the former, physiological needs create tension, which is relieved by satisfaction of those needs; pull theories draw motivation from the goal or from incentives such as fame, power, and money. Other motivational theories (Pervin 2003) emphasize growth and self-actualization. The source of energy is the motivation for psychological growth and maturation. Cognitive theories attribute a person’s motivation to the effort to 25

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achieve understanding and control over life. The person pursues consistency, not pleasure. Following Weiner’s (1991) discussion of the machine analogy, we showed earlier that a system has a structure, a goal, and a function and that its parts are mutually dependent and directed to achieve its goals. We departed somewhat from Weiner’s description by adding the need for the system to protect itself to ensure its ability to achieve its goal. Thus, the system’s main motivation is its preservation, and the function of behavior is to ensure such preservation. Growth and development are a result of a change process that the system undergoes continuously. The source of energy for the system (and hence for human behavior) resides in the existence of opposing forces inevitably leading to change, which are known as dialectics. Dialectics is an ancient term dating back to the Greek philosophers and has taken on different meanings (Buss 1979). It is also a common element of Chinese philosophy (Peng and Nisbett 1999). It can be viewed as a pattern of existential change (Hook 1953; Rychlak 1968, 1976a) and as a method of understanding change. In terms of behavioral, societal, or even natural system changes, the dialectic approach emphasizes the negation of existing states, contradictions, and conflicts. The first law of dialectics concerns the unity of opposites (Wood 1998). The nature of everything involves internal opposition or contradiction. This is probably the most obscure but important dialectic idea because it is the most willfully paradoxical, seeming at times to amount to a flat denial of the logical law of noncontradiction. Hegel holds that contradiction is the source of vitality, drive, and activity (Riegel 1973). It exists in reality and should not be avoided or discarded. Hegel argues that being is characterized by contradiction and negativity, whereas becoming is a process in which a thing changes to something else, and the true nature of that thing is revealed (Copleston 1963). To know something, we need to go beyond the immediate state and see what that thing is not. The real essence of that thing is the unification of its two sides. Progress and change are the products of opposition and contradiction (Marcuse 1954). Because the search for contradiction leads us to look for what the thing is not, contradiction depends on a changing context (i.e., what the thing is not

DIALECTICS | 27

depends on the particular situation). The law of the unity (or interpenetration) of opposites holds that the essences of things include differing and opposed, often complementary elements or processes. The law of noncontradiction, which is the basis of logical thinking, states that two antithetical propositions cannot both be true and cannot exist at the same time and have the same meaning. Anything that is true cannot be self-contradictory or inconsistent with any other truth. For example, Popper (1940) claims that contradiction can never occur within facts, and facts never contradict. Popper and others refer to formal logic and formal contradiction, which is indeed self-annulling. But dialectic contradiction is concrete contradiction; it is a part of a thing and determines its unity. The existence of negation and contradiction within the same event, thing, or phenomenon leads to the assumption that truth is relative (Buss 1979). Sayers (1980), following Hegel, emphasizes that contradiction is essential and necessary and is not a mere conflict but an inherent part of things. As a mode of understanding the world around us, the dialectic approach would make the following statements (Eldar, personal communication, December 18, 2006): t


t


The thought that a certain fleeting moment in time is a source of any meaningful observation about life is inherently wrong (i.e., linear thinking, which attempts to find cause–effect relationships, can be viewed as a point-in-time measurement of a phenomenon that is actually a more complex, multifactor, and multi-interaction process). Because things are in a constant state of change, one must explain them not in terms of seemingly noncontradictory stability but in terms of never-ending change, which moves things from one pole to another. Because contradictory forces are always present in any state of being, the exact position between them is determined by the relative strength of the multidirectional vectors that operate simultaneously. However, this presence is not necessarily irrational or unscientific.

The outcome of such contradiction is change, something new that is also inherently contradictory and thus leads to change (this is the second law

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of dialectics; Wood 1998). The dialectic approach relates essentially to a continuing process of change and may be viewed in this context. The third law of dialectics (Wood 1998) states the idea of negation of the negation. Change creates something new that negates what is changed; the change leads to a further change negating the previous change. This notion is similar to that of the positive feedback mechanism, which is also a mechanism of change. It also denotes mutual dependence of the individual and the system. The individual is shaped by the existing conditions but is also capable of changing them. Conflicts and struggles are necessary attributes of change and are likely to move the system to a different level of development. Change and development are products of the conflict between the opposing elements. Marx (1930) argues that every proposition (historical fact) has an opposing antithesis. The contradiction is resolved by synthesis, which will be negated by antithesis, which will, in turn, lead to synthesis, and so on (thus, synthesis becomes a thesis). Reality becomes a process, ever dynamic and changeable (Peng and Nisbett 1999). The existence of a contradiction serves as a rationale for a humanistic, as opposed to mechanistic, science (Rychlak 1976a). The Chinese concept of yin and yang—the passive, receiving, and meek versus the active and bold—is dialectic. Freud’s Eros and Thanatos also are dialectic.1 These are examples of contradictory and dialectic forces. Marx took dialectics into the social arena and established the contradiction in economic forces and the resulting struggle between social classes. Buss (1979) argues that Hegel and humanistic psychology share the view that behavior should be looked at in its context because things (behaviors and contexts) are interrelated and mutually dependent. Dialectic denotes relational meaning. The meaning of a thing is relational; it is tied to other things. Ultimately it is bipolar (Rychlak 1976a). We cannot comprehend the meaning of joy without relating to sorrow. We cannot relate to peace without considering war. Slave cannot exist without master. Love cannot be understood without hatred. Heracleitus argued that we cannot appreciate justice without relating to acts of injustice. When patients are asked for their dialectic meaning of depression, they may give answers such as “happiness,” “freedom,” or “vacation.” Freud embraced a dialectic approach conceptualizing the various psychic structures (Id vs. Superego) or instincts (Eros vs. Thanatos) as opposing entities even though

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he did not theoretically identify them as dialectic (Rychlak 1973, 1976b). Psychoanalysts try to identify the premises presaging pathology and then, through dialectic examination, look for the contradictions and inconsistencies between verbal and nonverbal behaviors, thoughts, and feelings. From there the patient is helped to establish alternative premises, on the basis of which he behaves. Others, such as Adler, Jung, and Rank, used dialectics to show that tension between the known and the unknown (what the client knows vs. what the therapist alternatively suggests) is the source of a dialectic confrontation that must be resolved in favor of the client. True dialecticians would say that no resolution is ever final but is a step in the endless process of change. The relational meaning leads to the thought that there is actually no objective truth and that truth depends on the person’s point of view, how she interprets events, and so on (Rychlak 1976a). This view departs from the machine metaphor and resorts to the judge metaphor (Weiner 1991). Here the person is viewed as evaluative, a decision maker, other-oriented. Marx argues that historical events do not exist “out there” for understanding but are subject to interpretation, which is related to the interpreter’s viewpoint (class identity). Rationality comforts us with the order and predictability we seek, but it does not necessarily represent actual life. We strive for rationality as we strive for order and predictability and try to use it as a reference for evaluating and organizing our reality and as a norm defining socially acceptable behavior (which we call rational behavior). Still, real life is filled with contradictions and uncertainties. Rationality is thus a means of organizing reality, but reality does not always follow rationality. The need for predictability, order, and stability compels us to resolve the dialectic contradiction and find a synthesis. This synthesis is temporary because circumstances and situations change, leading to a new contradiction (antithesis), and so on. The tension between the need for order and stability and the inherent unpredictability of things and events impels us to make an attempt at resolution. This resolution creates a temporary stage of stability, providing us with a sense of order, which in turn leads to change and development. We may say that the source of energy for system change and development is rooted in the fundamental dialectics of life. In therapy we often find ourselves trying to present the rational side of

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behavior to our clients and are baffled by their seemingly irrational behavior. We expect people to behave rationally and are disappointed when they don’t. These expectations represent the predominance of rationality but also a failure to acknowledge the importance of irrational and contradictory thought and emotional processes that are part of our unity as persons. The dialectic conflict is not learned or acquired but is inherent in our lives and exists everywhere. It is not experienced at an early stage in our lives and carried over thereafter. It exists here and now. The dialectic approach emphasizes the necessity of change through negation. For a thing to be real, we need to know what it is not, to go beyond the familiar into what is apparent. Unity is the acknowledgment of coexistence of both aspects of being. Kvale (1976) summarizes the principles of the dialectic conception: Dialectics involves studying human behavior as internally related to its context, emphasizing the social and historical aspects of the given situation. Dialectics is the study of qualitative change through the development of internal contradictions. . . . Dialectics accepts conflicting and interdependent conceptions of a phenomenon. . . . Internal contradictions within a phenomenon are the basis of development, which is influenced by external interrelations and interactions with other phenomena. (89–90) The existence of dialectic processes does not preclude the existence of rational, logical processes. The current scientific paradigm strongly emphasizes rational processes, believed to be the basis for understanding human behavior, and holds that dialectic processes are aberrant and deviant. It is expected that rational behavior will be the desired and dominant one (Weiner 1991). Striving for the dominance of rationality also stems from the fundamental need for order and predictability. However, our everyday life is filled with uncertainty, stress, and conflicting needs created by changing situations and interactions. The multitude of pressures leads to conflicting needs and behaviors. We achieve the reconciliation between dialectics and rationality by viewing rationality as a goal and the dialectic as an expression of actual

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life. Once dialectic thinking is accepted, it can use rational thinking for its explanation (“If there is an opposite meaning to something, then it may be that . . . ,” or, “If loss of control means control, then we may ask what is being controlled”). The dialectic approach can be used as a method for understanding and inquiry. Socrates applied a dialectic way of learning. He used questions and answers, always taking the opposite stand to the student’s (a method known as sophistry). In therapy sessions we may use dialectic thinking more deeply to understand the client and also as a method of opening up options. Should the client talk about how anxious and fearful he feels, the therapist, with careful timing, may ask about the benefits of feeling anxious. Another example involves a person who overeats; the therapist might ask whose worries she has taken on. DIALECTICS AS A METHOD

The dialectic approach is used not just as a theory for understanding behavior. It can facilitate our thinking. The use of the dialectic method is not sophism but a genuine attempt to expand thinking by highlighting the dialectics of thinking. This approach makes us consider other options in our attempt to understand behavior and relieve “stuck” patients. When we consider the possibility of an opposing view to a problem, its severity and intensity ease almost instantly. When a patient thinks negatively about himself and is asked to consider the positive aspects or functions of these thoughts, and he is able to see them, the negative feeling loses its intensity. Samai and Almagor (2011) conducted a study in which a group of students were asked to define anxiety. They were then given a short explanation of dialectics and were asked to define anxiety again. This time the definition included more positive references. The change in view of anxiety was maintained two weeks later. The interesting point is it was a one-time manipulation whose effects lasted for some time. In therapy, where a therapist uses the dialectic interpretation continuously, the effect is expected to last longer. Other studies (Beck and Strong 1982; Conoley and Garber 1985; Feldman, Strong, and Danser 1982; Kraft, Claiborn, and Dowd 1985) found similar effects with depression. Later in the chapter we shall discuss the functionality of the symptom.

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The combination of dialectic thinking and the identification of a symptom’s function is the cornerstone of our approach. The advantage of using the dialectic approach is that it forces clinician and client alike to explore more options. Searching for and finding different options is likely to help the client move out of a problem-focused, negative view of self and behavior. The ability to look for the dialectic pole can help in getting therapy unstuck. Once client and therapist are able to see other options, they have to change their view of the original problem and thereby change the client’s view of it and her competence in dealing with it; the client learns a way of looking at things that is more open, broader, and multifaceted, and this opens more cognitive, emotional, and behavioral options. DIALECTICS AND THE SYSTEM

Examining the nature of the system, one can easily see the dialectic relationship between structure and development. A common example of a dialectic statement is attributed to Heracleitus: “You cannot step into the same river twice.” The system is similar. Its structure is stable, but its content (members’ behavior, thinking, affect, relationships) is constantly changing over time, and there is a conflict between the structure and the content that leads to change (although it is slower and less apparent) in both. Being part of the system and following its rules means losing one’s unique and separated identity. Being individuated and differentiated from the system is the other pole of this continuum. Personal development over the life cycle can be viewed also as moving along the union–individuation dialectic. A person is part of a system but needs to be separate from it at the same time. This conflict is one of the causes of the mutual effect of structure and dynamics. The pressure for individuation is met by the need for union, and its resolution may lead to a change in both person and structure (e.g., changes in roles or rules). This change creates a new dialectic that requires a different resolution. DIALECTICS AND THERAPY

Dialectic thinking and method help us recognize the underlying source of the current difficulties. When the client tells us about his need for independence in the context of perceiving his spouse as domineering, we may ask where his dependency needs lie. Through this approach we may find that

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the client is fearful of expressing dependency out of fear of being rejected. Rejection calls for a search for love and approval. At this point the issue is not independence but the need for love and approval. When we see aggressive behavior we might look for the pain underlying it. When we see a passive, yielding attitude, we might ask ourselves what has happened to the unspoken anger. Later in this chapter we shall discuss a technique called reframing, which is a marvelous demonstration of a dialectic application. In reframing we actually relate to the dialectic meaning of behavior (e.g., an aggressive behavior is also a caring and loving behavior, or at least it contains the seeds of such loving and caring behavior). Another issue that will be discussed later in the chapter is the narrative approach, which I consider an application of the dialectic approach. In every person’s story there is an alternative story (a dialectic pole). A person who tells us how she has failed in life can tell a success story too. Dialectics can also be used as a method. When the client raises an issue, the therapist may use its dialectic meaning in order to expand the client’s view and understanding. client: I believe my wife hates my guts. therapist: I hear you saying that you believe your wife hates your guts; is it possible to assume that she cares about you and loves you? client: How is that possible? therapist: It seems that your wife invests a lot of energy in you. This investment means that she cares about you, and this is important for her. Why would it be important for her unless she has positive feelings about you? client: I have never thought about it that way. Clients usually focus their attention on the negative side of their situation. They are expected to do so because they came for therapy in order to deal with the negative aspects of their life. Therefore, they build a story depicting their miserable situation. The client talks about negative feelings emanating from his spouse. The therapist looks for the dialectic meaning of hatred and suggests caring and love. If the client accepts this suggestion, it may open up a new dimension in his view of his spouse. Another example involves a change in the client’s perception of his own pathological behavior.

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client: I feel very anxious almost all the time. therapist: What do you mean by anxious? What does it mean to you? client: I feel like I’m afraid of losing control over my life. Everything seems so threatening, and I feel helpless in trying to deal with it. therapist: I know it sounds strange, but I trust we have a good enough relationship to carry this, so I ask you where in your life this loss of control means having control. Is it possible that this loss of control helps you control something or someone? client: Do you mean that my feelings of loss of control allow me to control? therapist: Yes. client: I have never looked at it in this way. I need to think about this one. [After a while, maybe in this session or the next one] Now that I think about it, it seems that being anxious helps me control my spouse’s behavior. I can avoid doing things or make her do things by expressing anxiety. The client complains of feeling anxious. The therapist inquires about the subjective meaning of anxiety. When the client learns that anxiety is associated with loss of control, he thinks dialectically about having control. Because this a potentially highly significant change in meaning of the problem for the client, the therapist relies on the rapport established in therapy when suggesting this alternative interpretation of behavior. The client then accepts it and is able to see how loss of control can be turned into control. When he accepts this, the client’s view of the problem and of himself is likely to change. This is the essence of applying dialectic thinking, and we shall see later how it is used in therapy. Here is another example. Before the beginning of the dialogue, the therapist needs to establish joining and rapport with the client without attempting to challenge or change the client’s thinking or the way he presents himself. After joining has been achieved and the therapist has heard the client and formed an impression of the problem, she is ready to formulate a dialectic impression. Keep in mind that there may be more than one dialectic pole to the problem.

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j [talking about his difficulties with his spouse]: H is so critical of me, I can’t stand it. Yesterday we went to the UPS together, and I noticed how she reacted when I filled out the form in my small handwriting. I tore up the form and took another one and filled it out again, needlessly. I was so furious that I went back home, refusing to go with her to Blockbuster. therapist: You felt how critical of you H was, and that made you very angry. [Turning to J’s wife, H] How do you see it? h: I’m not sure what J is talking about, I wasn’t aware I was critical, but I have to say this is exactly how I feel he reacts to me. There’s nothing I could say to him that wouldn’t be interpreted as criticism. j: Yes, and she does it all the time. therapist: You know, it occurred to me that both of you are very critical of each other. It appears like you are both afraid of doing something that might anger the other one. The therapist begins to believe that because their marriage appears to be stable and they seem to genuinely love each other, they are cooperating in an attempt to avoid dealing with a different issue. Because criticism leads to distancing, it is likely that they are afraid of closeness. Having formed the dialectic hypothesis, the therapist is now ready to explore it with the couple. j: I really don’t want H to be angry with me. I’m aware she’s doing her best to make the best of our life, but I feel like I am being watched and limited. h: I don’t know what you are talking about; I try to do the things I know you like. I ask every time if you like it; we do what you suggest. It’s true that I’m critical, maybe even overly so, but you know I love and respect you. therapist: I hear you saying that you love each other and also that you are very critical of each other. I wonder if that means that you have something related to being close to each other you are not talking about. h: What do you mean? j: Do you mean we have difficulties in being intimate with each other? h: But we talk about everything, and we share everything, and I trust J completely. j: And I feel the same about you! h: Is something missing? j: Yes. We don’t talk about sexual relationships, and it’s been a long time since we’ve been together.

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From this point on, the couple was able to talk about their sex life, which appeared not to have been satisfying for quite a long time. The mutual criticism was replaced by cooperative efforts to find out what was not working in their sexual relations. This vignette reveals how dialectic thinking can help change the meaning of an issue and move therapy from a negatively emphasized interaction to a positive one. COTHERAPISTS’ DIALECTIC DIALOGUE

Doing dialectic work with a cotherapist can be a challenging yet gratifying experience. The therapists can play out the dialectic poles. While one therapist talks about the dysfunctional aspect of the problem, the other can refer to its functional aspect. Taking the preceding vignette as an example, the dialogue may be as follows: therapist (to her cotherapist): It seems that there is some anger between the two. cotherapist: I can see how much they care for each other. therapist: Are you suggesting that they use the criticism not to talk about something? cotherapist: Yes, I believe they are trying to avoid about something they are afraid of. therapist: They do collaborate in distancing each other. cotherapist: This is why I believe there’s something in being close that drives them away from each other. therapist: Let’s ask them and see what they think. The family or the client is now exposed to both sides of the problem and can see, through modeling, how the two sides can live together. Being exposed to such a presentation, the client is likely to change his view. The internal struggle with the problem is now externalized through the therapists.

3 HOW THE SYSTEM PROTECTS AND PRESERVES ITSELF The goal of the system, once formed, is to preserve itself. This means that the system is able to fulfill its mission: providing its members with a sense of order, security, belonging, and identity. The need for system preservation supersedes the existence of its individual members. The well-being of the majority surpasses that of the individual. A family member might sacrifice himself to save the system. Self-destructive behaviors—such as failing academically, abusing alcohol or drugs, developing or intensifying a medical problem, and at times even threatening suicide—are common examples of how family members attempt to save the system. This view of the questionably designated pathological behavior attests to the importance of the system for the individual, for whom it fulfills a crucial function. It gives him the expectation of a safe base that enables him to grow and prosper. The threat to its existence may lead to the features described earlier. Preservation is so important that the system uses numerous means to protect and perpetuate itself. It does so by binding (contract), distracting attention from system-endangering situations (scapegoat symptoms), friction control (emotional regulation), tension diffusion (emotional triangles), and symptom formation. CONTRACT

The launching of a system is accompanied by the signing of a contract by the founding members. This specifies each member’s privileges, obligations, and commitments. It may be written (e.g., a prenuptial agreement), verbal 37

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(the partners discuss it but do not commit it to writing), or nonverbal (no discussion takes place, but there is a tacit understanding about the terms of the contract). The contract may be private or public. In the case of a marital contract, the contract is signed at a public ceremony where the partners exchange vows of loyalty. The public ceremony, performed before other people and God, is more binding than a private contract. In many religions (e.g., Judaism, Islam), in addition to the public ceremony a financial contract is drawn up, designed to reinforce the bonds of marriage. The contract is binding or ceremonial, and people tend to honor it as long as it serves their needs. The private contract is very likely to be dynamic, and it tends to change over time and with changing circumstances. It reflects change in its signatories in areas such as education, occupation, position, living conditions, and economic status. These are natural developments likely to take place throughout life; if they occur simultaneously in the partners, they can probably lead to a mutually acceptable amendment of the contract. This may reflect role change or even role reversal (e.g., one spouse supports the other, who is studying for a degree, and after the latter graduates and begins to earn money, the supporter may become the supported). Another cause for contract change is the loss by one of the spouses of her physical or mental abilities due to illness or accident. All these instances call for a change in the contract. If the appropriate change is made and accepted, the system will be safeguarded and remain beneficial for all parties involved. However, often people are not even aware that the contract has changed or that it needs to change. In the former case the spouses may grow dissatisfied, behaving in a way they are not used to or filling a role they do not think is suitable for them. A spouse whose part in the contract was of a passive, acquiescing, and responsive kind may find himself asked (not necessarily directly) to behave differently, to initiate activities and take more responsibility for social occasions. This request may constitute an unacceptable breach of the contract, resulting in arguments, fights, and pressure to restore the original terms. In the latter case a power struggle is likely to ensue, and the spouses may not be aware of its underlying cause. Both are likely to be aware of the fight, of the fact that the other spouse is not responsive to his or her needs, and of his or her resentment but not of the real issue.

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The power struggle may end in a new contract, a dysfunctional stalemate, or a change in the system (separation or divorce). TRIANGLES

A human system consists of at least two elements, which are functionally and emotionally related. To be efficient, a system should satisfy its members’ needs. Everyday life presents ample sources of tension and anxiety for the system. The way the tension and the resulting anxiety are dealt with determines how healthy the system is. One common anxiety-reducing mechanism used by members of the family system is a triangle (Guerin et al. 1996). An unresolved tension in dyadic relations (e.g., between spouses) may threaten a breakdown of the system. The most helpful way to reduce the tension causing the threat is by discussing and clarifying the issues and resolving them. But if this way out is not feasible (usually because of the high-level anxiety stemming from the perceived threat to the system’s integrity, such as a fight that might potentially lead to separation), the dyad introduces a third element into the relationship, against which the two can now unite (create a coalition). The addition of a third element helps distribute tension and refocus the system on the third, nonthreatening element, a process called triangulation that promotes stability in the system (Guerin and Guerin 2002). The motherin-law is a traditional third party. She is a culturally accepted target for a couple’s difficulties. “You are just like your mother” is a commonly used maxim designed to displace the spouse’s annoying behavior. When the system becomes tense and anxious, and a threat to its survival is perceived, it may try to triangulate one of its members while sacrificing this member’s well-being. A behaviorally difficult child whose parents are experiencing marital discord is an example of a tension-reducing mechanism. At times we hear in therapy that people give birth to children in order to “strengthen” the relationship. Usually this means that the couple needs someone else to ease the tension. We shall discuss this issue later at length. A pet may also serve as a tension-reducing element. At times even an extramarital affair may serve this same purpose. A possible consequence of triangulation is that the locked (e.g., a child) member’s emotional development may become subservient to the system’s

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well-being and become emotionally or developmentally arrested. This mechanism is also called interlocking family pathology (Ackerman 1982) or the family projection process (Bowen 1976). A triangulated child is likely to choose a mate whose level of emotional development (differentiation) is similar to or lower than hers. This choice is usually made with the subconscious intention of preserving one’s self-esteem. When the parents suffer marital discord, they may pull the child into the dyadic system, or the child, fearing marital breakdown, will “offer” to help by developing difficulties in areas that will attract his parents’ attention (e.g., school, behavior, eating) and will also attract others’ attention as a cry for help. The targeted member is often considered the scapegoat or identified patient. Scapegoat and Identified Patient

Scapegoating is an ancient custom; it was used by the Israelites in the time of the Temple. The High Priest (Cohen Gadol) chose a goat (se’ir) on which were loaded all the sins of Israel. It was then driven off into the wilderness (Azazel) or thrown off a cliff. With the departure of the goat, all sins were forgiven. The system uses the scapegoat to help displace blame and project responsibility onto someone else. This “someone” is likely to be a family member who may already have difficulties (e.g., physical or mental disability, behavioral problems). Having a scapegoat releases the tension in the system by replacing it with a more benign stressful situation. An example is parents who bitterly disagree about their child’s schooling problems; they probably have marital discord. In this case, disagreement over the child’s problems does not carry the risk of system breakdown, which marital discord may. This stressful situation is less threatening to the unity of the system, and it may even strengthen it (the need to cope with a difficulty may lead to unity) and is likely to be socially acceptable. The parents do disagree about child rearing and how to deal with the child’s difficulties. Involvement with matters concerning the child releases the tension between the parents, reduces the threat of breakdown, and diverts attention from a more fundamental and therefore more dangerous conflict. The scapegoat is often also considered the identified patient (IP). This person is a family member who represents the family pathology. Often family

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pathology is manifested in individual pathology. For example, a wife can display depressive symptoms that are secondary to her spouse’s problems. A sixty-three-year-old woman was referred to therapy because of severe depression. She had been married to her sixty-five-year-old husband for almost thirty-five years and had three children, all married and living away from home. She came to the session with her husband, who was greatly concerned about his wife’s situation. She reported staying at home most of the day, usually sleeping. Her hygiene was poor, and she was dressed carelessly with no makeup. She reported that she did none of her usual house chores; she had stopped participating in her favorite social activities and felt sad, despondent, and helpless. Everything tasted the same, and she felt that her life was meaningless; she had suicidal ideation. During the intake, it was found that the onset of symptoms had been about a month before the session. When asked whether any significant event occurred in the family before the symptom onset, the couple mentioned that the husband, who was the CEO of a large company, had received a dismissal notice about three weeks before his wife became depressed. The initial symptoms appeared a week after receipt of the notice and worsened quickly. The effect of job termination was very bad because they were not financially well prepared for it, and the husband was to lose a substantial amount of needed money. His employment potential at his age was minimal. However, neither of them evinced much concern about this; when asked why, they said, “We have to deal with the depression now. Everything else will have to wait.” This answer clarified family dynamics for the therapist. Symptomatically, this was a clear case of major depressive disorder. However, the lack of concern about the loss of a job suggested the possibility that the depression was functional, helping them avoid dealing with the more devastating news. The wife became the IP, thereby helping her husband cope with the distressing turn of events. The husband, who had been perceived as the stronger one in their dyadic relations, retained his position in the system. This reformulation of the problem was affirmed by the chronology and pace of symptom development, along with the husband’s apparent lack of concern about his grave situation. The symptom itself reflects the appropriate affective tone of the family. The subsequent intervention actually focused on the

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husband and ended successfully after just a few sessions. The wife’s depression was ameliorated, and couple was able to deal with their future financial security. A three-month and one-year follow-up indicated continuous improvement. Another instance, more common in therapy, is a child brought to therapy by his parents because of educational and emotional difficulties at school. Usually help is sought for the child, but a system therapist would inquire about the parents’ marital relationship. Commonly, there would be marital discord. A case in point is that of Jack, a nine-year-old boy who was referred to therapy by his school counselor, who reported that Jack had educational, behavioral, and emotional difficulties at school (difficulties in handling failures and frustrations, aggressive and violent behavior applied to achieve his goals, no limits set at home, and difficulty accepting them at school). After a short intake it became apparent that indeed there was marital discord. Marital relationships are characterized by mutual estrangement (Jack slept in the same bed as his parents, his father appeared very passive and complained about his wife’s excessive controlling behavior of him and the children, and intimacy was absent from the relationship.) The parents did not agree about whether and how to discipline the children. Here we see a common situation in which the child, through his seemingly pathological behavior, expresses system difficulties, and more importantly marital difficulties, which may lead to divorce if openly encountered. The child takes upon himself the problem and becomes the IP. A wise therapist can see immediately what is going on and will recommend couple therapy rather than individual therapy for the child. In these cases, the IP shouldered responsibility for saving the system. We often encounter this phenomenon with family members (usually one member) who manifest a variety of symptoms that are designed, not necessarily consciously, to distract attention from a more damaging difficulty (e.g., divorce, severe illness). I believe that when one of the family members is the IP, suggesting individual therapy for the IP is unwarranted. Moreover, it is likely to have negative consequences overall. If therapy for the IP is successful, another child may develop symptomatic behavior, or the parents may deny the positive change or force the child back into the IP position. Should therapy fail, the IP’s behavior may worsen. Thus, the IP may represent the system to the outside world. The IP is not

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perceived as weak or inadequate, as one might think. On the contrary, this person is strong and functional. This is the person who says, “I am weak, I feel helpless. Help me.” This is in contrast to the person who does not admit to any difficulties and tries to maintain the impression of competence. This person is likely to feel alone and isolated and cannot generate support in coping with the difficulties. The IP heralds the difficulties of the system and calls for help from the outside world. The IP assumes responsibility for preserving the system by taking on the symptoms. The IP situation is typically dialectical. The problematic, symptomatic, needy member is actually a strong, responsible, and altruistic member of the family. An interesting and still unanswered question is who is likely to be the system’s IP. The first and perhaps most common candidate is a family member who already has some kind of disability (e.g., mental, developmental, physical, learning). A second common candidate is the eldest (or only) child, who, by the nature of her role, takes responsibility for the family when the parents fail to provide for it. Another person likely to take on the IP role is the youngest child. This child is the last to remain in the family home after the older children have left. If there is a problem in marital relations, this child may develop a problem to attract attention to the family or to distract the parents’ attention from the discord. The other children may also undertake the IP role; clearly, any member of the family system may serve as an IP. EMOTIONAL DISTANCE REGULATORY MECHANISMS

The roles members fulfill in the family help define the distance between them (Kantor and Lehr 1975), as do boundaries (enmeshed, disengaged). This distance is functional and smooths out the system’s everyday life. Working outside the home, living in different quarters, and following different cultural and religious customs are some of the measures used to create physical distance. Even though the distance is determined formally or physically, it has emotional implications. A role is associated with status and social distance (parents and children), whereas a boundary is more associated with emotional distance (disengaged boundaries usually mean emotional distance, and enmeshed boundaries mean emotional closeness). People tend to create a breathing space around them that defines their

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physical and emotional boundaries. It is a highly flexible space. It changes with respect to culture, physical setting, situation, and the person one is with; it tends to be greater with strangers than with people one knows. These factors determine the extent of the person’s interpersonal space. The space is needed to preserve perceived personal physical and emotional integrity. When this personal space is violated, the person feels discomfited and acts to restore it so that he feels more at ease. Personal space is related to the dialectic of autonomy–connection (Baxter 1990; Baxter and Simons 1993; Van Lear 1998). Interpersonal relationships involve dialectic contrasts, the central of which involves the need for autonomy, which is simultaneously related to the need for emotional closeness. The autonomy–connection contrast yields tension resulting from the conflict between independence and commitment and between individuation and separation. These are also reflected in approach–avoidance behaviors in marital relationships (Van Lear 1998). Charny (1992) relates them to the dialectics of distance–closeness and love–hate and suggests that dialectic relationships contribute to personal development (“Our weaknesses enhance our strengths,” 11). Feeney (1999) found that closeness–distance relationships (similar to autonomy–connection) in couples tend to change over time. This finding supports the idea that dialectics create tension, which leads to further change. Other studies (Hughes and Lieberman 1990; Macaskill and Monach 1990) that investigated the effect of stress factors related to a cancer-stricken child on the marital system found a similar pattern of distance and closeness between the parents. The emotional distance between family system members (husband– wife, parents–children) or between other people who are emotionally important to each other tends to oscillate regularly. First there is an inward movement, and people draw closer to each other. At a certain point the movement shifts outward, and people begin distancing themselves, but only to the point where the distance becomes intolerable. A movement toward more emotional closeness ensues. The degree of emotional closeness is determined by the quality of the relationship and the level of intimacy. The better the relationship and higher the level of intimacy, the closer the emotional distance. However, when the closeness reaches a level where the individuals feel threatened and become afraid of hurting, of being hurt or rejected, of losing control, of losing their own identity,

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and so on, a regulatory mechanism is activated to maintain a situationally optimal distance. The following vignette illustrates how the regulatory mechanism works: A married couple with two small children was referred for therapy. The father, an insurance broker, is forty-two. The mother, an elementary school teacher, is forty. Their careers are very important to them, and they put a lot of time in them. They married for love twelve years ago, and they describe their life as basically good and quite secure. They wake up in the morning, send the kids off to school, and go to work; the father comes home around 7:00 p.m., the mother around 2:00 p.m. They discuss their day briefly when they meet, and then each goes his or her way (e.g., computer, jogging). This routine continues for quite a while. Then, a fight ensues over who will pick up the kids from soccer. The fight lights up quickly and turns into a serious one. Both shout at each other and threaten to leave, and then, after a while, they stop fighting and each goes to his or her corner. Later that night, they talk about the fight and determine that the trigger for it was insignificant. They hug each other, have sex, and wake up in the morning feeling very well. They talk with each other and plan on doing things together that weekend, and indeed they do. After a week, life turns routine again, until the next fight. This vignette depicts the issue of emotional distance regulating mechanisms. The married couple has routine life. This routine revolves around work and the kids. They have no time for themselves as a couple. The growing distance leads to feelings of abandonment, resentment, and fear of losing one another. The fights are engineered to show each other how much they dislike the situation and how much they need each other’s attention (recall that the dialectical meaning of anger is both distance and caring). The fight and the reconciliation bring them back together and closer to each other. The return to routine marks the continuation of the cycle. Couples are ingenious in developing these mechanisms. The most common one is arguing (and its extreme is physical abuse). The expression of anger is dialectical; it means that the angry person needs to distance himself from the other person, but it also means that he cares about the other and is ready to invest energy and emotion in relating to her. Another

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mechanism is separation (e.g., work, travel, extramarital affairs, secrets). When the distance becomes too great and the relationship threatens to break up, another means is activated to bring the spouses closer, such as reconciliation or a crisis involving external elements (e.g., work, friends). By these mechanisms the couple is able to maintain a balance between closeness and distance that stabilizes the relationship. These mechanisms are dialectic, and the tension between closeness and distance leads to permanent change. These are genuine mechanisms, which couples may well misinterpret as dysfunctional and abnormal. When spouses realize how habitual and predictable their regulatory mechanisms for emotional distance are, their anxiety and threat levels decline markedly. The regulatory mechanisms for emotional distance regulate the level of intimacy the couple can live with comfortably. They underlie one of the most fundamental fears people cope with in interpersonal relationships: fear of intimacy. Fear of intimacy is defined as inhibition against sharing personal thoughts and feelings with a highly valued other (Descutner and Thelen 1991). Fear of intimacy is a lack of mutual trust and a sense of vulnerability in a close relationship. Hook, Gerstein, and Gridley (2003) summarize the basic components of intimacy; the first is love and affection. When people feel loved, they are willing to open up and share with the loving partner (Berscheid 1985). The second is personal validation: the knowledge and awareness of being loved, understood, and approved (Berscheid 1985). The third is trust: a sense of safety in the knowledge that your partner will protect your confidences (Hatfield and Rapson 1993). The fourth is selfdisclosure: the ability to reveal yourself on a deeper, personal level. This allows the expression of love, caring, trust, and understanding (Hatfield and Rapson 1993). Hook et al. (2003) confirmed these four elements in their factor analysis. The most fundamental element of intimacy is trust. Trust allows selfdisclosure and validation, which foster love, sharing, and caring. Erikson (1959) assigns great importance to the ability to be intimate and posits this as a goal for young adults. Erikson sees intimacy as a condition for commitment and the ability to form stable relationships and avoid loneliness. Being intimate is a way to avoid loneliness and gain support and nurturance (Brown 1995). It supports feelings of well-being, mastery, and recognition

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(Prager 1995, 1999). As expected, Hook et al. (2003) found that women placed more emphasis than men on love, affection, expression of tender feelings, and emotional sharing. THE SYMPTOM

In most psychotherapeutic approaches a symptom is viewed as the sign of a dysfunction. In psychodynamic psychotherapy the symptom is regarded as an indication of an underlying psychic conflict. In behavior therapy the symptom is viewed as a maladaptive behavior. The role of the therapist in the earlier tradition was to explore the psychic source of the symptom in order to identify the conflict, resolve it, and eliminate the symptomatic behavior. The removal of the symptom was deemed the goal of therapy. The system therapist treats the symptom as a means of communication. The presented symptom indicates that the system is experiencing difficulties, which may have no direct bearing on the presented symptoms. When a child displays aggressive behavior, including vandalism, disobedience, and truancy, an individually oriented therapist is likely to interpret these behaviors as an indication of conduct disorder or manifestations of distress (e.g., depression) and will treat the child accordingly. A system therapist will see the child’s behavior as an indication of a distressed and malfunctioning system. Further assessment of the system is likely to reveal that at the root of the child’s aggressive behavior lies marital discord. The focus on the systemic source of the symptom does not mean that the person manifesting the symptom does not suffer or does not have difficulties, only that the source of the symptoms is systemic. This does not mean that the symptom itself is meaningless. It is important not only in its communicative sense (as a call for help) but also in how it describes the person’s distress and its expression. The emotion expressed or represented by the symptom probably reflects the family atmosphere, covertly or overtly. From a system point of view, looking at the symptom as an individual problem is likely to be limiting and distracting. The manifested symptom is likely to be an “entrance ticket” to therapy. The symptom is communicative but most of all is functional (Haley 1976; Madanes 1981, 1984); it maintains the family homeostasis (Jackson 1967) by reducing destructive tension between the spouses (Vogel and Bell

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1960) through triangulation and thereby protects the whole family (Selvini Palazzoli et al. 1978). It can safely be assumed that when a behavioral pattern (symptom) persists over a long period of time it is indeed functional for the system. In this case, the symptom plays a part in preserving the system. Even though the symptom is associated with unpleasant, destructive behavior, its purpose is to prevent a worse situation (e.g., divorce, mental breakdown). Sometimes the tension between the spouses appears to be the result rather the cause of the IP’s problems, and the removal of the IP from the system (e.g., encouraging this person to leave home) may reduce the tension. Such is the case with a highly problematic child whose parents feel helpless, hopeless, and very angry. If the child’s problems mask severe marital discord, her removal from home will not help solve the underlying discord. Such “solutions” rarely succeed. We found the system view of the individual’s symptoms most helpful in trying to identify and understand the core problem on which to focus therapy. In most cases in which the IP is a child, the underlying problem resides with the parents. This observation, along with the idea of hierarchy, has led therapists to consider parents responsible for system difficulties. Clinical experience, which has shown repeatedly that treating the parents’ problem usually resolves the child’s difficulties, has reinforced this view. Many therapists take this direction. At a recent convention we informally surveyed our colleagues, asking them what percentage of their practice consists of family therapy in comparison with couple therapy. The responses suggested that therapists have significantly shifted in favor of couple therapy. Almagor (1997) argues that the reason for this shift is the therapists’ experience that treating those higher in the family hierarchy (i.e., parents) is more effective in resolving the child’s problems. At times, however, watching the unfolding drama of the system can make the therapist feel accusatory and blaming toward the parents. I shall never forget the following case. I received a request from family court to help parents reconnect with their children. After a long, violent, and abusive struggle, the mother was able to gain custody of two of their three children (a son aged nineteen and two daughters aged fourteen and ten). However, the older children chose to stay with their father, and only the younger daughter stayed with the mother.

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The younger child severed all ties with her father and her siblings, and the older siblings were cut off from their mother. From the intake and throughout the intervention, it was very clear that the hostility between the parents implicated the children directly (they witnessed their parents’ arguments and were obliged to testify against their mother in court). The children were torn between their parents, feeling loyalty to the parent they lived with and hostility toward the other. In individual sessions the children stated their readiness to abandon their hostile attitude and reconnect with the other parent. This willingness was then rejected by the other parent, and both parents did their best to maintain the hostile situation. Either they did it openly (“How can I persuade the child to see the other parent if that parent tries to cheat me out of my rights to the property?”) or subtly by conveying to the child their dismay at the other parent’s behavior. Right from the beginning, I felt pained and frustrated watching how things developed. On one occasion I warned the parents against involving the kids in their struggle and predicted that their lack of flexibility in trying to resolve divorce contract issues could end in a regression in the children’s condition. After that meeting the two older children agreed and began interacting and visiting their mother; the youngest still refused any contact with her father. Nevertheless, the hostility between the parents continued. Soon after the change was made there was a regression, and the situation returned to the pretreatment baseline. Apparently, I had failed to convince the parents to change their behavior. Even though the parents expressed willingness to change the situation, the pain and hostility that characterized their relationship prevented them from nurturing their children’s welfare. At this point I realized that I was in the same position that two other professionals working with the family had gotten into before. They ended up blaming one of the parents for the situation; the only difference was that I blamed both parents. But like them, I felt helpless in trying to change it. Understanding the parents’ pain and empathizing with them did not succeed in preventing them from involving their children in their fights and alienating them. The parents’ fears of dealing with their own problems had led them to stubbornly keep their child as the IP. Their child was assigned the task of saving the marriage. Still, this example is a rare exception. Responsibility for the current

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situation, problematic or not, lies mostly with the parents. The question is not whether there are parents to blame. The parents are always there to be blamed for their children’s failure or success (even though the former is more common than the latter). The question is at what point the responsibility is also shared by the child or becomes the child’s and whether the parents’ perceived responsibility is material for treating the current problem. If a child is a preschooler, there is little doubt who is responsible and who can be instrumental in helping the family. When the child is an adolescent we begin asking ourselves how responsibility for the solution is shared between parents and children. When we talk about a young adult or an adult, the question of parents’ responsibility may appear academic. It is needed in order to explain the problem, but it might have nothing to do with solving it. Moreover, we believe that parents do their best to rear their children, given the knowledge and educational practices of that time. But after a while, when difficulties appear, people begin to reevaluate their past behavior in light of current knowledge and practices. Consequently, they blame themselves for something they actually had no control of. Therapists should be aware of this, or they may blame the parents wrongly. Having the parents to blame for the difficulties is counterproductive if it becomes an excuse for not dealing with the problem in the present or for avoiding the problem altogether. The symptom functions in the system as an attempt to save it. The IP’s situation illustrates the basic system axiom: the existence of the system is more important than the well-being of its members. However, at times the symptom is so severe that the system is likely to break down, as in cases of incest, child abuse, or infidelity.

4 SYSTEM DEVELOPMENT AND LIFE CYCLE The system is an entity that has a structure and interacts continuously with the intrasystem and extrasystem environments. This interaction leads to a change in the system, making it a process rather than stationary, so it can be understood only within a time dimension. Like a living organism, the system develops and changes over time. These changes occur in a systematic series of phases that correspond partly to the individual’s development. The change is not so much evolutionary as revolutionary. Transition from one developmental stage to another is likely to involve a life event crisis (Haley 1973) that demands a change in the system. Zilbach (1989) calls these transitional life events family markers, which demand new adaptation. Gerson (1995) argues that each transition requires the system to reorganize in order to meet the challenges of change. The more competent the family is in using its resources, such as economic, emotional, and mutual support (what Walsh 1996 calls relational resiliency), the more able it is to adapt to transitions and use them to consolidate the system. Hadley et al. (1974) found that the onset of psychiatric symptoms was correlated with developmental–transitional crises related to the addition and loss of family members. The dialectic conflict characterizing each stage of the family life cycle is that of movement from separation to unification or from unification to separation. The basic dialectics in family development can be conceptualized as closeness–distance or love–hate (Charny 1992). At each stage a change is needed, which may be conceptualized as an attempt to find a dialectical synthesis for the new situation. Consequently, the system is ever-changing. Each stage is signified by a predictable marker, but 51

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unpredictable events (e.g., death, divorce, illness) may alter the course and nature of the development. The developmental scheme depicted here is general and likely to have many exceptions (e.g., ethnic, cultural, religious; see Carter and McGoldrick 1988). The number of stages, and their onset, are entirely arbitrary. Duvall (1977) divides the family life span according to changes in the number of members of the family. This author focuses on child rearing as the focal event in family transitions. Carter and McGoldrick (1980, 1988) use a multigenerational model of the family life cycle. There is interplay between the individual’s life cycle and the family’s. If the family’s developmental sequence is disrupted (e.g., by a nondevelopmental crisis such as a car accident), so is the individual’s course in life (e.g., by injury) and vice versa. The system evolves cyclically. From two separate individuals it becomes a union; this expands with the birth of children and then contracts when children leave home. The system dies with the death of the spouses. The family system undergoes a process of expansion and contraction. The most notable family system dialectic is the unification–separation that characterizes most of the stages, when a family member is about to join another system (e.g., child goes to school, retirement).

STAGES IN LIFE CYCLE

Courtship

The formation of a family system begins when the married partners first meet. Finding a romantic partner appears to be culturally related. In some cultures marriages are arranged, often with the help of matchmakers; this limits a person’s choice of partner. In such cultures matching is usually made on the basis of demographic, ethnic, and social status and financial ability. The individual’s wishes may be taken into account, but these are not the only factor or the most important. In the Western world, where individuality, independence, and freedom of choice are emphasized, mating depends more on the people one meets. Mating appears to be an evolutionary phenomenon. People seek each other for the purpose of forming relationships, with the primary goal of

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reproducing their genes in order to continue the species. Sexual strategy theory (Buss and Schmidt 1993, extending Trivers’s 1972 parental investment theory) argues that males will couple with as many females as possible who show fertility markers (e.g., youth, physical attractiveness of the face and breasts), whereas women look for resourceful men (who can defend and provide for the woman and her offspring). Buss (1989) conducted an extensive study (more than ten thousand participants in thirty-seven different cultures) and confirmed these conclusions. Evolutionary theory explains the need for coupling and how the selection is generally made but does not predict why a particular man will choose a particular woman, who will similarly choose him. How does the search narrow down to that specific person? People in the Western world usually look for mates among people with whom they often interact, a tendency called the propinquity effect (Berscheid and Reis 1998). Proximity to a potential partner can be geographic or computer mediated (Lea and Spears 1995). People seek those who are similar to them, rather than those who complement them (Berscheid and Reis 1998; McPherson, Smith-Lovin, and Cook 2001), in demography, attitudes, and values (Newcomb 1961) and interpersonal style (Duck and Pittman 1994). Little and Perrett (2002) found that people judged as similar to the rater received a higher rating on attraction than those not similar to the rater. People who are similar to us are likely to like us (Condon and Crano 1988), validate us (Byrne and Clore 1970), and agree with us (Rosenbaum 1986). In short, people who are similar to us are more predictable and less threatening and give us a sense of security; therefore, they are more likely to be potential candidates for marriage. Proximity and similarity limit the number of available people, and it may be reduced further by physical attraction. Several studies have documented the value of this element. In his meta-analysis of these studies, Feingold (1990) found that both males and females valued attractiveness, males somewhat more than females. In behavioral attraction rather than attitudinal, the sexes evinced no difference (Feingold 1990). Regarding marriage, Regan and Berscheid (1997) found that men preferred a physically attractive marriage partner more than women; unexpectedly, women did not find such characteristics as social or financial power and a college degree more desirable in a prospective spouse than did men. Langlois et

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al. (2000) found that attractive children and adults were judged and treated more positively than unattractive children and adults, even by those who knew them. So the importance of physical attraction should not be underrated. However, both men and women rated honesty, trustworthiness, and a pleasant personality as the most desired characteristics in a marriage partner (Buss and Barnes 1986; Regan and Berscheid 1997). Men apparently preferred women younger than themselves, whereas women preferred men about their age (Buss 1989; Kenrick and Keefe 1992). Proximity, similarity, physical attraction, and desired personality traits help us to limit our choice of mates out of a large number of people with whom we are acquainted. The question of how we find and connect to a specific person, the one we want to share our life with, and who wants the same of us, still stands. Suppose you are a student looking for a mate. The number of suitable candidates who meet these criteria is very large. Still, you need to narrow this number down to a single person whom you desire and who desires you. A question I routinely ask my clients at the first intake session is, “What was it in your partner that attracted you the first time he or she caught your eye?” Incidentally, and independently of the current distress the couple is experiencing, this question usually raises the first smile in the session. The question takes the couple to one of the happiest times in their relationship. The answer directs us to the likely source of their mutual attraction and conflict. It reveals the partners’ mutual expectations and fantasies. Charny (1992) describes this process eloquently: “Our spouse is often is a looking glass in which we are privileged to see the worst in ourselves disguised in an outer form that is opposite to our style, so we can pretend not to recognize ourselves” (410). Earlier studies by Lay and Jackson (1969), Norman and Goldberg (1966), and Passini and Norman (1966) explored the effect of length of acquaintance on the validity of personality trait ratings. They found that the internal validity of the ratings was high and independent of length of acquaintance. Internal validity is the lexical structure of personality, which is the result of the use of language to describe the various characteristics (see also Almagor 1996; Almagor and Koren 2001). However, external validity depends on length of acquaintance: the longer the acquaintance, the more valid the description. The discrepancy between a

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belief (a “click,” discussed later in this chapter) and an empirical finding explains how first impressions may be mistaken. People tend to base their impressions on few cues, mostly related to physical appearance (eyes, stature, chest, buttocks, or face) and behavior (joking, serious, or lively) and then build perceptions based on traits associated with these cues and their projections onto these traits. A woman who has brown eyes is perceived as soft and warm. This is likely to be generalized to her being a motherly, loving, and caring person. Time of acquaintance will allow an assessment of the validity of these impressions. The more rigidly the first impression is held, the more distorted the perception of this person will be. The initial perception becomes a self-fulfilling prophecy. This may sustain an invalid view of the person for a long time. Recognition of an invalid perception may lead to severance of the relationship or changing perceptions and behaviors, and hence the nature of the relationship. Nevertheless, most couples seem to overcome the inaccuracy of that impression and find other binding areas of interest, whereas those who cling to the initial impression may find it difficult to accept the change. It stems from our wish to find a partner who will help us heal the wounds we suffered in earlier relationships or experienced or were exposed to in relationships with those significant to us (Hendrix 1990, 1992, 1994, 1996). For example, a person who perceived his parents as domineering and too strict will want to find somebody who may appear like his parents but whom he perceives as being capable of change. By changing our partner we gain a feeling of competency and ability to complete unfinished business. The wish to correct the wound is shared by both partners, although the nature of each wound may differ. Should our wish come true, we may well have a successful marriage. Hendrix’s view assumes that everyone experienced a traumatic childhood. This may be true for couples who need or seek therapy, but it does not necessarily apply to all couples. It can easily be assumed that with the absence of relevant information on the first encounter, we find in the future mate what we miss in ourselves. Thus, we look for a mate who complements the needs that are important to us. For example, a person who is steady, reliable, and unadventurous may look for a partner who is lively and adventurous.

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The idea that we look for someone who will complete us is not new. Actually Winch, Ktsanes, and Ktsanes (1955) and Winch (1967) theorized that “each individual seeks within his or her field of eligibles for that person who gives the greatest promise of providing him or her with maximum need gratification” (1967, 756). Unfortunately, research has failed to replicate and validate Winch’s theory. Two reasons for this, I believe, were the use of pencil-and-paper personality questionnaires and the fact that participants were asked to rate a number of needs or traits (see Murray 1938 and Jackson’s 1967 Personality Research Form, respectively) without indicating their relative importance (Meyer and Pepper 1977). Kerckhoff and Davis (1972) conducted an interesting study in which the process of choosing a mate was delineated and found that similarity in demographics and values preceded complementarity of needs. Karp, Jackson, and Lester (1970) found that engaged women saw their ideal selves (when these differed from their actual selves) in their fiancés. Meyer and Pepper (1977) suggested that complementarity of needs may be related to marital satisfaction. Still, the question of meeting the particular person whom we would like to marry and who will want the same of us is still open. In a Western-type culture this question may be partially answered by what we call the click phenomenon. The “click” encounter occurs instantaneously, and people who experience it feel as if they have known each other for ages. The amount of information exchanged between potential mates during the click is enormous and sometimes erroneous. However, on their first encounter, the partners usually learn very little about each other. The information conveyed rests on contextual (e.g., place of meeting and type of people usually found in that place), physical (senses), and behavioral cues. Another possible factor in narrowing down the number of suitable candidates may be simple luck. This is an unpredictable factor, but it may be akin, but not identical, to the click phenomenon. Lykken and Tellegen (1993) found that a mate is chosen randomly, even if the choice involves identical twins. After partners have met and decide they want to be together, they will try to strengthen the relationship. They are likely to live together and share their lives without getting married. This is usually considered a test period, in which the partners check each other out before they commit for life.

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This testing period is not necessarily a reliable measure for future relations. Cohabitation is still part of the courtship stage, in which the partners have the option of leaving the relationship. The existence of this option may allow more flexibility in expectations and behavior, which will not be present after the wedding. Actually, Bumpass and Sweet (1989), analyzing data from the 1987–1988 U.S. national survey of families and households, concluded that couples living together before marriage were more likely to break up than couples beginning their life together with marriage. This finding is consistent with the “optional” view of cohabitation before marriage and lends more support to the importance of the wedding vows. Aron et al. (1989) suggest that reciprocal liking, in which each potential partner reinforces the other in connecting and forming the relationship, is the answer. Hazan and Diamond (2000) suggest attachment theory as a possible explanation for mate choice. They argue that reciprocal liking triggers romantic infatuation, which leads to close physical contact and bonding. These explanations still leave us with the question of how reciprocal liking is triggered. How is the choice made at this crucial point? The courtship is marked by two intertwining dilemmas: the need to establish a trustful relationship and the ability to allow oneself to be vulnerable in the relationship. People who want a long-lasting relationship would like to ensure trust in their partner before making the marriage vows. They need to know they can entrust their partner with their secrets and allow themselves to be vulnerable in the relationship. If they feel this way, then the marital relationship will be a secure base for them. Therefore, the dialectics of this stage in the relationship are those of trust–mistrust and guardedness–vulnerability. The Wedding Ceremony

The wedding ceremony is a public statement about one’s intention to be married. The bride and groom exchange vows that affirm their loyalty and support for each other under all conditions. This is a public statement confirming the purpose of the marriage: exclusive belonging and security. The public statement is designed to fortify the bond. A public commitment is believed to be stronger than a private one (Pallak, Cook, and Sullivan 1980). This unequivocal public commitment is the reason why living together

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without marriage differs so from being married. People who live together can leave the relationship at will. The partners are aware of this and behave accordingly. The courtship may continue as long as the pair lives together. But the wedding ceremony is a public declaration that the option to leave is abandoned. Having a child or jointly owning a home is another way to assert commitment to each other. The importance and meaning of the wedding ceremony may lead to a minor crisis. The dialectic issue here is that of commitment versus avoidance of commitment. The bride- and groom-to-be must decide whether they want to be committed to each other. At times people may feel fear or even panic as the wedding day nears. The idea that they are going to lose their freedom sparks second thoughts. The bride- or groom-to-be may rethink the whole idea of marriage. One of them might act on this fear and cancel the nuptials. Such a situation is considered a minor crisis because it usually unfolds when all the wedding arrangements have been made and there is no easy way out. However, for most people this crisis passes fairly quickly. The wedding ceremony signifies a major turning point in the relationship; courtship is over, and the spouses are left to explore each other’s wishes and needs and to develop a new balance in the relationship. The movement is from separation to unification on the separation–unification dialectic poles. First Year of Marriage

After the ceremony and the traditional honeymoon, where, it is hoped, everything has been glamorous and beautiful, the married couple returns to “real” life. The initial stage after the ceremony lasts about a year or until just before the first child is born. It is devoted to building the dyadic system and usually ends with the first pregnancy. The spouses learn each other’s habits and how to change or accept behaviors in the other that they do not like. During courtship these behaviors were tolerated because of the tentativeness of the relationship. Now that the courtship is over and spouses feel secure in the relationship, there is a mutual attempt to change undesirable behaviors. This process can be turbulent. Clashes may erupt over trivial issues, such as bed sharing, house cleaning, and relations with the in-laws.

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This phase ends when the partners settle most of the disturbing disputes and feel secure and confident in the relationship. Role divisions are being established, and each spouse finds his or her place in the relationship. Tumultuous relations are extremely important in building the dyadic relationship. The ability to fight indicates basic security in the self and in the relationship. The secure feeling makes possible authentic expression of needs and should not be deemed problematic. The crisis functions to develop an open, satisfying relationship. Optimally, relations are peaceful and everything is done by mutual agreement. However, much of the time the “peaceful” relationship is just a cover for fear of confrontation, difficulty in dealing with anger, or fear of being rejected. When this is the situation, the relationship is likely to be problematic in the long run. The dialectic issue here is that of unification and individuality. How much am I willing to give up of myself for the other without losing my separate identity? At issue is finding the point where unification and individuality feel comfortable. Either spouse is likely to undergo a behavioral change intended to accommodate the partner. For example, in my first marriage I was the adventurous, stimulation-seeking partner. In my second marriage I was the stable, less adventurous, more passive and solid partner. Obviously these transitions were relative to my spouse at the time. This phase is critical because, as noted, it often ends with the couple’s first pregnancy. After the first child is born, child rearing becomes the focus of the relationship, now triadic. The next time the couple is alone together will be when the last child leaves home, and this may take many years. If the newlywed couple enters this period out of coercion (e.g., unplanned pregnancy, unwanted or forced marriage), they will see this period negatively, as a time of contending with unwanted circumstances beyond their control. This period will then be seen as one of confrontation and adjustment to an exceptional situation. The couple is likely to regard marriage as a burden. This is the period in which the in-laws, for better or worse, may become part of the marriage. If the in-laws are too intrusive they are likely to endanger the newly formed system. This may also occur when the spouses fail to set limits for their in-laws, giving them license to hinder the couple’s ability to develop intimacy. If the in-laws become too intrusive, the couple may then set limits on themselves and cut themselves off from the extended

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family. This tendency may increase closeness between spouses. Obviously, the desirable relationship would include more cooperation on both sides and respect for each other’s boundaries. In this case the in-laws may try to stabilize the relationship and support the newly formed system with their help and experience. This period can also be, and for most couples is, a period of joy, of mutual discovery, and of first experiences as a married couple in almost every area of life. It may be a period in which the spouses find their best fit in whatever they are doing, and each gladly takes up his or her role in the marriage. The child-rearing period may last for many years. Today, with longer life expectancy and career expectations in the Western world, people tend to marry later, to delay having children, and to spend many more years with their children. Still, when the last child leaves the house the parents will be left alone. We used to believe that the child-rearing period lasted most of our lives, but it does not. About half of our adult life span will be spent without children. The memory of what it is like to be alone without children will bring the parents back to the initial, dyadic phase. If this period was experienced negatively, the couple will probably find themselves in the same muddy waters. Difficulties that were masked or avoided in that initial period will come back to haunt the couple years later. The reverse holds true if that period was one of satisfaction. First Child

The first child indicates a significant and substantial change in the system (what we shall later call a second-order change: a change in the system’s structure or rules). It is no longer a dyad but a triad. The arrival of the new baby changes the system’s power equation. The infant takes precedence over everything else. He or she is now the most important and powerful person in the system, the one who determines the family’s daily activities (e.g., when to eat, sleep, make love, take a nap, or travel). The relationship is now parent–child and not spouse–spouse. An unequal-sided triangle has been formed. The mother–baby relationship is much tighter than that between the parents, particularly if the mother breast-feeds the baby. The husband is temporarily pushed away, leaving the stage open to the mother and child. Several studies (e.g., Belsky 1985; Tucker and Aron 1993) have found a decline in passionate love at this transitional phase.

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Mahler (1967) claims that the parents embark on a developmental process, beginning with a symbiotic phase between the baby and the mother, in which each sees the other as an extension of self. The infant relies on the mother for food, nurturance, and security. The quality of these relations will later determine the child’s ability to use this early interaction with a primary caregiver to develop cognitive–affective schemas of self and others (Bretherton and Munholland 1999). These relationships are considered the basis of later development based on a dialectical model (e.g., separation– individuation: Mahler 1967; or relatedness–autonomous identity: Blatt and Blass 1996). These relationships polarize the family between unification (baby–mother) and separation (mother–father). This dialectic will force a change in the system that will lead to its reorganization. The mother’s ability to provide the child with security depends largely on her relationship with her husband. The better, more nurturing, and more secure this is, the better the mother is able to impart security to the child. During the first period after birth, the couple’s relationship is put on hold because the baby takes precedence. The husband, who is outside the newly formed dyad, traditionally provides for and supports his family. This will continue up to the point where the husband feels left out and neglected. These feelings motivate the husband to reclaim his position so that a balanced triad is formed. To accomplish this, the father has to urge the mother to ease the symbiotic relation and clear a space for him. This maneuver is an opportunity for the child to move on to the separation–individuation phase (Mahler 1967). First Child Goes to Day Care

Another developmental transition is when the child first goes to day care or school, a move that entails separation from the parents. Sometimes the child may express extreme anxiety, which makes the separation difficult for both the child and the parent. This is often called separation anxiety and is referred to as an individual, child’s, pathology. But behind every anxious child there is an anxious parent. Lipsitz et al. (1994) report that childhood separation disorder is more prevalent among patients with recurrent anxiety disorder episodes than among those with a single episode. In a critical review Silove et al. (1996) found evidence of a link between early child’s separation anxiety and adult panic disorder. These children’s

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fears often concern something catastrophic that might befall the parent (e.g., car accident, disappearance). For a child to have these fears when he is not cognitively mature enough to comprehend them, or even if the child is mature enough, means that the child may feel responsible for the parent (i.e., he may believe that if he stays with the parent no such catastrophe will happen). This may lead to the understanding that the child does not feel secure enough. This feeling originates with the anxious parent, who finds it difficult to separate from the child for the very same reasons. The anxiety felt by the parent may have a bearing on the marital relations. Incidentally, these difficulties are not often manifested in the couple’s subsequent children. Parents usually learn the business of child-rearing on their first child, and the others benefit from that one’s experience. The first child represents the change from dyadic to triadic relations. He paves the way for the other children and poses a challenge to the dyadic system. The next transformation period is likely to occur during adolescence. This stage is also marked by separation (parents–child), versus individuation (child–peers, significant others) or unification (triad) versus separation (parents–child). The child meets new friends, teachers, and caretakers and receives feedback about behavior. So do the parents, and these feedbacks may create pressure for change. The pressure emanating from the altered situation will force the system to adapt to it by changing the position on unification (more movement toward the separation pole); the new range from unification to separation will lead to the next phase. Adolescence

It is hard to determine when adolescence begins (our youngest daughter began adolescence at the age of four, another child at the age of twenty) but easier to determine when adolescence ends (although some never outgrow it). This is a confusing period in its timing and also in its nature. Traditionally, the boundaries between generations were clearly set. A parent’s authority was rarely challenged. This authority was based on values, experience, information, and economic and physical power. Today Western society is much more open. Information flows freely; the world is being transformed technologically, culturally, and educationally. Parents’ values and experience are challenged by the wealth of information available in

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the electronic media (e.g., TV, the Internet). Children’s rights are closely watched and protected. Consequently, parents are losing their powerful position and ceasing to maintain their values and moral position. This is accompanied by potential loss of authority over the children. Once, parents inherited their position; now they have to earn it. This phase is the heyday of the dialectic view. Parents usually try to instill independence in their children, but when as adolescents they claim it, their parents strive to retain control over their behavior. I remember my daughter, after getting her driver’s license, asking for the car. I looked at her and said “Why? You’re too young to drive alone.” Some parents feel a need to let go of the child or young adult. They understand that she should take upon herself adult commitments (e.g., driver’s license, military service) The dependence–independence issue is very important for the parents and the adolescent child. This dialectical conflict is manifested between and within generations. The parents and the adolescent experience it, and the intergenerational conflict centers on the same issues. In families where there are tensions and discord, the adolescent may play a homeostatic role, so letting the child go may mean that the parents will have to face each other. By contrast, some children want to become adults but are fearful of the task and look to their parents for help. This confusion may be manifested in rebellious behavior that stereotypically characterizes adolescence. Actually, only about a third of adolescents manifest this kind of behavior. The majority experience this period calmly and peacefully. Clashing with the parents signifies an attempt by the child to test the strength of the system. A power struggle ensues. This is not an ordinary power struggle with a winner and a loser. This power struggle is usually aimed at losing. A strong system can contain the child and his rebellious behavior (the child has lost the power struggle but has won a strong and reliable family). A family that can accomplish this will find, by the end of this period, a young adult, sharing his parents’ values. Should the system fail to contain the child’s behavior (the child has won and has lost his family as a source for support), deterioration and more pathological or deviant behavior by the child can be expected, which can reach the extremes of drug use, promiscuity, criminal behavior, and so on.

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This period is a test for parents and adolescents alike. A proper transition enables the adolescent to develop an individuated personality yet remain connected with his family of origin. In Israel, adolescence ends abruptly with military service. In a few short months the child is transformed from a youngster to a man or woman responsible for other people’s lives or extremely costly or deadly equipment. The conclusion of the youngest child’s adolescence signifies the start of a long period in which the children are busy building their lives and the parents can focus more on their own careers. This stage is a demonstration of the separation–individuation dialectic shared by parents and their adolescent children. The Empty Nest and Grandparenthood

In terms of the life cycle, life from the time the first child is born until the last child leaves home is uneventful. The life course is generally predictable, and it recurs from one child to the next. The children play their part in the family; the parents advance their careers and achieve some kind of stability. Life is routine. Obviously, this is a generalized, naive depiction of this period. Life can be full of events, for better or worse. Children begin school and eventually graduate, and parents move along in their lives. These are predictable and expected shifts that require no change in the way the system functions. However, unpredictable events can occur (e.g., layoffs, financial difficulties, accidents, illnesses) that are likely to alter the flow of life. These changes are random, so people are not prepared to deal with them emotionally, physically, and sometimes financially. These traumatic events may change the system altogether in terms of role division, relationships, hierarchy, and so on. The period from the beginning of parenthood (first child) to the end (last child leaves home) may last for about twenty years (for a family of two children). During this period the parents learn how to live with each other and with the children and how to resolve differences while the children are still at home (e.g., triangulation). Marital difficulties are managed, and life becomes stable. When the last child leaves home a significant change occurs in the system’s functioning. First, this transitional phase may be accompanied

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by a decrease in passionate love (Tucker and Aron 1993). Parents may have to cope with feelings of emptiness and depression, especially mothers who choose to be with their children rather than pursue a career (Carter and McGoldrick 1988). This phase is marked by the children’s departure but may also include the entry of other people (the children’s spouses, grandchildren). This phase can be seen as an opportunity to do things as a couple, now that the financial burden has become lighter. It can also be regarded as a traumatic period in which the couple has to deal with the new situation and also with their own parents’ growing old, ailing, and dying. If the marriage has solidified, and interest in and focus on the couple has not returned, the family may try to hold onto the last child; the couple may even move toward divorce (Solomon 1973). This may become a complex period. The way the couple handles it may be related in part to how well they handled the first year of marriage. Spouses often recall this period as the best of their marriage and yearn to return to it. In fact, this is the only model they have of their ability to function as a childless couple. The dialectical conflict in this period is that of separation–unification. Separation from the children is juxtaposed to the need to reunite as a couple. Along the way, the children marry and have children of their own. This allows the parents to enjoy having grandchildren. Grandchildren are a new experience. The couple can enjoy having little ones around again, this time with none of the responsibility and all of the pleasures; they can play with them, babysit them, and help their parents. As noted, this may also be the time when the parents need to take care of their own parents. They are growing old, may have health problems, and may need special care. This period is closely related to and prepares for the last phase in the family cycle. Retirement and Role Change

The time since the last child left home presents the couple with the challenges of rebuilding couplehood, treating their children as adults, and preparing for the last phase: retirement. Grandparenthood can offer an opportunity to compensate for the couple’s perceived faults in raising their own children and find refuge and meaning at this point in life.

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Retirement is a major change in the couple’s life. Routines of time and place are about to change. Separation of home and work, a cornerstone in adult life, is now replaced by more shared time. Work as a buffer in the relationship disappears. The balance is changed in many spheres of life. Financial difficulties resulting from the expected decrease in income, health problems, and dependency may become major problems, especially for those who value being independent and having their own space. Roles in the marital relationship are subject to change during the transition period, when the children become more self-sufficient. They are likely to live outside the parents’ home, and the spouses in retirement gravitate more toward each other. Retirement means more time spent together, and the dialectic experience is one of moving from separation toward unification. This brings up the question of whether retirement is good or bad for the spouses. Financial security is likely to improve feelings about retirement. A social network is also likely to contribute to positive feelings, and the quality of marriage and family relationships play a key role in the response to retirement (Kim and Moen 1999; Moen, Kim, and Hofmeister 2001; Williams and Guendouzi 2005). The quality of the marital relationship can be adversely affected by declining financial resources (Szinovacs, Ekerdt, and Vinick 1992) or deterioration in health (Booth and Johnson 1994). Knobloch (2008) found that relational uncertainty as manifested in communication and sexual relations was a strong predictor of marital quality. Parents may become dependent on their children for financial or physical support. This exchange of status is difficult for all involved: the children need to function as parents to their parents, and the parents depend on their children. Retirement is a major source of crisis, whose resolution is determined by the quality of the relationship, financial resources and health, the proximity of the children, and the nature of the relationship with them. Retirement also signifies the last phase in life. Still, it may take years until the system expires with the death of the spouses. Now death and dying become pertinent issues. Friends and relatives pass away. Health problems increase awareness of the end of life. Daily life has to be reorganized entirely on retirement. The spouses must learn how to spend more time together. It is likely that one of them will die before the other, and the surviving one will have to completely reorganize

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her life, living alone. The ending of the current system is accompanied by the expansion of the replacing system: the children and grandchildren. We have discussed the life cycle, its different stages and accompanying crises, and how the family system adapts to and copes with these changes and crises. All these stages involve a dialectic movement from unification to separation or from separation to unification. There is an ongoing process of expansion and contraction in the system from its birth to its termination. During these stages systemic changes occur, expressed in system members’ functioning on all levels: personality, behavioral, emotional, and interpersonal. This attests to the strong relationship between the system and its members and the influence they exert on each other. In chapter 5 we shall discuss the issue of change: what it means and how it comes about.

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5 HOW THE SYSTEM CHANGES

A change is a core concept in the system approach. As outlined earlier, the dialectic nature of the system’s dynamics entails change as an inevitable and continuous process. Nature and people change all the time. It may be difficult to predict the exact nature of behavioral or other changes, but we know for certain that a change will take place. Unfortunately, we cannot predict a particular and significant behavior of an individual, such as suicide or mental breakdown. Prediction of behavior at the individual level appears more difficult than prediction of behavior at the couple or family level. Often I find myself able to predict a couple’s behavior much more accurately than the behavior of my individual clients, even when the latter have attended therapy much longer (see chapter 3). Behavior seems to become more orderly and less random as we move away from the individual level. In this light, change can be addressed on two levels: the behavioral symptom (individual) and the system rules. FIRST- AND SECOND-ORDER CHANGE

Family and system behavior is governed by rules. These are sets of restrictions governing the individual members’ or the system’s behavior in terms of cognition (how or what to think), affect (regulation of emotional expression), and behavior (how to behave). The rules are established to preserve and maintain the system’s structure so that it can provide order, stability, security, and a sense of identity for its members. A change of a rule is always accompanied by cognitive, affective, and behavioral adjustments. Watzlawick, Weakland, and Fisch (1974) distinguished first-order change, which is a behavioral change that does not involve a change in 69

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system rules, from second-order change, which does involve a change in the system’s rules. For example, the IP of a family in therapy was the youngest child, age eleven, who exhibited severe behavioral problems at school. The family consisted of the husband, a longtime alcoholic; his wife; and eight children, each separated from the next by about two years. A pattern was revealed during the intake session: each child had behavioral problems between the ages of ten and twelve, then that child’s problems subsided, and the next child developed them. This is an example of first-order change. The system’s rule was that the children’s difficulties were needed to maintain system homeostasis and stability. The fact that the family came for therapy with the youngest child only, and with no other child before then, reinforced this interpretation, precisely because this was the last child. The family came to realize that the underlying problem was actually marital, related to the parents’ relationship; the consequent shift in therapeutic focus from the family to the parents attested to a second-order change. The family no longer needed the children to keep it intact, and the parents could work out their own problems directly without triangulating the children. Another example is the case of a couple who came for therapy because they felt that their fights were getting out of control and they were afraid of a breakup of their relationship. During the intake it became apparent that these fights were preceded by a period of intense (enmeshed) closeness. The emotional distance regulating mechanism is the system rule (“We cannot be too close; it is dangerous, so we need to distance from each other after we have been too close”) underlying the fighting. The more common example usually is that of a child who is having behavioral difficulties in school or at home. These difficulties are often associated with a marital conflict. The therapist’s goal is to help families undergo a second-order change that will enable them to establish the necessary conditions to achieve their goal. A symptomatic system (first-order symptoms) may appear stable even though there is a deterioration process that is slowed down by the symptoms, but eventually the system will reach the point where the underlying, second-order difficulty will show up. This system cannot accomplish its developmental goals. The case of the double bind is an example of a stable system with a faulty communication pattern that may lead to symptomatic behavior (Bateson et al. 1963; Sluzki and Ransom 1976). This communication pattern is expressed by two contradictory messages sent simultaneously,

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when the receiver cannot decide which of the two is true. The recipient may become confused and, should the pattern persist, demonstrate depressive and even psychotic behavior. There are several types of second-order change. The first is a natural, developmental change associated with transitions in the life cycle. These are predictable changes, which mostly are within the family’s control (e.g., marriage, childbirth, moving). At times the family may need intervention at such a point to help it advance along the anticipated path. The second type is unpredictable changes, such as the death of a child, injury, illness, financial difficulties, or unemployment. Responsibility for this change may lie within the system or may be external (i.e., accidental). In any event, the system must change and readjust to the changing circumstances. Third is a catastrophic change, resulting in total breakdown of the system, such as death of a spouse or divorce. This discussion highlights the two types of change that are related to and nourish each other. A first-order symptom is secondary to a systemic difficulty and its outcome. A second-order difficulty is related to governing mechanisms of system operation (e.g., rules). This view reinforces the importance of reaching a second-order change. In the next section we explore some basic means for helping families and therapists shift from first-order problems to their second-order source. REFRAMING

Reframing is a technique widely used by structural and strategic therapists (Nichols 2009). It means relabeling the family’s problem or symptom according to its functional meaning (Eckstein 1997). A child’s aggressive behavior can be relabeled as a heroic attempt to divert attention from the parents’ marital problem to the child’s aggression. The marital problem may endanger the system; the child’s problem may force the parents to stay together and take care of the child. Reframing is a special case of dialectics because it refers only to the positive pole of a symptomatic behavior. Nevertheless, using reframing helps shift attention from a diversionary first-order symptom (i.e., the child’s aggressive behavior) to the second-order source of the problem (i.e., the marital conflict).

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EXTERNALIZATION

In describing their problems people tend to say, “I’m anxious” or “I’m depressed.” Such language indicates that the person does not differentiate between self and difficulty, so that the problem becomes ego syntonic. This association between self and problem suggests that the person has internalized the problem and may see its resolution as a result of a major change in her personality or belief system. Externalization of the problem offers the person an opportunity to change her self-definition from being the problem to possessing it. Externalization is a process in which the problem becomes an external object. Rather than talking about “being depressed,” we can talk about “depression taking hold of my life.” Once the problem becomes an object, we can no longer consider the person as the problem. We view the problem as an agent influencing the person. This process is very similar to the process used in hypnosis, where the threatening emotion is replaced by an object (e.g., anxiety turned into a balloon). The external object can thus be manipulated, changed, destroyed, or befriended. G, a fifty-year old male unemployed artist with no financial difficulties, was referred to therapy complaining of panic attacks. These attacks, which had begun after his parents’ death, were disabling. He could not go shopping at a supermarket because he suffered these attacks whenever he stood in line for the cashier. Likewise, he could not go to restaurants or any other public places. He became totally dependent on his wife and children for any activity that required being in public. He came to therapy seeking change so that he would no longer be anxious. G had left a low-level factory job after his father died because he thought the job was below his intellectual level; because he inherited a large amount of money, he decided to become a painter. He was quite talented but did not like presenting his work in public. He felt that he needed to do something to change this situation but was afraid of failure and humiliation once he presented his work publicly. Very early in therapy it became clear that the underlying dialectic conflict was that of dependence–independence. Being a child depending on an unearned income relieved him of the need to take responsibility for his life. The function of the disorder became perfectly clear. It helped him avoid taking any responsibility because he was “too damned

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anxious to do anything.” The first step in therapy was to help G realize that the anxiety was actually functional for him. Having grasped how he was using anxiety to avoid doing things he did not like (such as meeting people), he was able to separate himself from it and treat the anxiety as a “friend” he could count on to help him in time of need. This realization helped him to limit the use of panic attacks to incidents that he thought were important. Going to public places ceased to be a problem at this point, and thereafter he was ready to cope with other missions in his life: moving to a studio of his own and then presenting his work in public (for which he received a modest review). Zimmerman and Dickerson (1996) describe a family having difficulties with their teenage daughter, who was betraying their trust. They chose to focus on the rift between the parents and daughter. They talked about the rift that led to the daughter’s behavior and helped the parents see the rift as a uniting force helping them to grow closer. Identifying the function of the problem is the first step in externalizing it. Once the problem is externalized, it can be controlled and used to benefit the person. The dysfunctional value of the problem markedly decreases, to the point of nonexistence of the problem. Externalizing the problem helps the person or family to separate from the story they have built around the problem and cope with it more effectively (White 1991). From the dialectic point of view externalization is the active creation of a conflict. Making a symptom ego dystonic instead of ego syntonic creates a polar distinction between the person and the problem. These dialectic poles force the person to change his view of the problem from internal to external. The conflict is between being the symptom and possessing the symptom. SUMMARY

This chapter outlined the theoretical basis and the premises guiding functional dialectic system therapy. Let me sum them up in order to set the stage for the next chapter: t
t


A person’s basic needs are for security, predictability, belonging, and identity. Provision of these needs is possible only in the context of a system or relationships.

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t


A person’s behavior is functional and meaningful. Its goal is to meet basic needs.

A fear of not meeting one’s needs, coupled with a history of learning and life experience, eventually leads to development of seemingly pathological, maladaptive behaviors. The function and meaning of the so-called pathological behavior can be brought to light through the use of dialectic understanding and methods. The therapeutic intervention is designed to uncover the function and meaning of behavior as means of building or restoring person’s safety in the context of relationships. Safety and reassurance enable the person to explore, change, and deal with the uncertainty of life in a more adaptive and beneficial way (“All is for the best”). The process of therapy is as follows: 1. 2. 3. 4.

Establish joining and build a working alliance with the client. Assess and conceptualize the problem in dialectic terms Contract therapy. Explore and work through the conceptualized problem in the context of the therapist–client relationship (build the safety net). 5. End therapy. 6. Follow up.

Part II deals with the establishment of joining and dialectic conceptualization of the problem. Chapter 6 further explores the contributions and hurdles to joining in the context of the dialectic method. Part III emphasizes and further explores the issue of joining: conceptualization and reconstruction of the safety net and the therapeutic process. Part IV describes the process of therapy, and Part V deals with ending therapy and following up.

PART II

THE INTAKE

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6 JOINING AND ESTABLISHING THERAPEUTIC ALLIANCE A client called me hesitantly and asked whether I was a clinical psychologist. When I said that I was, he asked whether I did therapy with couples. I told him that I did, and his next question was how much it cost and whether I had time to see them as a couple. At that point I scheduled an appointment to see them both. This is a typical appointment-setting call. The future client inquires about the therapist, his qualifications, and his experience in dealing with the client’s particular problem; this provides the therapist with a clue as to what the problem is. It is also the beginning of the intake but not of therapy itself. This begins earlier, when the client becomes aware of having a problem. This awareness usually leads to an attempt to change the situation. Having concluded that things are still not working well, the client turns to the professional. This usually happens after a triggering event, the straw that breaks the camel’s back. The intake, the meeting between the client and the therapist, is the most important phase of therapy. During this step in therapy, therapist and client establish their working alliance (Greenson 1978), their joining (Minuchin 1974), their “good-enough engagement” (Flaskas 1997), or their empathic collaboration (Duane and Hill 1996). “The alliance refers to the quality and strength of the collaborative relationship between client and therapist in therapy. This concept is inclusive of the positive affective

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bonds between client and therapist, such as mutual trust, liking, respect, and caring” (Horvath and Bedi 2002, 41). The therapist–client relationship is the basis for therapeutic work. Not only that, it has been shown (Wampold 2001) that joining, along with other therapist variables, accounts for most of therapy outcome variance, far exceeding technique. Research has shown that therapists rated high in joining skills have a lower rate of premature dropout from therapy (Bischoff and Sprenkle 1993). A meta-analytic study by Crits-Christoph et al. (1991) indicated that an experienced therapist and use of a manual were not important for the therapy outcome, in comparison with the role of the relationship. The intake may take a session or two, rarely more, and includes five stages: 1. Joining. Establishing a working alliance between therapist and client. The therapist gets to know the client on a more personal level. This knowledge may later contribute to a better understanding of the client’s life situation. 2. Exploration. The reason for referral is explored. Information is collected about the problem, its history, its cause, the triggering event, and its function. Information about suicide, substance abuse, and any other possible abuse, along with family history of both psychiatric and medical problems, is assembled at this point. 3. Problem redefinition. The therapist forms a functional dialectic system (FDS) view of the presenting problem, considers its functional and dialectic underlying cause, and presents it to the client. The ensuing discussion will optimally lead to an agreed definition of the focus problem. 4. Treatment plan. Once agreement is reached on the focus problem, therapist and client need to decide what form therapy will take, who is best suited to conduct it, and who is to take part in it. If the therapist and client decide that someone else should do the therapy, referral to that therapist follows. I shall talk about this issue extensively in chapter 7. At this point, formal assessment will be sought, if needed, in order to clarify and assess the extent of the deficiency, impairment, or pathology. The issue of formal assessment is problematic from the point of view of FDS, because of its

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systemic context focus, and will be discussed more extensively in chapter 7. 5. Contract. This stage consists of therapist and the clients signing a contract that specifies the objective of the intervention, those present, rules of conduct, and payment. Issues of confidentiality must be discussed at this point. The following sections set out a detailed account of each stage.

JOINING

Who Attends the Intake?

Before the intake session begins, the question arises as to who will attend the first meeting. In the preceding example, the client who called for an appointment defined the problem as a marital one. If the client defines the problem as a family problem, the family will be invited for the intake. So the answer to our question is in the hands of the referring person. There may be an exception to this rule: when the referral problem has to do with children, it is highly recommended that the entire family be invited. This affords the therapist a more comprehensive view of the problem and the system of which the child is a part. Such a broad view helps us identify the primary problem more easily or directs our attention in a different direction. A question can be raised at this point: why adopt this approach with respect to a child but not a couple or an adult? In the case of a couple (or parents) it is assumed that parents are higher in the system hierarchy. Intervention at a higher level of the hierarchy is more likely to produce a second-order change. This change, once achieved, will be generalized to the children. The answer with respect to an adult client is not that simple. If the client’s reason for referral concerns interpersonal relationships, and the client has a spouse or significant other, it is advisable to see them both (again, with the aim of obtaining a broader view of the problem and understanding that it is a product of the relationship and those in it). If the client has no

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spouse or partner, or she defines the difficulty as an individual one, then the course will be an individual one, albeit with an understanding that the problem definition may change. When I ask to meet with the family, the client often asks who is included in the family. My usual answer is, “Whomever you consider a family.” This can include everybody who lives in the house at that time, including infants or grandparents (or even a pet). Sometimes it includes family members who do not live at home but are important for the family (e.g., older siblings). The ground for this request is the wish to become familiar with the system. The need to see the whole family, or rather all those who are involved in the problem, arises from the respect owed to the place of each member in the system and to each member’s role in the intricate relations that constitute the system. Each member of the family system harbors a unique version of the problem. Each member looks at the exact same events, yet spouses commonly describe them in a way that suggests that they live in two different worlds. One partner says in a session, “I arrived home yesterday expecting, after I talked about it in therapy, that my wife would be waiting for me and we would have five minutes alone so I could discuss things between the two of us.” His wife relates the same event: “He came home and immediately wanted to go to bed with me.” The two of them do indeed live in the same house and share the same bed. Why do small children need to attend the intake session? This question is relevant even for babies. Including small children allows observation of how the various members interact, what coalitions are formed in the family, and how older family members cope with the children. Who helps? Who is in charge? How do the parents exercise their authority? Furthermore, children are highly sensitive to their parents. They are likely to protect them, to wedge a barrier between them, or to not let them shy away from disclosing and dealing with problems. They may even help them identify the problem by saying, in effect, “I am not the problem; your deteriorating marriage is the problem!” At times, when all family members are invited to the intake, not all of them will come. What can be done then? The first question to ask is why that particular member did not show. Was he sick? Did he have other commitments? Did he refuse to go to

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therapy? The answers to these questions are very important. They tell us how important therapy is for these family members. If the family comes to therapy when one of its members, who is sick, is absent, this shows that therapy is indeed important. Yet it also shows that they are willing to forsake that person. The therapist has to learn the meaning of this partial attendance. Is it an opportunity for the family to talk about the missing member behind his back? Did they discuss the issue with the person and receive his permission to go to the session? In the former case, it is advisable to postpone the session until the absentee feels well enough to attend the session. The implicit (or explicit) message is that this member is as important as the others, and he will not be left out. In the latter case, the family has already acknowledged the person’s importance by requesting and obtaining his permission to go to the session. In this case I would hold the meeting and ask the other members to share the meeting with that person. When a family member has other commitments that prevent her from attending the session, this may mean that she does not see the problem as urgent or does not see herself as a partner in the problem. It may also mean that this person is conveying a message to the therapist about who the real client is. (The absent person? This is a dialectic issue: the person who considers herself not part of the problem may in fact be very much part of it.) Also, the missing member and the family may be colluding in order to avoid talking about an important issue. In such a situation the therapist has to decide whether he is willing to accept that this person will be absent or to insist that the family find a way to bring the person in. It is recommended that the therapist aim for the latter. But if the person in question refuses to come to a session, the therapist may assume that a covert message is being sent to the others that she sees herself as part of the problem, even though the overt message is the opposite. Nevertheless, parents might come to a session without their children because they are higher in the system hierarchy. The implicit goal is to make parents more skillful for their children, so it can be reasonable to have parents in therapy without their offspring. The issue of who is present in the intake session is important because of the role each member plays in the system. The therapist sends the message that everybody is important, and every effort must be made to ensure everyone’s presence.

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Joining and Therapeutic Alliance

The intake is the first face-to-face meeting with the client. Nonetheless, it is not necessarily their first contact or the beginning of therapy itself. A phone call, a client’s file, or an e-mail contact is likely to precede it. The client and therapist engage in joining (Minuchin 1974), a therapeutic alliance, or rapport. They need to establish a friendly, empathic, trustful, and sincere relationship that will serve as the foundation for the therapeutic work. Research has consistently demonstrated that the quality of the therapeutic relationship is immensely important and is a strong predictor of therapy outcome (Hill 2004; Horvath and Luborsky 1993). Without sufficient joining there will be no cooperative effort to make therapy work. With adequate joining, client and therapist share a mutual trust that allows them to ply the turbulent waters of therapeutic work. Early in my training in psychodynamic psychotherapy I was warned against making mistakes (e.g., making premature interpretations, befriending clients) in my dealings with the client, for fear of jeopardizing therapy. The assumption behind this stern attitude was that the therapist is an expert and an authority, and whatever the therapist says and how he behaves carries much weight with the client. Consequently, I was terribly afraid of saying anything or behaving in a way that might be inappropriate or unprofessional, so that the client would leave therapy. It took me a long time and a good number of blunders to realize that making mistakes is part of human relationships and that as long as I had rapport with the client, they would have no ill effect on therapy. Numerous studies and meta-analyses have affirmed that client–therapist relationships are the most important factor predicting the outcome of therapy (Lambert and Ogles 2004). However, joining is not something established during the intake, and it cannot be assumed to last throughout therapy. As with any kind of interpersonal relation, joining must be renewed in each session. Although the therapist and clients share the wish for the success of therapy, they constantly feel fearful and insecure that this fragile, intimate bond might break. Joining must be established with all clients. However, there are some clients with whom it is difficult to join. These clients probably trigger unpleasant associations and countertransference responses that, if not

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recognized, may jeopardize therapy. Therefore, the therapist must make sure to join with the client before he attempts to intervene. How Do We Join?

For the therapist to join with the client, he needs to see the client as a person, as one whom he really likes knowing and befriending. With this in mind, I usually begin by stating the purpose of the meeting (“so that we can get to know each other and learn about the problems”), then by asking neutral questions that address seemingly trivial and nonthreatening issues, such as the client’s name (e.g., if the name is unusual I inquire about it), age, and occupation. (I spend a great deal of time on this because it may provide me with information about the client’s life, such as the kind of work and how much time she spends at work.) An engineer in a high-tech company is likely to have a job that is hardly understood by her spouse and kids, to spend much time at work, usually under pressure, and to suffer uncertainty about job security. Hearing the client talk about her occupation helps the family understand and appreciate it better. Quite often this is the first opportunity people have to talk about themselves in the presence of others. It also allows family members to get to know each other in a way they have not previously experienced. This may also direct attention to potential problem areas in marital and familial relations (e.g., time with spouse, intimacy, time with kids, priorities). This process is repeated with every family member, old or young, beginning with whoever wants to begin. I do not skip or disregard any of the members, and I try to relate to each of them on her own level and in her own mode of communication. Family members usually wait their turn (although the therapist may have to calm down those who are impatient, promising to give them their time). I proceed in this way even with very small children. The feedback on this method is highly positive: people report feeling listened to, which may be a new experience. I will move to the next client only after I feel I have joined with the first, or if it takes too long I will get back to that person to make sure joining has been achieved. When joining is not achieved, it could be because I have experienced a negative countertransferential reaction. The patient triggered a negative feeling that relates to my own difficulties. In this case, a better approach is

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to ask, “What do I like in the client?” There is always something positive to find in anyone. If not, I can move on to the next client and later return to the previous one. If the therapist cannot join with a client despite all these efforts, he indeed has a problem. In such a case the therapist may be stuck. To deal with this, the therapist may seek supervision or even consider referring the case elsewhere. This process has another function, which is important and beneficial. It helps assuage initial stressful and stormy feelings. At times people come to therapy extremely distressed and demoralized. They want to be heard and given an instant solution (as they do with a physician). A therapist responding to this request by asking, “What brought you to therapy?” risks being drawn into the storm and unable to assess the client’s condition objectively, simply because he is not familiar with the client or the circumstances of the referral. Joining with the therapist enables the client to calm down, put things in perspective, and then relate the problem at hand. Another essential process is that of changing problem definitions. People usually come to therapy with a problem they recognize, are familiar with, and want to change. However, during intake the definition of the problem is likely to change. A, a ten-year-old boy, was referred to therapy manifesting severe symptoms of obsessive–compulsive disorder (OCD). The family was asked to come for an intake. It was explained to the mother (who initially called the therapist) that the therapist wanted to get to know the family. The mother, K, forty-seven years old, had worked as a lab technician in a pharmaceutical company for the last twenty years, and the father, T, forty-eight years old, was a self-employed architect. T was not getting enough work because of the deteriorating housing market. T was exceedingly concerned and anxious. He did not share his troubles with his family, to save them the worry, and was trying to find work so that their lives would continue as usual. The mother told the therapist that she was diabetic and had found recently that she was unable to control her sugar level and was experiencing difficulties with her vision. She also reported having suffered mild coronary heart disease that necessitated a two-week hospitalization. The family had two children. The older child, H, had just returned from

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a six-month trip to East Asia. H had intended to stay there longer but had interrupted his trip at his parents’ request. They expressed consternation over his younger brother’s situation. A was a fifth-grader who had been doing very well at school until about three months before, when the situation rapidly deteriorated. He had had OCD symptoms before, but they had been mild, just “strange habits,” and there was no need for professional intervention. It was clear that the family was tremendously distressed. The parents’ health and financial worries, and the lack of communication about them, appeared to bear down on A. He was the one who was with his parents when their situation began to worsen. [At this point the therapist began considering the idea that A’s problem was related to the family problem. The fact that they were trying to hide the situation from the child only exacerbated his condition, to the point where the OCD symptoms became debilitating. It appeared that the family sought therapy only after A’s problems had worsened, and it was also assumed that A’s problems were a way to get the parents into therapy and recruit H’s help (the functional aspect of A’s difficulties). The parents were too frightened to admit having problems and felt quite helpless to deal with them.] The therapist was empathic with the family, noting that they were in a very difficult and stressful situation and stating that he would feel helpless if he were in their shoes. Later, turning to A, the therapist commented on how much he thought A loved his family and how concerned he was about what he feared was taking place. Referring to H, the therapist noted how important the family was for him in that he cut his trip short to help them shoulder the burden. The family began discussing their problems and reached the conclusion that A’s problems were secondary in importance to the parents’. They told the therapist that they thought this because A appeared most anxious about his parents, and this desperation had led to his deteriorating condition. They were worried about their own situation. At this point the therapist suggested that they meet as a family for several sessions to clarify matters and see what they could do about their situation. The knowledge acquired during the intake changed the problem definition from a child’s OCD to a family problem. The proposed treatment plan

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included both family therapy to deal with the acute family problems and medical consultation for the child and the mother. The focus changed from the original child’s difficulty to a family hurdle. This is only one of countless instances of the same phenomenon: throughout joining, a change also occurs. The opportunity for all system members to participate in the meeting and to share information is likely to lead to a change in problem definition. When the therapist feels that joining has been achieved, it is time to move to the second stage of the intake: exploration. EXPLORATION

Why Did the Clients Come for Therapy?

The client comes to the intake session complaining about troubling symptoms and asks the therapist to help him relieve those symptoms. Some therapists are likely to agree with the client’s initial description of the problem and help him overcome it. When a client comes for therapy he may well know best the problem that is troubling him, but he probably neither understands its etiology nor comprehends its extent or its relation to other problems or people. When this missing information is obtained, the problem definition may change. That is, the client’s initial problem definition may be misguided or misinformed. This does not mean that the person lacks self-awareness or autonomy, only that the client is in distress and needs help. People in distress are likely to have a narrower view of the immediate problem and are likely to be preoccupied with their own unhappiness. They are likely to feel helpless because they have failed to correct the problem. Mostly, they are not used to thinking systemically. In this case, systemic thinking means considering the person and problem within the context and thinking circularly in terms of the client’s contribution to the problem. The role of the system-oriented therapist is to map the client’s relationships with significant others and attempt to position the symptoms in the system matrix. By doing so, the therapist is likely to elicit a changed meaning for the symptom, and a different referral reason emerges. The preceding vignette demonstrated how the child’s symptoms can touch on and be functional

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for all members of the family in various areas of life. This teaches us that the identified patient (IP), who is the reason for the treatment referral, might not be the one who really needs therapy. However, it may mean that the person who comes to therapy does so altruistically (and apparently from selfish motives too, such as gaining attention or avoiding responsibility), to help others through attention-seeking behavior. This behavior is meant to help others who are more in need of therapy, or whose problems present a threat to the system’s integrity, to perceive the problem and get help. So a client may come for therapy because she is having difficulties or because she cares for others who may or may not be aware of having a problem. Many times a spouse has told me that her partner does not want to come to therapy, but she is willing to begin therapy on her own or even come to therapy for the missing person. During intake the therapist needs to establish the motivation for therapy, the underlying problem, and the identity of the “real” client and invite that person for therapy. Assessment

At this point, and even after the redefinition has been achieved, the therapist needs to assess the presenting complaint, mental and medical history, family history, educational and occupational history, and various risk factors. There is no set order for obtaining this information, although it is recommended to begin with the presenting complaint. Exploring these areas is essential for a thorough assessment. Sometimes other problems exist that are masked by the current problem or are augmenting it. Also, other problems may need to be dealt with during or even before the continuation of therapy (e.g., further medical or neuropsychological assessment). Presenting Complaint How urgent is the problem? How long has it lasted? What was the immediate triggering event that led the client to seek therapy? What is the cause of the problem as understood by all the participants? What are the factors sustaining the problem? The therapist needs to keep in mind that different people define and see problems in different ways and attach different meanings to symptoms, constructs, and behavior. Depression may mean something different to different people and be manifested differently

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by different people. Sharing the different meaning helps to clarify and improve communication between the participants. This can be assessed at the beginning of the session, or at any point in its course, depending on the process and content of discussion. Mental Health History

What other experiences have the participants had with mental health professionals? What type of interaction was it? What was the main issue in therapy? How was that therapy administered? Why was it terminated? Why did the client not return to that therapist? What medications were administered? Medical History

Are there any medical problems in the family? What has been done about them? Is there any current treatment? What medications are currently used? What specific medications? Is there any kind of medical or organic problem that has any implications for the client? Family History

A family history is the story of the family from the day the parents met. The story of their first meeting is likely to be a unique episode in the session. This is often the first time the spouses smile during the session. I usually ask them to recall their first meeting and then state what it was in the other person that first attracted them. The answer can be telling in terms of expectations and fantasies projected by one onto the other. Then I ask for details of the history of the marriage and of their passage through the relevant stages of life cycle, their choices along the way, crises and how they dealt with them, role division, and so on. This actually gives us the background to the current difficulties. Educational and Occupational History

This history helps us understand spousal differences in terms of educational and occupational achievements and expectations. I can better understand the demands put on the client and how he has achieved his current position. It is also highly recommended that the therapist communicate with school authorities (teacher, principal, counselor, and psychologist).

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This involvement will help to reduce pressure from the school by providing a communication line to the therapist, and it offers the school a means to collaborate in the treatment plan. Risk Factors

These include suicide threat (Goldston 2003; Range 2005; Range and Knott 1997), physical and sexual abuse (Bow et al. 2002; DeVoe and Faller 2002; Kooiman, Ouwehand, and Ter-Kuile 2002; Lock, Levis, and Rourke 2005), and substance abuse. These factors must be attended to at the beginning of therapy. Suicide threat must be thwarted so it won’t loom over therapy and block progress. Having gathered relevant information, the therapist is more knowledgeable and better prepared to make the appropriate diagnosis or problem delineation. He is now ready to continue to the stage of formulating a definition of the problem core and obtaining its acceptance by the client. DEFINITION OF THE FOCUS PROBLEM FOR THERAPY

At any stage of the intake session, the therapist may grasp the underlying problem. Not all problems and clients will need a redefinition, of course, but the importance of identifying the underlying problem cannot be overstated. The underlying problem is the source of, and closely related to, more overt problems. Removing or changing the underlying problem is likely to change the nature of the other difficulties. How is the underlying problem discerned? Here is where the FDS approach is needed. When a client reports a problem, it can be safely assumed that there is a dialectic pole to the problem (e.g., aggression–pain, helplessness–strength). Sometimes the dialectic pole is not obvious and must be unearthed through identification of the function of the behavior problem. For example, if a client reports having panic attacks, it is assumed that underlying them is a fear of losing control. So the panic attack’s function is to regain control. The next question is, to regain control over what or whom? To answer this question, the effect of the individual’s problem on other areas of life and on his relationship with significant others must be assessed. For example, if the answer is that the client wants to relinquish control to someone else (as occurs when someone else takes responsibility when the panic attack occurs), the attack can be viewed as functional and goal oriented.

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Dialectically, viewing the panic attack as means of gaining control means that the client does have control over it (remember, the initial assumption was that panic attack is associated with fear of losing control). So the panic attack is a way to gain control over something or somebody else (a spouse? a parent? an illness?). At this point, the issue is not the panic attack but the relationship with the person at whom the attack is directed. From the process outlined here it can be clearly seen how the definition of this problem has changed from panic disorder to a relationship difficulty. The therapist’s task at this point is to ensure that the new definition is acceptable to the client. If it is, therapist and client can devise and agree on the treatment plan. Again, it must be emphasized that the therapist must achieve rapport and join with the client before reformulating the problem. Otherwise, it may be deemed a disrespectful attempt to undermine the client’s efforts. The reformulation of the problem is a major step and creates a secondorder change. In the process, the client who views herself as being under control and as trying to achieve something functional and positive for the system has changed her view of herself. Let us consider the following example: A twenty-two-year-old single woman was referred for therapy after a hospitalization for brief reactive psychosis. The woman, N, was good-looking and shy, and she came to the session with her parents. The therapist asked the parents to join the session. The father, Y, sixty-seven, a retired construction worker, explained that they had accompanied her because they were extremely concerned about what had happened. Apparently, N had joined a religious group in a remote part of the country and detached herself from the family. The parents tried to persuade her to return, and they went to the group’s house to try to force her to leave. She refused to cooperate, and shortly afterwards she suffered the attack and was taken to the emergency room of a nearby hospital. The other children in the family are an older sister, H, twenty-five, and a brother, J, the oldest, who committed suicide two years previously when he was aged twenty-five. The older sister lived in a different state and expressed no wish to return home. The mother, L, sixty-two, was a homemaker who had never worked outside the house. The couple had been married for twenty-eight years. They were married quite late, when L was

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thirty-four. This was a first marriage for both, and it was arranged. There was no medical other psychiatric history in the family. When the father spoke, there was a sense of urgency and tension in his voice. L looked sad and resigned. Y was highly concerned about his daughter. N had been living with them before she joined that group, and her parents thought that living with them was good for her, especially after the older daughter decided to leave home. When asked why it was good, the mother answered that they were afraid she might do the same thing as her brother. Apparently she had reacted very badly to his suicide. From being a top student she lost interest in her studies and became severely depressed. They nursed her at home until she recovered. [The situation appeared complicated. N’s psychotic episode seemed related to her disengagement from the family. It may also have been connected to the death of her brother, which lingered over the family. N appeared quite calm and organized and did not report any difficulties; she said that she wanted to study at a college nearby, and until she graduated she would stay with her parents. Several hypotheses were weighed: (1) The depressive and psychotic episodes function to divert the parents from dealing with their son’s suicide. These attacks give them the opportunity to redeem their guilt (by taking better care of her). (2) N’s difficulties sidetrack her parents from dealing with their marital problems. Why did their son commit suicide? (3) Is the focus problem N’s problem, or is it J’s suicide? (4) Was J’s suicide in any way connected with the parents’ difficulties? How should these questions be answered? The therapist decided that he would see the family, and a psychiatric consultation for N was needed.] The therapist told the family that even though they came for N, he believed that her difficulties were related to the family as a whole because they all cared greatly about each other. Their relief was clearly visible on their faces when they heard this, and they gladly accepted the plan. The next session focused on the history of the marriage, and it emerged that the father had physically abused the mother from the beginning of their marriage almost to the time of their son’s suicide. The father had special relationship with N, whom he adored and whom he paid much attention. N was very angry with her father but tried to suppress it (it came out in a passive–aggressive way). When the therapist cautiously asked about the suicide, the mother began to cry while the father maintained an impassive face. N sat quietly and then

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told the therapist that she thought her parents had not dealt with the suicide and that they needed help. N said that she had tried to help them (she did not elaborate on this) but failed. [At this point it became clear that the parents’ marital difficulties were the source of this dreadful situation. The parents apparently needed couple therapy to try to sort out their lives and find a way to live with their reality. Also, N had to find her way out of the helping role and live independently, emotionally and physically.] The therapist was very empathic with the family, suggesting that the parents needed someone to help them unload the burden. They agreed, but N asked what she should do because she did not think she needed to be with her parents while they dealt with their own problems. The parents objected to N’s withdrawing from therapy. It was decided then that N would continue coming until the parents felt safe enough to let her withdraw from therapy, but they also agreed that she needed to be in individual therapy with another therapist to help her deal with her own problems. The case described here is difficult, but it represents the dialectic functional formulation. The problems of the IP appeared to be functional for the family (and her). In breaking down (twice) she was able to help her parents to show themselves as competent and caring (dialectics). However, while trying to help her parents by becoming sick, N wanted to free herself from them. The only way she knew was to become more severely disturbed. The psychotic episode is viewed as an attempt to attract outside help (the parents could not contain it at home) and draw attention to her parents. This time it worked, and the therapist was able to size up the situation and perform the appropriate intervention. Therapy continued for more than a year, during which time the parents moved to couple therapy that focused on their marital relationship and worked through their grief and mourning. N continued her individual therapy with no further episodes and was able to leave home, continuing to study and live independently in a shared apartment. Once problem redefinition has been achieved, a treatment plan can be formulated. The treatment plan is based on the agreed problem definition, the intervention goal, the specific technique or approach, and the participants.

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TREATMENT PLAN

A treatment plan includes several steps that create the format for therapy. Makover (1996) argues that therapists often have an anti-planning bias because they fear that spontaneity in treatment will be lost, that therapy is too complex and individualized to be planned, and that because the most important factor is the relationship, planning is meaningless. But actually, every therapist uses a treatment plan. The plan is born out of decisions based on conscious choice or a habitual way of doing therapy. A treatment plan is formulated in several steps: Step 1: Identifying the Focus Problem. Using the FDS approach, the therapist is likely to spot the core problem underlying the various ills the client has presented. The skills acquired through this approach will enable the client to deal more effectively with other problems in life. From this point of view, it is difficult to agree with the “problem list” approach (e.g., Hayes-Roth, Longabaugh, and Ryback 1972; Woody et al. 2004). This approach is based on the idea that therapy can move across phases, and in each phase a different problem from the initially developed problem list, or a new one, can be the focus of therapy. Systematic treatment selection (Beutler and Clarkin 1990; Beutler, Clarkin, and Bongar 2000; Martin and Barlow 2010) is another approach used to match treatment with client. These two slants represent a symptom-focused approach. The effort is centered on detailed information gathering about the symptom and the person. However, learning about the person is aimed at acquiring a more comprehensive view not of him but of the resources and conditions deemed necessary for treatment planning. The major disadvantage of these approaches is that they are individually focused in terms of diagnosis and therapy alike (with heavy reliance on the Diagnostic and Statistical Manual of Mental Disorders [DSM-IV-TR; American Psychiatric Association 2000]). This narrow approach does not allow full appreciation of the problem at hand from an FDS point of view.1 This approach is being challenged by consistent research findings attributing the major source of variance in the various psychological disorders to demoralization or distress (e.g., Almagor and Koren 2001; Tellegen et al. 2003; Watson and Tellegen 1985). These findings undermine the rationale of the DSM approach and question the validity of the psychological

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disorder approach. A related issue is comorbidity. Many of our clients suffer from more than one disorder simultaneously (e.g., anxiety and depression, anxiety and personality disorder). The FDS approach is distinct from symptom-focused approaches at the moment of diagnosis. Whereas the aforementioned strategies rely on the presenting problem and DSM-type diagnoses, the FDS approach rests on a more comprehensive, systemic view of behavior. By this approach a different diagnosis may be achieved, which is not necessarily a DSM-type diagnosis. Nevertheless, even with FDS new problems may arise during or after therapy. In this case we may assume that the role of the therapist, with the client’s collaboration, is to identify the major problem area and to work on a second-order change through this problem in the hope that the client’s condition will improve to the point where no further therapy is necessary for some time. Step 2: Defining Goals and Expectations. After the core problem has been identified and agreed on, the therapist is ready to ask the participants for their goals and expectations of therapy. These may be broad and abstract (“We want a better life,” “I’d like to feel better about myself and our marriage,” “I want to be happy”) or more specific (“I would like to be free of this anxiety,” “We would like to have a better sex life,” “We wish we could talk to each other”). Expectations and goals must be related to the core problem and agreed definition. If they are not, it means that such an agreement has not really been achieved, and the therapist needs to spend more time clarifying and achieving consensus over the core problem. (Once, after a long and tiring session, I thought that the clients agreed that the newly defined problem was their marital relations. However, as the clients were leaving, the father asked me, “And what about X’s [his daughter’s] behavior; don’t you think she needs a therapist?” At this point I realized that the message has not been well received, and I immediately invited all of them for an additional session before we began couple therapy.) Step 3: Choosing the Best Way to Approach the Problem. Once the problem is defined and agreed on and expectations about the outcome are clarified, the therapist needs to ask herself what the most helpful way to approach the problem is. Today we have scores of techniques and approaches to help us find the best way (e.g., Corsini and Wedding 2004; Goodheart,

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Kazdin, and Sternberg 2006). Before deciding on the specific technique to be used, the therapist needs to decide what general format therapy will take: individual, couple, or family. This decision is based on the core problem. If the problem is defined as one of relationships, and the person has a spouse or a steady companion, the best approach will probably be couple therapy. If the core problem is defined as the parent–child relationship, the best approach is likely to be family therapy, parent guidance, or couple therapy (depending on an agreement between therapist and client on which format is more desirable). When a core problem is defined as anxiety disorder, and the client is an adult, the best approach may be cognitive–behavioral therapy, psychodynamic therapy, or any other individual approach. This decision is made with reference only to the type of core problem and the client’s needs, without consideration of other limitations. Step 4: Choosing the Therapist. Once the therapist has decided which is the best approach to use for the problem and the client, he needs to ask himself whether he is competent to deal with it. For example, I know that I am not competent to do sex therapy. If sex therapy is recommended, I refer the client to a colleague who I know is competent in this approach. At this point the decision is whether to refer the client to another therapist or to work with the client. Sometimes this may be a difficult choice. At this point in therapy, a joining has been established with the client that involves emotional involvement on both sides; it is extremely hard to tell the client that you are not the right person to help him with the problem. On the other hand, doing something that you are not competent to do will not serve the client well (and may also be conceived as an ethical violation). This problem is put to the client, and he makes a decision jointly with the therapist. A crucial consideration is the client’s refusal to be referred and his wish to stay with the therapist even though the therapist has recommended differently. In this case, I believe a second alternative should be sought, and its limitations compared with the recommended approach should be explained to the client. If the client agrees, therapy will continue. Step 5: Choosing the Specific Techniques to Be Used. Once the goals, expectations, mode of therapy, and therapist have been decided on, the determination of a specific technique or mode is left to the therapist. Choosing a specific technique is complicated. My experience tells me that a therapist can use any technique she finds suitable as long as it meets the goal of the therapy.

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The therapeutic goal is a strategic target for therapy, and the choice of a specific technique should be made in its light. The chosen technique must be consistent with the general orientation of therapy. It is difficult for me to see a psychodynamically oriented therapist shifting to behavioral techniques in the midst of therapy. This shift is likely to disrupt the transferential relationship. It is also difficult to envision couple therapy changing into individual therapy and back to couple therapy without reducing the therapist’s impartiality. This issue will be discussed further later in the book. This discussion outlines the decision-making process that any therapist needs to go through. Some of the process is accomplished more concisely, depending on therapist’s breadth of knowledge. The ethical code (American Association for Marriage and Family Therapy 2002) requires that the therapist obtain informed consent from the client. This consent involves sharing with client the aforementioned steps. Having the client consent to therapy under these conditions contributes to her sense of responsibility for treatment and makes her an equal and a worthy partner to the therapeutic effort. At this point, the therapy contract can be discussed. THE CONTRACT

The contract is an agreement, verbal, written, unwritten, or understood, specifying the terms for therapy. It contains the agreed focus problem and goal for therapy, participants, technique to be used, ethics and rules of conduct, and payment. The contract can be written but usually is not. Nevertheless, an agreed contract must exist for every type of therapy. The contract means that both therapist and client agree on the problem to be worked on in therapy. The agreed problem also means setting goals for therapy. One of the perils of therapy is that of a therapist and a client holding different goals for therapy. Sooner or later it will become evident that there is disagreement between client and therapist or that the expectations of one side or the other have not been met. When this happens the possibility of different agendas must be examined. Otherwise, the therapist may be justified in assuming that the client is resisting therapy. With two agendas, no resistance can be assumed, and the differing agendas must be examined before therapy can continue. It is possible for therapy to work despite differing agendas. For example,

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parents might object to couple therapy and prefer to focus on their child’s condition. The parents’ goal is to help the child. The therapist’s goal is probably the same, but he wants to attempt to help the child by treating the parents, whereas they are likely to focus on the child. In this case the therapist will concede to the parents and work with them on their difficulty by treating the child’s problem. The strategic goal for therapy is shared by the therapist and clients, but the tactics are clearly different. Agreeing on the problem allows the therapist and clients to determine who will take part in therapy. Whether therapy will be individual, couple, family, or any other formation is negotiated with the clients. However, once an accord is reached as to the participants, they will need to be present throughout therapy, unless the therapist and client agree otherwise. This policy sends a message that each participant is equally important and therefore has to be present at the session; if not, the session will be canceled or another arrangement will be made to ensure that the missing person remains essential and involved. I began my career by adhering tightly to this principle; when I relaxed it, I found that the underlying message is very powerful and important for the client, and so I turned a full circle and have stuck to it since. As part of informed consent, the therapist needs to tell the client about the approach to be used in therapy, about any alternative approaches that may suit the specific problem, and about their advantages and disadvantages. If the client prefers an alternative that is not within the realm of therapist’s competencies, transfer to another therapist may be considered at this point. If the client accepts the recommendation, the therapist can continue working with this client. It is also important to agree on the length of therapy at this point. Managed care plans set limits on the length of therapy, which for most people may be insufficient. However, the FDS approach can ensure that the first step in intervention, problem redefinition, will be completed, allowing a natural change process to take place. When this is not enough, more sessions are needed. In the absence of managed care limits, a ten- to twelve-session limit can be agreed on. As the end of the therapy approaches, a reevaluation is made to assess the level of improvement and the need to continue therapy. In any case, a follow-up date is set at this time. The follow-up is intended for an evaluation of the client’s status. At that point a decision is made

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with respect to termination or continuation, with the same therapist or another. A three- or six-month follow-up is recommended (the follow-up is discussed further in chapter 14). At this point, confidentiality and ethics (see the Appendix) must be discussed. The therapist must clarify ethical and legal issues that involve confidentiality and its breach as specified by ethical standards and by law. This must be done at the outset of the therapy in order to forestall difficulty and loss of trust during its course. The patient who is aware of the limitations imposed by confidentiality can choose which issues to discuss or to avoid. However, if during therapy the therapist finds that she has to report child abuse, for example, but has not initially informed the client, it will be very difficult to explain. The client will feel betrayed, and rightly so. The client is likely to feel deprived of the opportunity to talk about these issues. Obviously, the drawback is that the client may withhold crucial information from the therapist, and somebody else might be harmed. Nevertheless, honesty and integrity require the use of the recommended approach. Some people think that being in therapy helps one cope with these problems even if they are not raised in therapy. Moreover, one may assume that eventually therapy will be recommended for that problem, and if the person is already in therapy it will be taken care of. But how can a problem we do not recognize be dealt with in therapy? Rules of conduct relate to issues such as time of appointment and payment. Therapist and client need to schedule appointments for therapy, with the agreement that this time is reserved for the client. Should the client be unable to make the appointment, he must notify the therapist ahead of time (usually at least twenty-four hours) so that the therapist can make other use of that time. Obviously, the therapist has the same obligation to the client. If the client does not meet this condition, he has to pay for the session. This condition is meant to underscore responsibility of both sides to keep the contract. If the therapist fails to meet the condition, she will not charge the client for the session and may not charge for the next one. Setting a time frame promotes better understanding of the motives behind a violation of the agreement. Issues related to resistance to therapy can be raised only when the contract is articulated to both sides. A patient (or therapist) who fails to show up for therapy at the agreed time and place without prior notice needs to probe the motivation behind it.

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Is it dissatisfaction with the progress of therapy? Is it fear of an anticipated demand, or a change, or a topic for discussion? Working through these issues may advance therapy. The last issue in the contract is payment. If a fee for service is included in the specific setting, it may be brought up at this point. Fee and payment arrangements must be very clear for the client, for the same reasons that the time frame must be kept.

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PART III

TREATMENT STRUCTURE: THE ENVELOPE

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7 THE ENVELOPE: JOINING

The preceding chapters dealt with the theory behind the functional dialectic system (FDS) approach and its application to problem formulation and treatment planning. Understanding problematic behavior, its function, and its dialectic meaning is essential for comprehending and defining the problem and for setting goals and planning therapy. The system’s structural aspect is particularly important because it constitutes an envelope for system dynamics and the therapeutic process. The structural elements are nonspecific. They apply to any therapeutic approach, not to FDS exclusively. They are closely related to and interactive with the application of any technique or therapeutic intervention. Creation of an adequate and appropriate envelope yields a positive and facilitative atmosphere, enabling both client and therapist to explore more openly the sensitive aspects of the problem and of themselves. The envelope embraces the therapeutic process and sets its limits and boundaries. The metaphor I use is that of a water pipe. For water to flow with minimum resistance, the pipe should be firm, without punctures, breaks, or leaks. Its interior layer must be smooth. If there are scratches, fissures, or breaches, the flow is interrupted and energy is lost in overcoming obstacles. This impedes and eventually halts the flow. Issues related to joining, contract, and resistance are envelope-specific. Rather, these are the core foundation of therapeutic relationships. They are essential for therapy but are not necessarily related to the technique used. Nevertheless, without an adequate envelope, therapy ranges from very difficult to impossible. Having a well-defined, smooth, and well-maintained envelope increases the likelihood of success in therapy. 103

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The focus of this chapter is on the structural, nonspecific elements of the therapeutic system (the envelope), and chapter 8 centers on the dynamic, problem-related elements (the process). We shall see that the relationship between the envelope and the process is dialectic; the envelope is the stable, fixed element, whereas the process is the concurrent, dynamic, and changing counterelement. The ground prepared at the structural level allows the therapist to implement interventions specific to the problem system and to maximize the efficacy of FDS. The use of FDS makes it possible to attend to both aspects of a situation and to be aware of the simultaneous existence of different and opposing views. A FDS therapist can use this circumstance to facilitate understanding and to counter and loosen one-sided, black-and-white beliefs and attitudes. When the client says, “There’s only one possible interpretation: he doesn’t love me!” the therapist is likely to think that this behavior suggests quite the opposite. Knowing whether the new interpretation is correct is not as important as acknowledging the possible existence of different and conflicting views of the same issue. The following discussion of these issues will focus on joining and resistance but is by no means exhaustive. I refer to the major issues that concern therapy, and I highlight those I consider important in the current context. A NEW SYSTEM IS FORMED

When a therapist newly joins the system, a new system is created. The new system consists of the therapist and the client. It may be expanded when a cotherapist, a supervisor, or a supervisory group is included (in the latter case the therapist is the connecting element between the original and the expanded system).1 The new system is different from the original because the joining therapist does not share and is not part of the system’s history; he or she brings new, second-order input to the system. Nonetheless, the new system shares all the characteristics of a system. It has a structure, and it develops and changes through its members’ interactions. The newly created system is hierarchically organized, where the therapist is at the top and client is below. This is a formal organization. The therapist’s position derives from her reputation, experience, knowledge, and professional status. The client accepts this position because it accords with his wish to be helped. However, when joining, a therapist may try to create

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a more equal-level situation in which everyone in the therapeutic system has an equal place. Yet there is still implicit acceptance of the therapist’s higher position. The client may not readily and immediately accept the therapist’s position and may feel a need to test her in a variety of ways before accepting her as trustworthy and dependable. Testing may be manifested as an intensification of symptoms, challenging of the therapist’s credentials or credibility, or resistance. The need to test the new member stems from the realization that she intends to change the system. The change is both welcomed and feared. For it to be successful, the client needs to know that he can rely on the therapist and that the latter is trustworthy, strong, and accepting before he can venture into the therapeutic process. The client may continue testing the therapist throughout therapy. The client wants to be loved, supported, and accepted, but most of the time, because of feelings of his own inadequacy, the client fears being rejected by the therapist or losing her love. Consequently, the need to sustain and maintain the new member is not limited to the intake phase alone but continues throughout therapy. Dialectically, the dominant position of therapist is misleading. As a system member, the therapist is highly dependent on the system (the client chose to come and cooperate and is free to choose not to come or to cooperate; the client pays for the therapist’s service, and the therapist needs to satisfy the client). The therapist holds the dominant position because the client confers it to the therapist. Consequently, there is a mutual dependency and acceptance of the therapist’s prominence—a typically intricate dialectic situation. This requires constant monitoring and cultivation. The following sections deal with these aspects of therapy. MAINTAINING, SUSTAINING, AND FOSTERING JOINING

The therapist, like the client, holds a set of beliefs that guides him or her through therapy and determines his or her approach to the problem and the client. The therapist draws from his or her own experiences in an attempt to understand, evaluate, and assess the client and self in therapy. Therapy is thus an encounter between people; each brings to the session his or her own guided or misguided consignment of life experiences, attitudes, beliefs, and values. Countless publications can be found on the importance of

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countertransference (e.g., of the therapist’s beliefs and attitudes) in therapy (e.g., Lambert 2004; Pappas 1989). There are some fundamental beliefs I have found particularly important in fostering and affirming joining: Joining is all about loving: the client needs to feel loved, respected, and appreciated. This may sound trivial, but it may not always be apparent or emphasized enough in our work. We tend to work with different people. Most of them are likable, but some are not, or they may seem unlikable at times during therapy. When I become aware that a particular client is annoying or irritating, I try to find something in her that I can connect with. There is always something, and once I have found it, I focus on it, and I remind myself of it whenever a negative feeling arises. This allows me to reduce negative feelings and resume joining with the client. Focusing on the client’s lovable and attractive characteristics helps the therapist overcome negative characteristics and makes it easier to maintain joining. Lack of love is what the client brings to therapy, and therapy is an opportunity for her to feel loved, even in a limited, albeit intimate, therapeutic situation. We work with people who may be different from or similar to us, whom we may or may not like, and we need to find ways to like them. Although disliking a client sounds inappropriate, and it is, the truth is that it occurs quite often in therapy. The belief that a therapist should like all her clients is a wonderful and important one but not necessarily a realistic one. I believe that this should be the goal we strive for in therapy: to love and like our clients. Nevertheless, we may find ourselves in situations where we feel negatively toward a client. This feeling is usually attributed to the therapist’s countertransference. The client triggers a negative emotional reaction in the therapist. Having such a negative feeling is highly adverse in therapy and blocks or disrupts joining. The client, who is usually extremely sensitive, perceives and responds to the negative reaction. We shall see later in this chapter that recognizing and sharing these feelings may be very helpful in therapy. We may consider the point in therapy where these feelings arise. If the therapist is aware of a negative emotional reaction from the start, this reaction can have different implications from those arising at any other point in the therapy. When a strong negative emotional reaction is felt at the time of intake,

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and it does not change throughout the course of therapy, the therapist needs to ask himself how appropriate it is to continue seeing the client. On the few occasions that I did continue in this way, out of shame or obligation, I found myself spending a good deal of time struggling with the issue, unable to be with the client without reservations or to work competently. This experience has taught me that when I feel this way I cannot really work with the client, and I had better withdraw from therapy. Obviously, I can work on my countertransference, take supervision, or consult with my peers. But the real issue is the client’s welfare: am I being fair to my client? The process of working through my countertransference may take time—at the client’s expense. My preference is not to continue working and not to add my difficulties to the client’s. Because this happens at intake, I can excuse myself by saying that I am not competent to deal with this case, and I can refer the client to somebody who is more competent. In so doing, I accept responsibility for the referral. Paradoxically, clients hearing this have thought better of me and have said they would like to stay in therapy despite my misgivings. Sometimes this discussion has helped me see different aspects of the client I could connect with. At other times I have had to insist on termination. The issue is entirely different when negative feelings arise during the course of therapy, when therapist is already committed to it. By then the reaction is within the realm of the therapy and is related to issues arising in it. The therapist is responsible for seeking supervision and finding out what has happened and what caused the change in feeling. Working on this reaction can change and facilitate therapy. Sometimes feelings can be disclosed and shared with clients (as discussed later in the chapter). All in all, every client deserves to be loved and has something we can positively connect with. This connection is an essential ingredient of joining. The feeling of love for the client does not preclude the existence of negative feelings. On the contrary, knowing that one is loved allows for these feelings. Both therapist and client may experience the whole range of emotions during therapy. Experiencing and trusting love allows us to use them to facilitate therapy. The therapist needs to provide hope. I imagine that my fellow therapists will rebuke me for using the word need. Nonetheless, I believe that its use

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in this place is warranted. Providing hope is vital for therapy. Let me begin by recounting the story of Pandora’s box. After Prometheus stole fire from Zeus, the gods concocted a plot to avenge the theft. They sent Pandora a jar she was unequivocally instructed not to open. As expected, Pandora could not resist the temptation and opened the jar. What came out were diseases of the body (e.g., gout) and of the mind (spite, envy, and vengefulness). Horrified, Pandora tried to close the lid and was not aware that hope lay beneath the diseases. Even though there is a controversy about whether Pandora did indeed let hope out, its fate may be elusive. The uncertainty accompanying hope is much greater than that accompanying spite, envy, or vengefulness. This uncertainty stands at the core of therapeutic work. The evils are usually present here and now, whereas hope belongs to the uncertain future. A person may lose hope when there is a threat to the provision of basic needs (order, security, belongingness, and identity) (Rodriguez-Hanley and Snyder 2000). The client who comes for therapy would like to believe that her condition is going to change for the better after the intervention. This hope, interwoven with joining and fear, enables the client to risk exposure, intimacy, and change while cautiously moving from hope to fear and vice versa. The client can be in therapy only with a therapist who believes a change is possible. However, if the therapist is unsure of the success of the intervention or loses hope at any point in therapy, the client is likely to give up more easily. Many times I have had couples in therapy who did not believe in their ability to change and save their marriage. On those occasions I felt as if I was the only one willing to vouch for their common future. After a while, when the storm was over and therapy ended successfully, I asked the couple what made the change for them. The usual response was that I did not lose hope. Conversely, when I did lose hope, and I conveyed it to the client in one way or another, therapy usually ended in failure soon after. The therapist’s ability to hold on while the client struggles to cope with the problem is the safe base or home port that allows doubts, dissatisfactions, disappointment, anger, frustration, and helplessness to be expressed in a way that leads to the opposite: change and success. A closely related tenet is the need to be sincere. Sometimes the therapist has a different view of a problem, sees things differently from the client, or has a value conflict. To avoid confrontation with the client, the therapist

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may keep these views to herself. In doing so the therapist distances herself from the client and breaches the client’s trust in her. My usual advice is that therapists ought to be sincere. They are not obliged to agree with their client; they are entitled to think and believe differently, and the client is entitled to know this. The client also needs to know that it is acceptable to have different opinions and values and that as long as these can be openly discussed, trust and joining will be maintained. Knowing how the therapist feels and thinks helps the client separate his or her own thoughts and feelings from those of the therapist. The client does not have to fear or guess where the therapist stands on the issues and is allowed to have his or her own attitude. Sincerity is a cornerstone in therapeutic relationships (Rogers 1951). There is a short-run temptation to avoid talking about conflicting positions, to put the discussion off, or to sidestep the matter, but eventually there is no escape, and these issues will have to be attended to. Otherwise, trust will be impaired and both sides will use resistance to avoid dealing with the issues. I remember one of my patients who held political views diametrically opposed to mine. This client advocated an extremely harsh policy toward the Arab residents of the West Bank, so much so that he wanted them to be transferred across the Jordan River. My views were very different, and it was extremely difficult for me to listen to him expressing his views without trying to persuade him otherwise or feeling abhorrence. After several sessions in which I tried in vain not to get into these issues, I decided to bring them up. We spent quite some time discussing our differences of opinion, and we came to agree that each of us was entitled to his own opinion, but this should not come between us. From that point on the pipeline was cleared and the therapy flowed without obstruction. We were able to look at our differences with humor, and they did not interfere with the treatment. THE CLIENT OFTEN DIFFERS FROM THE THERAPIST IN IMPORTANT CHARACTERISTICS

The therapist encounters people who are quite different from him in a number of respects, such as gender, socioeconomic status (SES), cultural and personal values, physique (appearance or disability), race, ethnic origin, and so on. These differences are likely to affect both the therapist’s and the client’s

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perspective of the presenting problem and its context. Sometimes neither therapist nor client will be aware of the differences, out of ignorance or denial; occasionally, despite recognition of their existence, neither will be aware of the importance of these dissimilarities. The therapist should be familiar with each particular client’s background and understand the roots and implications of the client’s culture, ethnicity, SES, gender, race, appearance, sexual orientation, and so on. Understanding clients’ subjective meanings of their attributes will enhance joining and therapeutic efficacy. These attributes determine how the system functions and its members’ beliefs about life and opportunities (educational, occupational, and financial) (Zuberi 2001). Cultural identity affects a person’s social role, beliefs, attitudes, rituals, meanings, behavior, and expressions of feelings and emotions. The importance of that subjective meaning is demonstrated by common and seemingly universal concepts such as romantic love. Romantic love has very different meanings in different cultures (Jankowiak and Fischer 1992). For example, the Japanese word for love (Amae) is more similar to the Western definition of dependency (Dion and Dion 1993). The Chinese gan qing means helping and working for another person (Gao 1996). These different cultural meanings reflect different attitudes and rules that affect behavior and emotional expressions (Levinger 1999). Cultural norms also define who is considered a family member, interpersonal interaction and relationship styles, the hierarchy in terms of age, gender, and power,2 the rules, behavior, and symptoms, and the conceptualization of mental health (Glick et al. 2000). A person who belongs to several cultures or subcultures simultaneously (e.g., white, blonde, single mother, unemployed) is likely to be affected by all of them. However, the person may feel a need to define herself in terms of one culture or another or to emphasize a particular culture in a specific situation or setting (e.g., in a situation with family or with peers). This dissimilarity can be expressed in a manner suggesting pathology, when in fact it is not. An immigrant is expected to assimilate into the new, sought-after, mainstream culture. The assimilation process is complex and often involves abandoning the old culture for the new. This process commonly entails an interim anarchic period in which the old culture is not accepted and the new one has not yet been assimilated. This period is associated with increased

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delinquency, suicide attempts, and other problems (Jasjnskaja-Lahti and Liebkind 2001; Jaycox et al. 2002; Ritsner, Modai, and Poznovsky 2000; Ullman and Tatar 2001). The more different the original culture from the adopted one, the more difficult is the necessary change. The process can be easy when there are close family ties and social support (Harker 2001). Being a member of a minority group (e.g., in terms of culture, race, gender, sexual orientation) is associated with stereotypes and prejudice. Prejudice is “a hostile or negative attitude toward a distinguishable group of people, based solely on their membership in that group” (Aronson, Wilson, and Akert 2005, 433). Prejudice has an affective, usually negative and hostile component; a cognitive, stereotypical component; and a behavioral, discriminatory component (Aronson et al. 2005). However, a prejudice need not be negative (e.g., “Jews are smart”), but it includes a set of expectations from the members of that group that may be unrelated to the characteristics of that individual person. Race, for example, is a common source of prejudice (Bobo and Fox 2003). However, a definition of race is quite complicated. In some states in the United States, even a person who was one-thirty-second black, without any black features, was considered black. Interracial marriage gives a person the opportunity to choose his or her own racial identity. For example, the tendency to categorize those who are different from mainstream society as similar to each other (outgroup homogeneity; Linville, Fischer, and Salovey 1989) can cause some to think of all people of Asian origin as simply Asian. This may be offensive to those who define themselves by their nationality or culture. Being a member of a minority group is not necessarily and universally negative. Belonging to a minority may strengthen relationships and support within that group (e.g., Orthodox Jews are a distinct minority that developed a powerful social support network for its members). It may provide secondary gains in particular situations (e.g., occupational, educational) and may help establish a unique and separate identity for the person (“I am African American” or “I am a Jew”). Some theoreticians assert that clients may use being part of a minority group as a defense against dealing with underlying, more threatening issues (Montalvo and Gutierrez 1988). Laird (1998) argues, “Culture is contextual. . . . It is always more or less changing and it is always emerging” (24). There is awareness that ethnic

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and racial categorization tends to change over time in configuration or importance (Omi 2001). I agree with Laird that the meaning of culture or of being a member of a minority group depends on the context and changes within it. A person may be more aware of the effect of being a member of a particular minority group in a particular situation (e.g., a disabled person using a wheelchair trying to board a bus), may feel differently about it in a specific situation (e.g., being with other members of that group in a protest vs. confronting a discriminatory act), and may use it to bolster self-esteem (“I am . . . and proud of it”). The more conscious the person is of being a member of a minority group, the more salient a place it may take in life. A person may belong to a number of minority groups simultaneously, and their relative conspicuousness will vary depending on the particular context. Unlike Laird (1998), I believe that membership in a minority group should not distract us from the more basic and fundamental issue: we deal with people whose racial, ethnic, gender, and other attributes, important as they may be, are just aspects of their being and who are still people who need help. Making membership in a minority group the issue, or a metaphor, in therapy may distract the therapist from seeing the person apart from the minority context and may potentially harm therapy. The opposite is also true: neglecting to address these issues may deprive us and the person of key elements that we need in order to understand that person. Come to think of it, we may consider that being a member of a minority group requires the acceptance of the majority group. A minority group is identified only in the context of a majority groups and derives its identity from that majority group. Actually, the existence of a minority group affirms the majority group. The therapist needs to be knowledgeable and respectful of these differences and aware of potential countertransferential issues that may be involved. It is advisable to address these issues as early as possible in therapy. The therapist should be aware of the contextual effect on psychopathology and be careful not to overpathologize culture-related behaviors. When a therapist approaches a client who is visibly different (e.g., in gender or race), it is quite clear that the client is also aware of this difference. The best approach is to address the issue as soon as possible to avert problems before a mutual commitment is made. The therapist may inquire about the client’s feelings about and attitude

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toward working with someone who is different. Even though therapy outcome research (e.g., Lambert 2004) is not unequivocal with respect to the effects of ethnicity, race, and other traits, these issues are relevant to the therapeutic relationship (Glick et al. 2000; McGoldrick 1998; Schwoeri, Sholevar, and Combs 2003). Therefore, discussing these issues with the client is extremely important. The client needs to know that the therapist is aware of the differences and, more importantly, is ready to deal with them. Of course, discussion of these issues is not limited to the context of therapist–client relations but can also be extended to other areas of the client’s life. Sometimes the client will not be aware of the effect the different aspect (e.g., race, culture, SES) has on his life. The therapist who is aware of these issues need not feel that she is insensitive and disrespectful in raising them. On the contrary, avoiding these issues may disrupt relationships and inhibit true joining with the client. The therapist should be aware that each characteristic of the client intersects with others, such as age, social class, gender, and sexuality (Cohen 1999). A client who belongs to a different racial or ethnic group may consider this fact essential to the therapy, but out of deference to the therapist he may not bring it up. A person may differ from the therapist in several ways but will consider some of them (e.g., having a physical disability, being black, divorced, or unemployed) more important for the therapeutic situation. If a black singleparent client comes because she is physically disabled and needs help with her disability, then certainly being physically disabled will be paramount in this situation. However, the other issues are not thereby excluded but must be addressed. A therapist inexperienced in dealing with physical disabilities should be aware that if this issue is the most important for the client, other issues in which therapist has more experience or knowledge will not undermine the client’s view. This is a countertransferential issue. The therapist may also be black, and in a white-majority culture this may prove an issue for therapist and client alike (e.g., the therapist may serve as a positive or negative role model; the client may believe that a black therapist may be less or more powerful in dealing with the authorities; a black therapist may consider race the issue to work on, more important than the disability the patient struggles with). Dealing with these issues will help both therapist and client learn why the issue is important for the

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client (assuming that the therapist is aware of its importance or the lack of it) and why it is important in this particular situation. This knowledge will be helpful in understanding the client and the personal significance of these issues. A therapist might encounter a client about whose attributes he has no particular knowledge. It is not disrespectful to admit a lack of knowledge. In this case I ask my client to be my teacher and guide me as to the effect of these attributes on her life. Then I ask how it is related to the problem that the client presented initially, or to the reformulated one later. Once I had clients of a religion of which I had only rudimentary, stereotypical knowledge. My readiness to admit a lack of knowledge and my asking them to teach me was very helpful in empowering the clients and very useful in assisting their change process. When they helped me understand them, it gave them an opportunity to examine their own views and better understand themselves. EMPOWERMENT

FDS enables the therapist, and consequently the client, to realize that behavior can be viewed dialectically (e.g., strength is also a weakness, and a weakness is actually a strength) and thus, more functionally and positively. The client who comes for therapy usually feels distressed, discouraged, or helpless. The client has usually tried out different solutions before coming for therapy, and despite feeling helpless and desperate he is still hopeful that a solution will be found. The client may appear skeptical, cynical, or distrustful and may state at the beginning of the session that he does not believe the psychologist can be of help. Nonetheless, the client has come to the session and wants to be convinced of the opposite, to be provided with hope. The client may feel that he lacks the necessary qualities that will make him more attractive or a better partner or that will make his spouse recognize and acknowledge these qualities. Self-esteem is usually low at this point, and the client wants the therapist to help him restore or improve it. The process by which a person gains more respect, appreciation, and regard is called empowerment. A person who is empowered is better able to take control of his life. Parents who feel empowered can be more helpful to their children (Nachshen

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and Minnes 2005). Empowerment has been related to lower parental stress, more flexible and adaptable family functioning, parental employment, and higher parental education (Scheel and Rieckmann 1998). Empowerment generates positive feelings, which in turn are instrumental in coping with the problem at hand (Folkman and Moskowitz 2000; Hastings and Taunt 2002; Taylor 1983). In this sense, every therapy is essentially an empowering process. My focus in this section is on how empowering is expressed and directly handled in the therapeutic session. How do we do it? How do we empower our clients? First, we provide them with hope. We do so by expressing it verbally, by accepting the patient for therapy, and by means of the therapy itself. The success of therapy is manifested by the empowered client making a change in her life. Second, by respecting and accepting the client we provide her with a sense of personal value. Third, we empower the client by focusing on her positive attributes (which actually emphasizes the dialectic pole). The use of FDS is inherently empowering because it focuses on the functional, adaptive, and positive meaning of the presenting problem. Being aware of this meaning, the client may move from a weak, pathological, needy position to a self-controlled, helping, and hopeful position. Fourth, empowerment is manifested in strict adherence to the therapy contract. For example, insisting that all members be present conveys the message that everyone is equally important, so much so that no meeting can be held if even one person is missing. Insisting that patients follow the contract sends a message that the clients are capable and responsible. Fifth, empowerment can be communicated behaviorally by giving the disempowered person a place at the meeting. For example, in a session with a family in which the father is considered passive and weak and his opinion is not respected, the therapist may consult with him, seek his advice in dealing with family matters, and ask for his help. This behavior makes obvious the therapist’s respect for the father. Because the therapist is respected by the family, this respect is likely to extend to the father. Another way of demonstrating empowerment is by having the client (or the therapist) sit next to the person who is the target of empowerment (spatial empowerment). For example, in a family session with an

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adolescent girl whom everybody in the family blamed for their problems, the therapist asked the girl (who sat somewhat apart from the rest of the family) to move her chair closer to him. Reluctantly, the girl moved, and the therapist began turning to her as if she were his cotherapist. The response was amazing. The girl, who had barely spoken, became animated and responsive. Sitting next to the therapist, she felt empowered and was able to say things and share observations about the family and herself that she could not allow herself before. A different kind of example is empowering through negation. A couple has come to therapy, and one spouse defames the other and says how bad a person he is. One might think that the person wants to justify or explain why they are in trouble (e.g., “He is selfish,” “He does not care at all about the relationship,” “He shows no affection and is indifferent”) and wants the therapist to see the same thing and agree with her. An FDS therapist will see this but also see precisely the opposite: the defaming spouse wants to hear that the partner is not as she describes him and that she actually made a good choice in marrying him. The spouse has come to therapy to tell how bad her partner is but expects to hear how good he is. Empowerment is a process by which the client is strengthened. It allows the client to develop a more equal-level, person-to-person relationship with the therapist and to use therapy more effectively. In this chapter, I have discussed how important joining with the client is. Joining means loving, respecting, and accepting the client. Joining empowers the client and makes it possible to cope with difficulties, overcome obstacles, and instill hope in the client. All of these are major contributors to the success of therapy.

8 DISCLOSURE

SELF-DISCLOSURE: CLIENT

Joining is a process of creating and maintaining a sincere relationship between the client and the therapist. The newly created therapeutic system is based on and functions through mutual trust. Trust in the therapist enables the client to reveal things about himself that he would not reveal under any other circumstances (even to the most intimate friend or spouse). It enables the therapist to be empathic and understanding and to use knowledge and experience to help the client. This openness is bolstered by the knowledge and assurance that information shared in therapy is kept confidential and will not be divulged to others or used against the client. The therapist’s underlying belief is that the client is fully self-disclosing. The therapist’s ability to understand the client’s situation is based on the premise that all information is sharable. The client is not expected to be fully conscious or aware of every aspect of his life. However, when the client knowingly chooses not to share relevant information, he is not selfdisclosing, and as a result therapy may be less effective. Does the client feel the same way as therapist about self-disclosure? The client comes to therapy seeking acceptance and support. Perhaps the client wants to present himself selectively to the therapist at first. Kelly and colleagues (Kelly 2000; Kelly, Kahn, and Coulter 1996) found that clients tend to present themselves more positively than they really are. They do so to appear more favorable to the therapist, out of fear of losing the therapist’s support and acceptance, and also to themselves. Presenting themselves in a more positive light allows them to avoid feeling helpless or admitting that their situation is that bad. When clients do this they are self-encouraging, 117

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and they bolster their own self-image and positive beliefs about themselves (Aronson et al. 2005; Fazio, Effrein, and Falender 1981; Gergen 1965). This modified self-presentation can be generalized from therapy to interaction with other people (Schlenker, Dlugolecki, and Doherty 1994). Note that the initial presentation during the intake session is likely to be the opposite in some respects because clients need to present their situation in a negative light in order to justify being in (and paying for) therapy. This is a classic case of cognitive dissonance (Festinger 1957, 1964) in which clients feel the need to distort reality in order to justify the situation they are in. But they try to present themselves (their personality and motivation) in a positive light. When a positive image is accepted and reinforced by the therapist, it is likely to be internalized (Quintana and Meara 1990). On the other hand, encouraging clients to talk about the negative aspects of themselves and their difficulties may consolidate a negative self-presentation and perception (Kelly 2000). Openness of that kind seems negatively related to therapy process ratings and symptom reduction, according to Stiles (1984) and Stiles and Shapiro (1994). This view of a selective, more positive self-disclosure does not necessarily contradict the view espoused at the beginning of the section. The client does not conceal relevant aspects of his life or situation. If the distressed client presents a more positive view of self and coping, isn’t this in fact what we want him to do? Clients in therapy are in multiple dialogues. They are in dialogue with the therapist, with others in the session, and with themselves. They want to be accepted and supported by everyone. Each of these others may have different expectations of the client. A wish to be accepted and supported may lead clients to present themselves in different ways to different people and to reveal distinct aspects of themselves to various people in diverse situations. These differing presentations are situationally contingent and also depend on the level of trust and relevance of that presentation for the particular situation. For example, a client may reveal things in therapy and talk in a way that is not customary in her relationship with her spouse. Her spouse may interpret this behavior as not being self-disclosing (“Why didn’t you tell me this at home?” or “I didn’t realize you felt that way”).

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A client who seeks support and understanding may fear that full disclosure will not serve her (for the reasons just cited) or may be afraid that self-disclosure will hurt her self-image or put her at a disadvantage in the relationship. This usually is associated with knowingly and deliberately withholding information pertinent to therapy. In this situation, lack of self-disclosure endangers therapy (and the client). A client who comes to therapy with a question about a potential major life change (e.g., personal goals, divorce, marriage, occupation) and is not self-disclosing runs the risk that inaccurate or slanted information may result in a faulty and inaccurate perception of the problem and its solution. A more difficult question concerns the client’s sincerity in therapy and the lack of trust that keeping secrets or withholding information implies. If this is the case, the trust between therapist and client will be adversely affected to the point where the therapist may feel unable to continue therapy or even trust the client. This in turn will negatively affect joining and the outcome of therapy (Beutler, Machado, and Neufeldt 1994). It is clear to me that, in therapy, a client’s self-disclosure is closely related to his perception of the therapist’s attitudes. If the therapist is sincerely accepting of the client, even after hearing negative revelations about or from the client, the latter is likely to feel better about himself. Being aware that the therapist has not rejected or judged him gives the client the impression that his situation is not that terrible, and therefore the client is not as bad as he had thought. Thus, the more open and sincere the client is in relating his difficulties, the easier therapy is for the client. Sometimes the client’s capacity for self-disclosure is not great at first, and he needs more time and reassurance to muster the courage to be more self-disclosing. When the therapist feels that the client is withholding information, 1 at first she may ask herself whether this holding back is connected to the relationship. Limits set on self-disclosure are usually linked to the interaction between client and therapist. The more open, accepting, and trustful the situation is, the lower the pressure for a distorted self-presentation will be. In my experience, when joining is good, clients are usually selfdisclosing, and if they appear not to be so, it is usually because I have not asked the appropriate questions or have not asked enough questions to clarify or obtain the relevant data. Thus, self-disclosure is “a valuable tool

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in a therapeutic relationship that facilitates exploration, introduces new perspectives . . . and conveys to the patient the possibility of creating a new, healing object relationship” (Bridges 2001, 22; see also Goldfried, Burckell, and Eubanker-Carter 2003). Another possibility is that when the client is not self-disclosing about an issue, he discloses another element of self. For example, if the client is not willing to discuss issues relating to sex, this indicates an area that should be looked into. It need not be there and then, but the therapist must keep it in mind and await the appropriate time when the joining is strong enough to bring the subject up. If I believe that a lack of self-disclosure is related to the client–therapist relationship, the next question is what the function of not disclosing is. Is it a defense? Is it a secret? Has it something to do with the other clients (family members)? Finding the answer to these questions is an essential part of the therapeutic process, and it is where the line between the envelope (structure) and the process become a little blurry. A note of caution is needed at this point. It may be the case that the client expects a secondary gain from the interaction (e.g., disability benefits). In that case, a negative or positive self-representation can be expected, and clients often give one (Braginsky and Braginsky 1967; Braginsky, Grosse, and Ring 1966). Self-disclosure is one of the most important features of the envelope, ensuring the uninterrupted flow of the therapeutic process. When it is lacking, joining is in jeopardy, and therapist needs to find out why it is so and act to ameliorate the situation. SELF-DISCLOSURE: THERAPIST

The need for the client to be fully self-disclosing is clear, but the question of the therapist’s self-disclosure is more challenging. My view is that the therapist’s self-disclosure is important for the creation of an open, sincere, equal-level client–therapist relationship, and makes it possible to explore the more complex and sensitive dialectics. Jourard and Jaffe (1970) found that a therapist’s self-disclosure increases client’s self-disclosure.2 The traditional psychoanalytic approach views the therapist as neutral in his or her attitude and involvement with the client (Greenson 1967; Gutheil and Gabbard 1993). Being neutral ensures the client’s autonomy

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and control. Others (e.g., Scaturo 2005a; Simon 1992, 1994) argue that in addition to hindering the therapist’s neutrality, a therapist’s self-disclosure may limit the client’s ability to separate from the therapist, may encourage a personal relationship with the client, and does not allow the therapist remain anonymous to the client. Schoener (1998) even claims that close relationships resulting from a therapist’s self-disclosure will make the therapist afraid of separating from the client even when a referral to another therapist is needed. Simon and Williams (1999) maintain that self-disclosures of personal experiences may also create role reversal, in which the patient attempts to rescue the therapist. They further state that self-disclosure may have a high correlation with sexual relations between therapist and client, a concern also shared by Fisher (2004). The need to protect the client’s autonomy to make her own decisions led traditional psychoanalytic therapists to ask their clients not to make any major life decisions during therapy for fear that the therapist would exert a conscious or unconscious influence. I believe that neutrality was misinterpreted as the elimination of all personal disclosure by the therapist. I heard a story of a therapist whose client had survived the September 11, 2001 terrorist attacks. The client asked the therapist whether he had been in town at that time, and the therapist refused to answer the question. Evidently, this “neutrality” reinforces an asymmetrical and hierarchical client–therapist relationship (Wachtel 1987). Also, it serves a defensive, self-protective function for the therapist. A nondisclosing therapist can maintain distance and avoid emotional involvement with the client. According to FDS, establishing joining or a working alliance requires a closer relationship between client and therapist, which moderates the asymmetry in the client–therapist relationship. Rosen and Lang (2005) maintain that “transparency pushes against the power imbalance inherent in the family relationship” (171). Appropriate joining is facilitated by open communication between client and therapist (Goldfried et al. 2003; Jourard and Jaffe 1970). The therapist’s self-disclosure increases intimacy, reduces uncertainty, and fosters personal growth. However, self-disclosure is culturally related; moreover, women tend to be more self-disclosing than men. A therapist’s sensitivity to his and the client’s value system is crucial in developing an equal-level relationship and fosters self-disclosure and

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mutual trust (Helms and Cook 1999). Constantine and Kwong-Liem (2003) and Burkard et al. (2006) argue that attitudes and beliefs relating to race and color must be addressed early in therapy and that self-disclosure has a positive effect on therapy. Pope, Tabachnick, and Keith-Spiegel (1987) surveyed psychologists and found that most (93.3 percent) of them used self-disclosure. More specifically, more than half displayed anger (89.7 percent), cried in the presence of a client (56.5 percent), or expressed disappointment with a client (51.9 percent). However, about 57 percent thought that expressing disappointment was wholly unethical. From the FDS viewpoint, a therapist’s self-disclosure of personal weaknesses can empower the client (unless there is a sexual overtone that might invite misinterpretation by the client). We shall see later how a vulnerable therapist can save a stuck therapy. Without doubt, this potential breach of boundaries between what is supposed to be therapy and what is not is likely to confuse or even threaten the client. Self-disclosure is likely to make an insecure and confused therapist more vulnerable, causing him to retreat from further disclosure and hindering closeness and openness with the client (Bridges 2001). However, certain agreed-upon codes limit self-disclosure, and they are stipulated in the Code of Ethics (American Association for Marriage and Family Therapy 2002; American Psychological Association 2003). These include sexual and romantic relations and business relations. As long as the therapist remains within the boundaries set in the Code of Ethics, there is no danger for the client or therapist. Still, self-disclosure may be inappropriate when the therapist discloses things not directly related or relevant to client’s difficulties or experiences or does so when a romantic transference is apparent. Maintenance of boundaries is independent of therapeutic orientation (Borys and Pope 1989). There may be cases in which maintaining more rigid boundaries and less self-disclosure is recommended, such as therapy with incest victims (Russell 1986), feminist therapy (Brown 1994), or addiction recovery (Katherine 1993). In most cases, though, keeping rigid boundaries increases the risk of losing flexibility in therapy and consequently limiting the therapist’s ability to help people when such flexibility is needed (Williams 1997). One of the most difficult cases for me in therapy is working with parents of children

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murdered in terrorist attacks. I live in Haifa, and my office is on a street very close to two sites of terrorist attacks. Our daughter was a high school student at that time who usually took the bus that was blown up in one of these atrocities but luckily did not take it on that day. Several families were referred to me after these murderous attacks. Maintaining an impassive look or attitude in the face of such a traumatic event was out of the question. The clients did not allow that. They needed to be hugged and nurtured. They needed to see the therapist crying (and I needed that too). Experiencing such a warm and loving attitude, they were able to work through their own pain and mourning. Later in therapy I found I had no difficulty reestablishing boundaries because that is what we both needed. Nevertheless, being too open and too sharing may run the risk of distancing the client. At times, self-disclosure may add to client’s negative feelings about self (“Why can’t I do it also?”; “Something is wrong with me because I can’t do it”). How much to share, with whom, and under what circumstances so that disclosure will be helpful is a matter of personal judgment. How the client reacts to the therapist’s self-disclosure is an important indication of whether self-disclosure is appropriate. When I disclosed my own personal experience, one client dismissed it, saying, “That is you and not me,” which I could deal with easily by suggesting, “You are correct, but can it apply in any way to you?” On another occasion the client said bluntly, “Your problems do not interest us; we have our own to deal with!” This response made me feel upset, insulted, and offended. It also taught me that with this client self-disclosure was inappropriate, and I should be much more cautious. Most of the time, sharing my own feelings and experiences (even personal ones such as severe injury or divorce) was very helpful for the clients and enhanced the sharing and closeness; “It’s good to know that you are a human being” is how they described their response. Gauging self-disclosure in therapy begins with the understanding and awareness that it is meant to serve the client. The client’s response to such disclosure is monitored carefully. When done appropriately, it promotes joining, validates the client, and improves the flow of the therapeutic process. The issues discussed in this chapter all contribute to and promote joining. Now it is time to turn to the opposite pole, resistance, and to see how we can use resistance to rejuvenate therapy.

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9 RESISTANCE: IMPEDING AND FACILITATING THERAPY This chapter focuses on interference in the therapeutic process—not necessarily intentional or conscious, but nevertheless stalling, subverting, or blocking the process. Such interference takes the form of resistance, power struggles, anger, and stuck therapy. Nevertheless, the therapist can use resistance to better understand the client and to facilitate therapy. RESISTANCE

Resistance is defined as anything (done by the client or therapist) that blocks the therapeutic process (Greenson 1967). Scaturo (2005b) characterizes resistance as an unconscious intrapsychic influence that acts against the therapeutic process. Resistance results from the patient’s unconscious wish to avoid the anxiety associated with dealing with her traumatic experiences, behaviors, unacceptable thoughts, wishes, or emotions. Resistance is usually associated with poor prognosis (Beutler, Moleiro, and Talebi 2002; Bischoff and Tracey 1995; Stoolmiller et al. 1993). This is the traditional, psychoanalytic view of resistance. The process of change, in any kind of therapy, means transforming from a disagreeable but familiar (and predictable) situation to a desired but unfamiliar one. The hope for change motivates therapy, but fear of the unknown leads to resistance. Resistance is manifested in a number of ways: being late for therapy or canceling without notice, forgetting sessions, leaving out a family member, refusing to talk about certain issues or refusing to talk at all, showing a defiant attitude, pushing to improve too quickly (a flight into health), delaying or not performing homework assignments, disrupting meetings, 125

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refusing to pay, or renegotiating the payment or contract. When resistant behavior originates with the therapist, it is called counterresistance and can be manifested in the same way as the client’s resistant behavior (see Robertiello and Schoenewolf 1977). Resistant behavior can be seen differently in the context of the functional dialectic system (FDS) approach. Given the traditional definitions cited earlier, resistance can be viewed as the dialectic pole of joining. Whereas the latter represents closeness, the former represents distance. Moreover, resistance itself can be considered dialectically in terms of its function. Resistance hinders therapy but is also instrumental for therapy. Studies on the effect of paradoxical therapy (e.g., Weeks and L’Abate 1982) found a positive correlation between the level of initial resistance and the positive response to and outcome of these interventions (Dowd, Milne, and Wise 1991; Olinsky, Ronnestad, and Willutzki 2004; Shoham et al. 1996). In paradoxical intervention, resistance is manipulated to foster a second-order change. The client stands between the poles of joining and resistance, and at each point of therapy the client demonstrates both extremes. From this perspective, resistance is as essential a part of therapy as joining. Resistance is as much a means of communication as is joining. The former communicates fear and caution, the latter closeness and love. Resistance can be a means of delaying discussing or confronting emotionally laden issues. Resistance can be activated when the client is not yet ready to venture into an issue that the therapist, or even the client, considers important at that time. The client may feel hesitant and anxious and then avoid the issue by manifesting resistance. Resistance is thus a mechanism enabling both client and therapist to regulate the pace of therapy and the emotional distance between them. When the client feels too close or dependent she may use resistance to distance herself while remaining in therapy. In this respect, resistance can be added to the list of the emotional distance–regulating mechanisms. Sometimes a client needs to regulate self-disclosure or is afraid of dealing with certain issues. He is willing to talk about the issues but fears losing the therapist’s support or experiencing an affront to his self-esteem. In this case, resistance can be a cry for help. The client creates a situation in which a crisis occurs in therapy. The therapist’s ability to recognize and

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understand the message conveyed by this behavior helps the client open the issue. In this regard, resistance is also a test of the therapist: of her sensitivity, persistence, and determination to help the client. It is a test of caring. Will the therapist pay attention? How will she react? Will she be accepting of this behavior? A common example of this kind of resistance is the defiant client. An adolescent girl was referred to therapy because of unruly behavior that caused her to be expelled from school. The school counselor recommended family therapy with a referral to me. I invited the whole family to come to therapy. However, only the mother and the girl came to the first session. [At this point I began asking myself who had not come. Why were those people missing? How does their absence serve the system?] As they entered the office the girl said, “I don’t want to be here, I don’t have to be here, I don’t want to talk with you. I came only because my mother forced me to, but she can’t make me talk,” and she sat far away from her mother, looking defiantly at me. [This is resistance: the girl does not want to be in therapy, yet she came and wants to tell me something. What does she want to tell me?] Encountering the resistance, I told her that I respected her wishes, but nevertheless I wanted to get to know her and her mother more. She did not answer any of my questions until I said, “I understand how difficult it is for you to be in a situation you feel you don’t belong in, so please tell me who ought to be here instead.” The girl reacted to this, saying, “They ought.” I asked her to clarify, and she said her parents needed to be in therapy because they made her life a misery. [This answered my initial question: those who are not here are those who need to deal with the marital problem.] When I guessed, “Are your parents contemplating separation or even divorce?,” she burst into tears and nodded. In the next session I saw her parents alone, and they became engaged in therapy for quite a while. Their daughter’s behavior improved without any further intervention. This bold and blatant resistance was actually a cry for help. The girl attracted attention to herself in the hope that somebody would read the message and respond to it. Another example may be this child’s behavior in a family session:

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The therapist was engaged in a discussion with parents over their relationship. Mike, their four-year-old son, was playing with toys and was seemingly absorbed in play and not paying attention. When the parents began to talk about their fights, the boy began yelling, tossing and kicking the toys around. It was very difficult to calm him down, and he repeated over and over that he wanted to go home. [At that moment it was clear to me that the child screamed to silence his parents, to prevent their fighting. The child took responsibility for his parents’ relationship, and he was probably terrified by the possibility of a breakup. This meant that divorce or separation was probably an issue for them.] When I commented that it seemed to me that Mike was really afraid that his parents were going to break up, he went wild. It was very difficult to calm him down. After he finally did calm down (only after his parents promised him they would not get a divorce), I asked them whether Mike’s fear was justified. They confirmed this and looked with trepidation toward Mike. This resistance is an attempt to stall, to evade a fearful issue by sidetracking therapy, and it also communicates the issue clearly to the therapist. Resistance may also serve the function of boundary testing, a test of the therapist’s ability to withstand negative behavior by the client. A therapist who is able to accomplish this, like a good parent, shows care and concern for the client. Resistance can also reflect the client’s doubts about the therapist’s competence. The client is afraid to confront the therapist, the authority, and he resorts to resistant behavior. In this case resistance can be connected to actual situation in therapy that requires awareness and consideration by the therapist (e.g., when therapist forgets an important piece of information about the client). Resistance can also be a manifestation of a therapist–client or a client– client power struggle. This issue is discussed more extensively in the next section. Resistance can also be the first reaction when change is at hand. The client (and maybe even the therapist) who is afraid of the anticipated change resists, attempting to delay or prevent it. The anticipated change means that the client abandons a nonadaptive, undesired, but familiar and predictable behavior in favor of a new, different, and adaptive yet unfamiliar behavior. The current or former pathological behavior is part of the pattern

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that provides the client with a sense of order and predictability. The new and anticipated behavior presages a period of uncertainty. This conflict or ambivalence raises anxiety and may lead to resistant behavior until the client has amassed enough support and reassurance to make the change (Rasmussen 2005). Resistant behavior when change is expected may also be related to ending therapy.1 A change means that ending is imminent. Fear of losing the therapist’s support, care, and understanding, of losing a significant relationship, is quite powerful in ending therapy. We shall look at this issue more extensively in Part VI. Resistance is a means of communication between the client and the therapist and also between family members. The meaning of resistant behavior can be understood in its interpersonal context. Viewed as a communication medium, it loses its negative, obstructive meaning and can be seen as a message that needs attending to. Scaturo (2005b) discusses various clinical dilemmas and also suggests seeing resistance as a friend rather than a foe. Joining and resistance are two dialectic poles present throughout therapy and an integral part of it. POWER STRUGGLES IN THERAPY

The common perception of a power struggle is of one partner wanting to dominate or coerce the other. Underlying this definition is the postulate that a power struggle requires at least two cooperating parties; therefore, it is systemic (partners are members of the same system). Hoffman (1981) argues that power struggles underlie family difficulties. FDS focuses on its function and dialectic meaning. A power struggle is meant to achieve some objective. The inherent objective of the power struggle is to achieve or restore stability or equilibrium (thereby ensuring the provision of basic needs). System members are engaged in a power struggle either to win or to lose it. Actually, it is a Hamlet-type situation, the “To be or not to be” part of the system. It certainly does sound counterintuitive that a person engaged in a power struggle expects to lose it! However, both options do exist, and this is the essence of FDS. Let us discuss two scenarios. In the first, a client’s therapy contract specified a weekly session, but almost from the start the client began rescheduling sessions to the point of losing any consistent pattern. The therapist became irritated by this behavior and wanted the client to establish a clear

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and consistent schedule, so he brought the issue up in one of the sessions. The client readily agreed, and for the next two sessions he came at the scheduled time. Then he reverted to his erratic schedule. When confronted again by the exasperated therapist, who felt unable to continue this way, the client responded by saying, “I didn’t realize it was so important to you. I just thought it was important because you have so many clients.” The client’s response highlighted the fact that it was indeed a power struggle. The patient interpreted the therapist’s flexibility in scheduling as a sign of not caring and was testing him to the point where the therapist reached his limit. Then, out of fear of losing the therapist, the client yielded and kept a regular schedule thereafter. A functional and adaptive system is able to set limits and keep appropriate boundaries. Setting limits and boundaries is associated with system stability. This in turn involves the system’s ability to meet its members’ basic needs. A system that fails to confer on its members a sense of security arouses anxiety and insecurity. The individual member then seeks to regain, or force the system to provide, these needs. One way of ensuring this is by testing the system’s strength and stability. Then, if the client is rejected by the therapist, he has won the power struggle but lost the therapy. If he loses the power struggle, he wins a strong, stable, and reliable therapist. If the therapist rejects the client, he has won the power struggle and lost the therapy. Being stronger than the therapist means loss of the therapist’s authority and ability to set limits. Winning the power struggle means that the client is stronger than the therapist, that he can make his own rules, and that he thus has lost the therapist’s support. On the other hand, the client losing the power struggle means that the system has withstood the pressure emanating from the client, thus affirming its own strength and stability. The client can then rely on the system for safety and stability. This reassurance is extremely important in helping the client make the desired change. The second scenario is one spouse belittling the other and forcing her to do as he wishes. As long as the “powerful” one is able to win these struggles, he can maintain self-esteem as long as the other is being put down. This is an intriguing situation because there is cooperation between the spouses, with a predictable outcome. The one who has “lost” (the one who is being

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successfully put down) reinforces the self-esteem of the “winner.” By doing so, the “loser” ensures the stability of the system and the protection by the “winner.” So the “winner” actually depends on the “loser” to maintain selfesteem and reciprocates by providing support and security. If the “winner” loses, it undermines the system, and both partners lose. In therapy we see this when the client tries to degrade the therapist by belittling her credentials or skills. When the client does so, he tries to maintain his self-esteem by being derisive and by putting down the therapist. Despite this attitude, the client stays in therapy and expects the therapist to be there for him. The client wants the therapist to be strong and dependable, and by struggling with the therapist (who does not terminate therapy or appear too hurt) the client ensures that the therapist is indeed strong and accepting, a result achieved only by testing her. These scenarios demonstrate the dialectic and the function of a power struggle. The “loser” is the “winner” and the “winner” is the “loser.” Every participant loses and wins in a power struggle, and a loss is a win, just as a win is a loss. A power struggle can also be a means to confirm the relationship between the two spouses while allowing emotional distance and avoidance of intimacy. A power struggle entails distance (two separate entities) and closeness (emotional investment, dependency). This view makes the power struggle a mechanism of emotional distance regulation. A power struggle may be viewed as means to establish distance, thereby preventing or inhibiting intimacy. On the other hand, the sense of mutual validation that accompanies the struggle provides a basis for closeness and intimacy. Usually the partners in the power struggle are aware of its benefits and detriments. A power struggle may also be a form of resistance. The client who wins a power struggle with his therapist avoids dealing with issues that may be too frightening or difficult for him. The client who resists therapy may do so because he is afraid to face significant issues and tries to control the situation in order to avoid doing so. The first scenario described earlier applies here as well. The client uses the power struggle to assert himself to the therapist. If the client wins, therapy is likely to be in trouble. The client is successful in avoiding dealing with these issues. One of the most common power struggles in couple therapy usually takes place during the first session.

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When a couple comes to therapy, in most cases the wife is the seemingly more motivated one, and the husband comes at the wife’s insistence. The husband then announces at the beginning of the session that they don’t need therapy because they can solve the problem on their own, and talking to or having a third person present, a psychologist of all people, is worthless (although he will mention that this is nothing personal because I am a very nice person, and obviously, glancing sideways at my certificates on the wall, a respected one). This comment is obviously meant for both his wife and me. Now we are all engaged in a power struggle. If his wife and I win, we will have therapy, and the husband will probably become an ally. If the husband wins there will be no therapy, and we all lose. The wife answers, “We have tried so many times before, and we always get back to the same place. I am tired of it and afraid that we are going to lose our marriage.” The husband reacts, “If you just tried harder, everything would be different.” (They may go back and forth until they both turn to me in frustration and despair.) My response is to ask the couple, “Is being married to each other important to you?” (Establishing a common goal usually reduces tension and fear.) Then I ask, “Please share with me what have you tried before and why it did not work.” Here I try to point out how they both cooperated in an attempt to solve the difficulty and try to show the positive (dialectic) aspect of their cooperative attempts (distance and caring) without assigning responsibility to either side. If I am successful, I will probably hear from the husband that he never thought of it this way, and I have earned his respect and cooperation. The power struggle is highly predictable. Both spouses are aware they are in trouble and cannot solve the problem on their own. One spouse is ready to accept help from a third party, but the other is not yet willing to relent and concede his position (we should bear in mind that they were in a power struggle before coming to therapy, and the decision to come to therapy is part of that struggle). They will do so after the therapist has proved that she is trustworthy,2 does not take sides, and knows what she is doing, or is doing things in a different way. When this happens, the therapist’s authority is accepted, and therapy moves on. This discussion characterizes power struggles as a dialectic mechanism whose function is to restore, force, or maintain the system as a need provider. A second role is to regulate the emotional distance between the partners

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to the power struggle. Therefore, it is vital for the therapist to realize the meaning of the power struggle and use it to facilitate therapy. Power struggle is essential for system development. In the case of adolescents it allows the transition from a hierarchical relationship to a more equal one (Smetana 2005). Power is a tool that allows system members to find a new position along the union–separation continuum. Omer (2001) describes escalation of the power struggle as means of losing control over the fight. Escalation leads to disengagement. However, escalation also defines the “red line” in the relationship and marks the point of return. Thereafter the sides will seek a new status quo in the relationship that will last until there is a need for a change. Power struggle is an essential, powerful dialectic mechanism, serving important purposes in system functioning. It redefines roles, empowers seemingly “weak” members, establishes boundaries, and regulates relationships. ANGER IN THERAPY

Before beginning the discussion of anger we need to define the various emotions associated with anger, namely hostility, aggression, and violence. Anger is defined as “a strong negative emotional reaction, indicating fierce displeasure that may lead to aggressive behavior. It may be caused by a loss of control and an attempt to regain it” (http://wordnet.princeton. edu). Anger is a feeling that is oriented to some real or supposed grievance (Betancourt and Blair 1992; Smith and Ellsworth 1985; Weiner 1985; Weiner, Graham, and Chandler 1982). Hostility is defined as “a state of deep-seated ill will” (http://wordnet. princeton.edu). Hostility is “antagonism or enmity, a warlike attitude, deep-seated hatred, meanness, or acts of overt warfare” (American Heritage Dictionary 2004). Aggression is defined as “a disposition to behave, an act of initiating hostilities. Aggression is an act or threat intended to cause injury or harm” (http://wordnet.princeton.edu). It is “a behavior characterized by physical or verbal attack. It may be overt or covert (domination, submission). In a mild form it is assertion, and is appropriate. It is a violent action that is usually unprovoked. Aggression may expressed in a covert way; domination, submission” (American Heritage Dictionary 2004).

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Violence is defined as “an act of inflicting injury or death. It is more intense than aggression” (http://wordnet.princeton.edu). It is an extreme physical force exerted for the purpose of violating, damaging, or abusing. The various definitions form a spectrum where at one end is anger, an emotion but without the intention or behavior of causing harm; then comes hostility, which is a more intense negative emotion and an attitudinal set that is likely to produce aggression. Next, aggression and violence are behavior intended to cause harm; violence is more extreme. Anger, hostility, aggression, and violence are expressed in an interpersonal context. In the present context I confine myself to anger (violence and abuse will be dealt with later in the book) as it is expressed in therapy and as part of the therapist–client interaction. I believe that aggression and violence have no place in the therapeutic session; when they do occur they represent a rupture of the therapeutic envelope and are likely to lead to immediate termination. Obviously, my current focus does not detract from the importance of dealing with aggression and violence. These are amply discussed elsewhere (e.g., HoltzworthMunroe et al. 1997; Straus and Gelles 1986). An emotion is considered adaptive when it protects the individual. Anger is an immediate and direct response that defends against attack or intrusion. Appropriately expressed anger promotes self-empowerment, assertive expression of need, and interpersonal separation and boundary setting. Anger is also a reaction to fear or shame, or it follows attributions of malicious intent. We may use it to intimidate or control others or to force others to give us what we want or need (attention, affection). Usually the individual is unaware of the instrumental function of the emotion (Paivio 1999). Surkin (2001) argues that inability to express anger is often the source of children’s emotional difficulties. Anger is an overt reaction resulting from feelings of frustration and helplessness. Underneath there is a fear of losing control over the relationship. At bottom there is pain—pain associated with fear of loss of love or of need provision. The person cannot express the pain directly, fears loss of control, and feels helpless and frustrated. These feelings are translated into anger. Recognizing the source of pain is the major component in reconciliation, the mutual reassurance of love and loyalty. This may be why patients with anger problems who are seen in clinical

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settings are less inclined to consider anger reduction a worthwhile treatment goal (Tafrate and Kassinove 2003). Anger is their means of reassurance, and they are not likely to give it up unless their need is met. The expression of anger may represent loss of control over rational behavior, but it is intended to gain control over the situation. Anger is a powerful mechanism for emotional distance regulation. It allows distancing while ensuring caring and attention. The expression of anger leads to distancing, but the emotional investment in anger means connection. Therefore, anger is used to draw the therapist closer by distancing him or her. Distancing creates a fear of rejection and abandonment that drives the partners back into the relationship. Anger is also used to vent negative emotions, restore stability, and reduce stress. It is a natural reaction to feelings of frustration. People tend to get angry when they are frustrated or when they feel misunderstood or rejected. They express anger in various ways, either directly (e.g., raising the voice or stopping talking) or indirectly (e.g., expressing dissatisfaction, refusing to cooperate). The most important issue in dealing with anger is its outcome. When the situation in which anger has been expressed remains unresolved—that is, the partners do not discuss it, do not attempt to understand what it signifies, and do not seek to reconcile—anger becomes detrimental to the relationship. In this case the level of frustration and the intensity of the anger are likely to escalate. This escalation will probably lead to a more intense anger over less important issues. However, when reconciliation and resolution can be attained, anger becomes reinforcing and fortifying and brings the partners closer. The feeling that an obstacle has been removed creates a sense of closeness and reaffirmation of close relationship. Anger has no place in the common perception of the therapist–client relationship. Several studies (e.g., Deutsch 1984; Farber 1983; Plutchik, Conte, and Karasu 1994) found that anger and criticism directed toward therapy and the therapist are very stressful for therapists (second only to suicide threats). Pope and Tabachnick (1993) found that the majority of therapists reported feeling afraid or angry when faced with abusive behavior by a client. However, if we want to join with the client and form a working alliance by creating an atmosphere of cooperation and equality, anger should take

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its proper place in therapy. The therapeutic relationship is similar to any other close, intimate connection. The client shares with the therapist things he might not even share with himself. For this sharing to take place, the therapeutic situation must be safe and open for the client and the therapist. Anger can be expressed in a situation where the client feels sufficiently safe and secure to express negative feelings or in a situation where the client or therapist pays no heed to the consequences of expressing it. In the former case the therapeutic atmosphere is more open and clean, whereas in the latter it may signify the end of therapy. Anger directed at the therapist may indicate the client’s need for attention (especially when the session includes more than one client) or feelings of being misunderstood, or it may indicate frustration with the therapy, with the therapist, or with the client herself. It may be a way to turn the attention of the client and therapist alike to an issue that both have avoided. It may also be a way for the client to approach an issue she is afraid of. Anger is thus a signal that something needs immediate attention (Potter-Efron 2005). Anger also means that the client is involved and has sufficient energy to behave angrily. If channeled appropriately, this energy helps the client make a change (Potter-Efron 2005). Furthermore, Van Velsor and Cox (2001) see anger as a vehicle for change in cases of sexual abuse. Some studies have found that expression of anger is likely to be a positive outcome for women whose depression has replaced sadness and anger (Stiver and Miller 1997). This discussion points to the dialectic aspects of anger; it both distances people and brings them closer. It is a negative emotional reaction that stems from a positive source. It is directed at other people and expresses a subjective feeling of pain. When appropriately resolved it bonds the partners together. Anger can be functional in interpersonal relationships, where it facilitates venting stress, seeking attention, and feeling close. WHEN THERAPY IS STUCK

At times the therapy feels stalled, or stuck. Therapy is considered stuck under the following circumstances: t


When there is no change. The therapist or client recognizes that an expected change has not yet materialized. This can be an indication

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t


t


t


t


of resistance on the part of either therapist or client or a collusion to avoid ending therapy. Therapy becomes stuck when the therapist takes sides and abandons his system-allied role. In this case, the therapist has become swamped by the system, has become triangulated, and has lost the ability to be helpful. The therapist is unable to see the system as a whole but adopts a certain individual’s view, which renders him biased in therapy. Obviously, this is not the case when taking sides is done consciously with the purpose of aligning with, or recruiting, a system member to facilitate a change. The therapist overidentifies with the system. In this case, she does not empathize with the family and maintain its boundaries but loses her own boundaries, consequently losing the observing ego function. In one story about the infamous Baron von Munchausen’s adventures, he gets stuck in quicksand and pulls himself out by his own ponytail. The therapist’s ability to consider various options, explanations, solutions, and perspectives is lost. The therapist then shares the system view and actually reinforces it while losing her observing-ego function. A stuck therapy can occur when client and therapist collude in halting the process. A fear of the anticipated change or difficulty acknowledging failure, or an attempt to avoid the expected termination after the change, may contribute to this collusion. “Secrets are a systemic phenomenon. They are relational, shaping dyads, triangles, hidden alliances, splits, cut-offs, defining boundaries of who is ‘in’ and who is ‘out,’ and calibrating closeness and distance in a relationship” (Imber-Black 1993, 9). When shared by all family members, secrets help make the family more cohesive and close but not necessarily more adaptive and functional.

The content of secrets may be positive (e.g., an adolescent girl who keeps secrets about benign behavior from her parents in order to differentiate herself but reveals them to friends). Secrets can also be toxic (Imber-Black 1993) and can break and endanger relationships because they involve a breach of trust (e.g., infidelity, drug use).

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The meaning of secrets is related to how well they are kept. Secrets that are poorly kept (e.g., leaving traces such as receipts and documents for others to see) can be a cry for help. The “secretive” person sends a message to his partner: “I want you to catch me because I don’t want our relationship to terminate, so you’d better watch out for yourself and me.” When secrets are well kept they are intended to preserve the current system and serve as balancers and stabilizers for the system. The partner who has a wellhidden extramarital affair does not want her marriage to end but uses this relationship in order to satisfy needs (e.g., excitement, sex) that are difficult to meet in the marriage. Thus, the pressure on the marital partner is lowered, and the stability of marriage is maintained. However, when a well-hidden secret is revealed, the damage to the system is irreparable at worst, or extremely difficult to restore at best. The major reason for this is the loss of trust. Loss of trust is highly traumatic because trust is the cornerstone of a relationship (this is the basic stipulation allowing needs for security, predictability, and identity to be met). The trauma will never be erased or fully restored. Like any other traumatic event, it is not erased; its neural pathways remain intact, although a bypass can be established that will put the trauma back in the memory alley (Mayne and Ambrose 1999). Secrets are also associated with shame or fear of consequences of the behavior that is kept secret. Aside from being the reason for keeping a secret, shame is a driving force of compensation for the shameful behavior. The compensatory behavior may include heightened self-control, a tendency to perfectionism, denial of shameful behaviors, cynicism (“do not expect reliability or constancy in a relationship”), and a sense of incompleteness (“do not complete your tasks so you will not feel good about yourself ”) (Mason 1993). The need to keep the secret may lead to overcontrol of others in an attempt to keep it covered. Having a secret may be an issue of control and its loss. A person who knows a secret may have power over the person holding the secret and can benefit from this knowledge (bribery). Sometimes having a secret is powerful (“if I have an extramarital affair, that may give me power over my wife and the therapist”). On the other hand, having a secret whose exposure will involve hurting others can lead to a feeling of loss of control and even to submissive behavior. Exposure of a secret is a not an easy issue. There are risks and benefits

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in exposing a secret that must be handled with extreme caution. Sometimes the exposure of a secret is accompanied by feelings of relief. A burden is unloaded, and the person can deal with the underlying issues rather than avoiding them. In other cases the revelation of a secret may have dire consequences for the person or the system (e.g., a long-standing extramarital affair, incest, sexual abuse, or an unreported mental or physical illness). In these cases keeping a secret becomes a moral and value-laden issue in therapy. Should a secret be revealed at any cost? Should the potential short- and long-term effects be considered before this decision is made? Who makes the decision? The answer to the last question is the therapist or the person keeping the secret. If the person keeping the secret chooses to reveal it, or if it is found out by another member of the family or by an outside source (e.g., medical records), the issue is coping with the consequences and attempting damage control. However, if therapist suspects the existence of a secret, he must decide whether to pursue it. This is a serious dilemma for therapists. If the secret potentially endangers therapy, the therapist runs the risk of losing the clients whether the secret is revealed or not. Suppose that a therapist, feeling the therapy is stuck, suspects the existence of an extramarital affair. The suspected spouse denies having an affair, but the therapist remains suspicious. At this point the therapist is handicapped. The fear that the secret is real, despite the denial, paralyzes him. Pursuing therapy and working on the relationship seems inappropriate in face of a potential minefield threatening to shatter the couple’s life. The denial, or rather the therapist’s feeling, prevents opening the issue and stalls therapy. In fact, this was a problem I encountered in my practice. I worked with a couple on a provisional divorce agreement as a way of alleviating anxiety on the couple’s way to reconciliation. At a certain point in our work I sensed something wrong. Agreedupon issues were overturned in a later session, and others, unexpected ones, turned up. I suspected that the wife had consulted with her lawyer after the session (without informing me or her husband), and I believed it to be the reason for the stalled therapy. My cautious inquiry to that effect was vehemently denied. I remained unconvinced and decided that I could not work competently under this kind of presumed threat. I could not trust the client, but I could not say so after the denial. I could not explain it to the

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clients because this in itself would cause problems, whether I was right or wrong. Feeling helpless, I decided to terminate therapy. I took responsibility for the termination by claiming incompetence. The couple was visibly troubled, confused, and pained. They could not figure out what happened. Why did their therapist feel so incompetent that he could not continue? About a year later the wife came back for a consultation and admitted to having an extramarital affair at that time. So it was not a lawyer but a lover! Sometimes you know there is a secret and feel that you have to continue with therapy because raising the issue is going to be worse than keeping it covered. For example, when a therapist suspects the existence of sexual abuse, and the client does not admit it (or there is no other way to corroborate the suspicion), I would not press for exposure. The reason stems from what we now call the false memory phenomenon (Brainerd and Reyne 2005; Loftus 2003). This phenomenon concerns the therapist’s ability to change the client’s recollection to match the therapist’s expectations. 3 If my suspicions are incorrect but the client acquiesces and agrees that the event did take place, the damage would be insurmountable for the client and the family. However, working in the aftermath and with the cognitions that may have resulted from the event (negative self-evaluations, guilt feelings about vague and unnamed events or people), without its actual revelation, may be as effective as working on the issue itself. In this case I would work on the client’s autonomy in controlling her current life and accepting responsibility for it, no matter what the past holds for her. Some secrets can be kept private because they do not endanger the relationship or other family members (e.g., a child who stole from his parents and told the therapist on condition that she would not tell the family). A point of caution is in order. I usually tell my clients at the start, whether it is couple or family therapy, that if any member wants to have an individual session I would agree only if that person received permission from the other participants; also, the person requesting an individual session should know that the content of that meeting would later be made known to the other members, by me or by that member himself. Being told secrets that I cannot share puts me in an untenable situation. Such is the case when a client wants to share with me that he is having an extramarital affair unbeknownst to his spouse. How can a therapist work on a relationship knowing this?

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However, if I find out about such an affair, I have several choices. The first and best option is to encourage the person to share the secret with the spouse. The second option is to insist that the person terminate the affair within a limited time frame (a few weeks), after which, if the affair has not ended, I will terminate therapy without sharing with anyone else what I know (using the procedure described earlier of pleading incompetence). As can be seen, there are a number of ways in which therapy gets stuck, and the therapeutic process is blocked, halted, or suspended. Obviously, stuck therapy is another indication of resistance in therapy, and once the therapist is aware of it, this may be an opportunity to facilitate therapy. HOW TO UNSTICK THERAPY

The first and most important way to begin to unstick therapy is to recognize that it is indeed stuck. The points discussed in this chapter are indications of a stuck therapy. Being aware is the first step in changing the situation and getting unstuck. Once the therapist is aware of the resistance, he can open up the issue; this is a wonderful opportunity for client and therapist to join in expressing their feelings about therapy and themselves. This opportunity is likely to lead to heightened feelings of closeness and intimacy between client and therapist and will foster mutual trust and disclosure. A useful way to unstick therapy is the dialectic method. When therapy is stuck, something else may be moving. Accordingly, the therapist may ask the clients what is going on while they are not moving. This sounds odd, but it often sparks a productive reaction from clients. They begin talking about other areas of life where things are different, and this usually opens new avenues in therapy. Another useful method originates from FDS. The therapist may ask the client what function resistance or being stuck serves. Again, the discussion of the function opens up the process and frees up therapy. Incidentally, the use of dialectics is a foreign experience for most clients. The first reaction is usually one of puzzlement and confusion. “How is that related to the issue? Is it possible that I can gain anything from it?” They do not ask, although I can see it in their faces, “Is he out of his mind?” Then, out of respect to me, they begin thinking over the question and soon begin to see it differently.

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Another useful technique is the therapist’s helplessness. A therapist who is aware of therapy being stuck and thinks she has no way to unstick it may use a measure of last resort. This can be applied only rarely in therapy; otherwise, it loses effectiveness or backfires. One of the last-resort measures is the therapist announcing that she feels helpless and does not know how to proceed with the therapy. This statement is usually surprising and raises the client’s anxiety, even though he is also aware of the situation. The client wonders, “What is going to happen if my therapist does not know what to do?” “Does it mean the therapy is over?” “Is there no chance for change?” This anxiety creates a productive pressure on the participants that, in most cases, results in new insights or new directions for work. In my entire career, spanning more than thirty years, I have had only one case in which, after I declared myself helpless, therapy was terminated. If these approaches don’t work, the therapist can turn to consultation. Either the therapist seeks the supervision of another therapist (with the client’s permission, of course), or he invites the consultant to a therapy session. Doing this does not detract from my authority as a therapist. On the contrary, my willingness to admit weakness usually garners more respect from the client. The client realizes that I am human, and when I do not know what to do, I ask for help. My asking for help empowers the client and radiates a feeling of partnership, equality, and cooperation. We both need help from somebody else. This chapter has dealt with the envelope of therapy, the nonspecific issues that facilitate the therapeutic process. The issues of resistance and its diverse manifestations were discussed in the context of FDS. Joining and resistance are dialectic. One negates the other, but it is not one versus the other. Both coexist in and throughout the therapy. Each has its own range of optimal functions; joining is bounded by the amount of closeness and self-disclosure, and resistance is bounded by the amount of anger. For both, excess means tearing the envelope (breaking the pipe) and endangering the therapeutic process. The tension between resistance and joining paces the process; it slows or facilitates it. Their coexistence makes the therapy rich and full. The dynamic balance between the two allows intervention to take place.

PART IV

TREATMENT PROCESS: THE DIALECTICS OF THERAPY

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10 FUNCTIONAL DIALECTIC SYSTEM VIEW OF SYMPTOM AND PSYCHOPATHOLOGY Chapter 9 dealt with the envelope of therapy, the nonspecific issues that facilitate, foster, and maintain joining and a working alliance. Joining facilitates inquiry into different, less familiar, or foreign terrain. The client in therapy understandably focuses on the negative, distressful aspects of life. The client’s ticket to therapy is the negative feelings and the distress or demoralization associated with his current situation. Exploration of the functional aspect of the symptom and the situation is far from the client’s mind at that point. In fact, if clients were initially able to see both sides simultaneously, they would probably not need therapy. For the client to see the functional aspect of the situation, a safe situation must be created in which he is made aware of the therapist’s respect for the problem and acceptance of the client before being able to contemplate the issue. To reiterate, sufficient joining is a necessary condition for making a dialectic functional reference. The current chapter deals with process issues. At this point we are ready to deal with the dialectics of the symptom. The chapter begins with a discussion of the distress–control dialectics of the symptom. Being able to see the two poles together, both therapist and client are able to undergo a second-order change with respect to the presenting problem. The chapter proceeds with the functional dialectic system (FDS) view of the symptom and continues by presenting a number of therapy vignettes to illustrate the

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use of FDS. The next two chapters present the use of FDS in working with specific therapeutic issues. Symptoms and syndromes (i.e., psychological disorders) are considered means of communication between the client and his particular and relevant system. When the system functions adequately, it is presumed that communication between system members is satisfactory and that people are able to present themselves in a meaningful, appropriate, and accepted way. It is further assumed that when a system member feels dissatisfaction or fear about system integrity (e.g., fear of parental separation, fear of loss of control), the person responds in a way that communicates distress and is also likely to bring about a change and attempt to restore control. The communication is dialectic and includes both an admission of weakness and helplessness and an attempt at change and control, which is an indication of strength. The person who manifests the symptoms, the identified patient (IP), communicates distress so that she will be heard and the danger will eventually be removed. However, when the person is unable to communicate effectively, a pathological, seemingly maladaptive symptom will appear. The symptom is an amplification of the distress signal. This is analogous to a person who raises her voice when she is uncertain she is being heard or when she wants to silence others. The symptom is thus a message sent by a member to the system or beyond its boundaries signaling that the system is in jeopardy. The aim of the symptom is to communicate distress in order to affect or prevent a change in the system (e.g., diverting attention in order to reduce tension, or triangulation) or create a crisis (e.g., an extramarital affair, a physical or psychological breakdown) so that system integrity will eventually be restored and preserved. The IP wants to alert other system members or environmental agents (school, social agencies, extended family, or friends) to the perceived or experienced difficulties in the system. The intensity of the symptoms depends on the response to the distress signal. The quicker and more effective the response, the less intense the message (i.e., symptom) needs to be. The symptomatic behavior may be encumbering or disabling to a certain degree (e.g., back pain, paralysis, illness). At best it may limit the person physically, but it is not necessarily accompanied by psychological

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distress that incapacitates the person in major areas of life (occupational, social, interpersonal, or familial). When this occurs it may mean that the intensity has not yet reached the level of psychological disorder. At worst it may adversely affect functioning in major life areas and reach the level of a psychological disorder. The emphasis I place on the manifestation of distress as the core meaning of pathological behavior is not accidental. A demoralized or distressed person is discouraged and pessimistic; this person perceives life as failure, has poor self-esteem, feels overwhelmed and unable to cope, and may suffer anxiety, depression, or somatic complaints. Frank (1973) sees demoralization as the basic condition of a person seeking help. Demoralization is the key component of psychological disorders. Not surprisingly, recent studies (Almagor and Koren 2001; Tellegen et al. 2003) have found that the major portion of the variance of psychological disorders as assessed by the Minnesota Multiphasic Personality Inventory is attributed to demoralization (or distress). The contribution of distress is noteworthy for disorders such as anxiety and mood disorders, antisocial and schizoid personality, schizophrenia, and other psychotic disorders. Demoralization or distress is akin to the dimension of pleasantness–unpleasantness, which reflects higher-level general hedonic valence (Tellegen, Watson, and Clark 1999; Watson and Tellegen 1985). It is also a stable personality dimension related to the lexical structure of personality as manifested in the major personality structure (e.g., neuroticism in the Big Five [Costa and McCrae 1985] and negative affectivity in the Big Seven [Almagor, Tellegen, and Waller 1995]) and other personality characteristics (Almagor and Ehrlich 1990; Tellegen 1985). It may be considered similar to “g” factor in intelligence (Spearman 1932). The fundamental, underlying condition of a person in therapy is that of distress. The expressed symptom is only its manifestation. Which symptom will be chosen is contingent on several factors that are likely to render its meaning idiosyncratic, even if it fits into a known pathological category. The specific syndrome or disorder is a complex product of genetic predisposition and environmental factors. The choice of symptom is likely to depend on genetic predisposition, learning, culture, and situation. For example, in the case of anxiety disorders, the fear of loss of control is a core symptom. Rangell (1978) wrote, “The ultimate fear is psychic

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helplessness; complete, not just partial, loss of control” (229). This is the central symptom around which the pathological behavior is organized. When a person feel threatened, this activates the fear of losing his resources. In turn, this threat activates the myriad symptoms expected to regain control or prevent losing it. The person is afraid of losing control of his physical or mental capacities or the ability to sustain his basic needs. His world (external and internal) is in danger of collapse. To cope with the threat, the person needs to reduce the stimuli to a manageable number. The world needs to be simple and predictable. The cognitive system activates thought-restricting processes; thinking becomes dichotomous, and the world is divided into black and white. Complex thinking is avoided in order to save energy and clarify circumstances. At times, thinking becomes focused on the impeding threat, and the person ruminates on it and is obsessed with it, as in the case of obsessive– compulsive disorder. To make the world more controllable, the person may withdraw from social engagements and may avoid leaving his familiar environment or evade certain potentially threatening situations, as in the case of agoraphobia and other phobic disorders. Emotionally, the person becomes fearful, excessively worried, avoidant, or lacking in initiative. The emotional response is a call for help because it is the most salient manifestation of anxiety. The person may develop behaviors (compulsions or rituals) or repetitive and intrusive thoughts (obsessions) that are meant to prevent ostensibly deleterious events in the future or to expunge those of the past, as in generalized anxiety disorder and obsessive–compulsive disorder. The symptoms can be debilitating, but they create a predictable environment that provides the person with a false sense of security and identity even though it reduces his level of functioning. Mowrer (1950) calls this phenomenon the neurotic paradox, in which behavior is simultaneously self-perpetuating and self-defeating. The dialectic question (and the functional one) relates to the function of fear of losing control. The anxious person may be afraid of losing control and consequently uses control-gaining behaviors that in fact lead to a further loss of control over her life. Dialectically, the effort to avoid losing control leads to a loss of control. Conversely, learning to lose control (i.e., let go) would, in turn, lead to gaining control. Losing control over her life may force somebody else to take responsibility for the anxious person (e.g.,

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a parent, spouse, or social agency). Taking responsibility for the person allows her to avoid it (“I can’t do it, I’m too scared” or “I can’t do it in time, I can’t concentrate because I’m too anxious”). The context in which this symptom is functional varies with individuals, couples, and families and therefore must be explored with each particular client. Nevertheless, the most important issue is the message conveyed by the behavior. For the behavior to be effective, the message must be clear and understandable to the other system members. The symptom most likely to attract attention may be the best choice. An already recognized set of behaviors (i.e., disorder) is a better and more familiar way of communicating distress. An emphasis put on food and eating at home is likely to be associated with a later manifestation of an eating disorder. If the parent is highly anxious, the child may very well learn and use anxiety as means of communication. If, through observation of others or personal experience, a child has learned to use a particular maladaptive behavior as means of seeking attention (e.g., somatic symptoms, temper tantrum), this will be the behavior used as means of conveying distress. Sometimes a symptom is used as a metaphor for the difficulty the system encounters (e.g., a phobia focused on cigarettes as a metaphor for the parent’s sexual difficulties). This discussion leads to the following conclusions. First, a symptom is a means of communication. Second, the symptom conveys the individual’s or system’s distress1 that originates in and is directed at the system. Third, the manifestation of distress is a product of a complex interaction between genetic predisposition, family history, learning, and the characteristics of the specific situation and system. One of the fundamental premises of FDS is that behavior is functional and goal-oriented. The goal is to ensure that the system is able to provide the basic needs of order, belongingness, security, and identity. To do so, the system must be preserved at all costs. That the alleged psychological disorder is functional for the person experiencing it, and for the relevant system, is the guiding light in evaluating behavior. The functional aspect of the symptom is the attempt to restore stability or to recruit help to reinstate it in the system. The servant here has many masters. It is entirely plausible that the same behavior (symptom, syndrome) will serve different purposes for different

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members or even the same member in various systems or situations. For example, anxiety disorder can be used by a person to shed responsibility (“I can’t do it, I’m too anxious”), to control others’ behavior (“Don’t confuse me, I’m too anxious”), or to draw attention to the fact that there is a problem (“Why is she so anxious? What’s going on?”). A symptom may have a symbolic or an expressive meaning that can be understood only in the context of the system (e.g., a young boy who tears apart a doll and who has watched his father beating his mother or an adolescent girl who is oblivious to her own hygiene whereas her mother is well groomed). A symptom may represent somebody else’s difficulties, as in the case of Munchausen’s by proxy (Marcus et al. 1995), in which a child manifests the parents’ difficulties through somatic complaints. This phenomenon is not limited to parent–child relations but can also be seen in adults. One of the vignettes in this chapter describes the case of a woman who developed depression instead of her husband. The specific type of manifested disorder (e.g., major affective, cognitive, or personality disorder) is likely to depend on genetic or familial predisposition. Most of the major diagnostic categories (e.g., schizophrenia, major affective, anxiety, eating, and personality disorders) in the DSM-IV-TR (American Psychiatric Association 2000) are more common among firstdegree relatives. It is also possible that a cultural setting or situational factors (e.g., TV, peers) may contribute to the choice of symptom and its meaning (Kirmayer 2001; Kirmayer and Young 1998; Kirmayer, Young, and Robbins 1995; Lopez and Guarnaccia 2000). A symptom is a means of dialectic communication. It conveys both distress and hope. Feelings of helplessness and distress coexist with attempts to restore control and strength. The specific symptom chosen to accomplish this is a product of several factors, so the function of a symptom can be understood only in the context of a system. The dialectic view helps change the perspective of symptomatic behavior from disabling and dysfunctional to helping and functional. This change is startling in that the person may not only gain control over the disorder but even make friends with it. Once this view is adopted, perception of the severity and uncontrollability of the situation changes immediately.

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Thus, FDS represents a more optimistic and positive view of the person and behavior. People want to change and grow but need to feel safe and secure in order to do that. Pathology is a means of communication designed to help restore or create that safety. The use of FDS allows a swift and easy transition from a state of hopelessness and helplessness to hopefulness and potency. An interesting and important question is whether the FDS perspective must be presented to the client as such. Should the therapist inform the client that he is going to change the course of therapy by turning to dialectic search for meaning? Or can it be part of the therapeutic process, where the issue is raised as needed? My answer is, “It depends.” At the beginning of therapy I present my approach as functional dialectic, and I explain briefly what these concepts mean. When asked, I give a more detailed explanation. However, most clients do not want more information. Nevertheless, when the time seems right for a functional dialectic interpretation, I usually begin with a statement that prepares the client for a change in line of reasoning and warn him that the new line may appear different and strange, at times even bizarre. I add that the patient is allowed to react freely or negatively to it, apologizing in advance for the change. Having said that, I want to soften any negative reaction, to correct for possible inappropriate timing and reduce anger and dissatisfaction. At the same time, the therapist’s response elicits curiosity, lessens resistance, and stimulates exploration. Even when clients are surprised or irritated by the interpretation and react negatively, most react by commenting how strange the functional dialectic suggestion is. Some reject it on the spot; some become angry. But I have not yet encountered a client who remains indifferent to the suggestion. They may react after a taking a little time to think things over, or they wait a session (rarely more) before they come up with a response. The most common responses are “I never thought about it this way,” “Is it possible that there is anything beneficial in this [anxiety, depression]?,” or “This is really strange. I need time to think it over.” Clients hardly ever dismiss the notion. Once their attention is swayed in this direction, they appear to find it relevant. The following vignettes demonstrate different applications of the FDS approach in individual, couple, and family therapy.

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THE ARTIST

Reuben, a fifty-five-year old Caucasian man, was self-referred for therapy complaining of panic attacks that interfered with his everyday functioning. Reuben was married with two children; the elder, twenty-four years old, a college graduate, was about to leave home. The younger child, a daughter, was seventeen. His wife, Rachel, fifty-one, was an insurance agent. Reuben was an artist who spent his time painting but had sold only a few paintings. He made his living renting out apartments he had inherited from his parents, and he also benefited from his wife’s salary and her father’s lavish support. Reuben was adopted when he was about a year old; his biological mother, a single parent, could not support him financially and gave him up for adoption. His adoptive father was described as authoritarian, cold, and demanding, and his adoptive mother was described as passive, yielding, domestic, and fearful of the father. Reuben reported that he and his mother were emotionally abused by his father. Reuben had worked in a low-level production line factory job. After his father died he sought psychiatric help. Following the psychiatrist’s advice, he quit his job and began painting. Reuben considered painting a major part of his life. When referring to what he initially called panic attacks, Reuben described incidents in which he went to the supermarket and found himself feeling very anxious when he had to face the cashier, feeling weak, as if he were about to faint. In other public places (e.g., shops, malls), Reuben reported feeling intense discomfort. He also described anhedonia. Interestingly, his paintings were all black and white and were based on photographs he collected or picked out of books. His paintings had a common theme: they did not show human figures. Aside from the short-term therapy with the psychiatrist, Reuben had no prior psychological treatment. He took medications, prescribed by his family physician, for his anxiety. There was no significant medical history and no report of drug, alcohol, or tobacco abuse. It was very easy to establish rapport with Reuben. He was amicable but not a pleaser; he talked freely about his difficulties but without showing appropriate emotional distress. He joked about his problems. Nonetheless, it was clear that they were taking a toll on him. He talked about his fear of exhibiting

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his paintings and said he did not like working alone and preferred working with a group under supervision of a veteran painter. Feeling safe in the rapport I had established with Reuben after two or three sessions, I tried to look at the function of the symptoms. moshe: Reuben, I know it sounds quite unusual, but can you think of anything you may have gained by having the anxiety attacks? His first reaction was a typical one. He looked at me, surprised and bewildered. reuben: How is it possible that I may have gained anything by having a problem? [After a long silence] You know, I have never thought of it this way, but do you think it may have something to do with my wife? [Then] It seems like I would like her to go instead of me to the supermarket. . . . It’s ridiculous. At this point it was very clear that Reuben was beginning to wonder whether I was right. moshe: Would you please tell me more about your relationship with your wife? reuben: Rachel constantly complains and criticizes me—actually not only me but everybody else, including herself. moshe: It appears that Rachel’s attitude annoys you quite a bit; how does it make you feel about her and your marriage? reuben [to my surprise]: Oh, I love her, and I believe my marriage is a good one. At this point it seemed that Reuben was relating to the functionality of the symptom but did not quite see the relation to his wife. Even though he saw a connection, he was not yet aware of its implications. My assumption was that Reuben may have been using the anxiety to draw Rachel to him and as a way to get back at her. By appearing weak and dysfunctional, he was able to enlist her support but also to indirectly express his anger toward her by forcing her to help him. Of course, it may also have put Reuben in control of the relationship while also relieving him of responsibility for activities he did not want to do. We needed to examine these aspects of his life. moshe: You said earlier that it may be possible that the anxiety attacks are directed toward Rachel, but you also indicated that this was ridiculous. You also told me that you love your wife, and I can tell how sincere you

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are. I am sure Rachel loves you also, but I wonder how she lets you know she loves you. reuben: She helps when I have the attacks; she brings my medication, and from the way she is angry with me I know she cares about me. moshe: It is great to know how Rachel loves you, but do you really think that you need the anxiety for her to show it? At this point the discussion focused on the function of the anxiety attacks and not on the attacks themselves. This was a major shift in therapy. The symptom was no longer the issue; its function was. The focus shifted from the anxiety attacks to his relationship with his wife. The issue had become the expression of feelings in their relationship and how the anxiety attacks were instrumental in that respect. Later I suggested that Reuben invite Rachel to the therapy. It turned out that Rachel did not want to come to therapy. Therefore, we worked on Reuben’s wish to be relieved of responsibility. moshe: We talked quite a bit about your wish not to be too responsible, and this leads me to thinking about whom you felt responsible for. reuben: For my parents, the kids, Rachel’s father. moshe: It appears that you have a lot of responsibilities. No wonder you want to be relieved of that. This response led to a lengthy discussion. Reuben talked about his relationship with his parents. He admitted hating his adoptive father and spoke of his attempts to protect his mother. Reuben did it by being a rebellious, undisciplined child who constantly needed attention. He was not a good student, and at the first opportunity he got married and left home. He married his first wife when he was discharged from the army, and this marriage lasted a year. This allowed us to move one step forward, when I further probed the functionality of Reuben’s symptoms. moshe: We talked about how difficult it was for you to carry such a responsibility for your mother and how awful it was for you to live in a house where there was no love. I know you love Rachel, and I wonder how you protect her. You told me that she has been in therapy for several years now, and I imagine she is having a hard time with herself. reuben: You again. . . . I believe that you do not think I help her. [After a long silence, he looked quite comfortable.] You are going to laugh about this one. I think I help her by being weak. She needs to take care

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of me, and now that our son is about to leave home, it may be more difficult for her. moshe: Why should I laugh? It sounds so normal. You love your wife, and you want her to feel better about herself, and you have learned that you can do that by letting others take care of you. That was a coup! Reuben looked at me, and his relief clearly showed. He began to laugh. reuben: Do you want to tell me I am so smart I could use “anxy” [as he nicknamed the anxiety] to help both myself and Rachel? This is just great. [He owned it! The second-order change had happened and had been assimilated. At this point the anxiety was externalized, disowned, and repossessed as a pet or a toy, something to use and enjoy.] These revelations were made quite early in therapy, and amazingly, his fears and anxiety attacks abated to the point where he felt just mild anxiety in the supermarket. Furthermore, he discovered the power of anxiety and used it when he felt he was being coerced into doing something he disliked, such as going to a restaurant with people he did not like (he excused himself in the middle of dinner because of his “growing anxiety”). Soon it became clear that Reuben made a friend of his anxiety and was manipulatively and consciously using it to avoid doing things he did not like or to rescue his wife. One more key change took place as well. Reuben began using dialectic thinking on his own. The first few times he did so using me as the source (“As you say, there needs to be a positive side to it”); later he began using it spontaneously. With this in mind, I asked him whether he would like us to shift into marital therapy to eliminate the need to use the anxiety in their relationship. This time he acquiesced, but his wife adamantly refused. Their relationship remained as before, and when I inquired about possible changes in other areas Reuben indicated that his relationship with his daughter was growing increasingly difficult and that his wife had moved from two weekly therapy sessions to three. It was apparent that the anxiety had served them both and helped his wife function better; as the anxiety abated her condition worsened, hence the increasing stress at home (as expressed through the fights he had with their daughter). However, Reuben reported that he felt better and was not concerned with the marital situation. It appeared that the anxiety may have also served as an emotional regulatory mechanism that helped them avoid intimacy. Despite my strong belief that marital therapy was indicated,

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Reuben refused to hear of it, but he did not want to end his own therapy. The ensuing sessions were devoted to understanding Reuben’s refusal to end therapy. Transference issues concerning his relationship with his parents and its projection onto the relationship with me were brought up. In the meantime Reuben’s improvement continued, humans and colors gradually appeared in his paintings, and he even sold one. Then the issue of adoption came up, and Reuben suggested that maybe his anxiety was a manifestation of his desire for love and affection and his anger toward his biological mother, who abandoned him when keeping him was too difficult for her. Reuben’s behavior could be considered childish, as a way to avoid the need to assume more responsibility and to be less dependent on his wife and her father (as it looked to me but not necessarily to him, as he pointed out). Reuben’s interpretation with respect to the function of anxiety, namely a wish to remain a child and cling to his anger and pain, and its usefulness with respect to Rachel, had become a source of strength. He could redirect the energy he had invested in being anxious toward establishing his independent identity by connecting to and completing his unfinished business: his adoption. Because he had no knowledge of his mother’s whereabouts and the reasons for her decision to give him up, he concluded that he may have been responsible for it because he had been a “bad child,” so bad that his mother decided to give him up. The adoption had been kept secret by his adoptive family, and he learned about it from remarks made by his classmates in second or third grade. Confronting his parents about this, he saw, for the first time, that his parents were anxious and fearful. They told him that they had kept the adoption secret because they wanted to protect him (and obviously to protect themselves from disappointment or from being abandoned by Reuben). I asked him whether he ever thought about finding his biological mother, and he said that he had frequently thought about it, but he was afraid that he might confirm his fears and that looking would only increase his anxiety. The anxiety functioned as an excuse for not inquiring about his mother. Nevertheless, and following his understanding of the function and meaning of his anxiety, he decided to go for it. The months that followed were very difficult as he made little discoveries about his mother, as revealed by the adoption worker, who had learned them from the file (e.g., he found out that his mother decided to give him up for adoption because she was not married, and Reuben’s biological father had left the country). Reuben doggedly tried to

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track her down. After months of searching he found out that his mother had moved to a different country, married, and had two more sons. It is important to point out how the initially anxious, self-deprecating person who had considered himself incapable of asserting himself found the strength and stamina to go through this arduous process to the point of resolution. For me it reinforces the dialectic idea that “weak” is actually “strong.” Once he found her, he needed his biological mother’s permission to arrange a meeting with her. Apparently, his mother had been waiting for him all those years to initiate the search. Her husband had known about Reuben from the beginning of their relationship. The happiness, anxiety, fear, hope, and relief were evident on Reuben’s face when he told me this. All his anxieties and fears (including fear of flying) were summoned to prevent him from going. However, because he knew the role he assigned to his anxiety, he resolved to meet his mother no matter what. Reuben and his family traveled to meet his mother and half-siblings. The meeting was a tremendous success. Reuben was received as a lost child found, and everyone was excited and happy. From that point, an interesting behavior emerged. Reuben was on the phone constantly with his mother, as if he was trying to bridge the time span and compensate for the lost time and his need for a mother. His mother was willing and cooperative in this endeavor, and she also seemed to want to atone for the lost time and resolve her guilt feelings for abandoning him. In any event, Reuben began thinking of setting himself up in his own studio; he had a well-received exhibition, his relationship with his wife improved, and he seemed to be quite happy. This vignette highlights the main elements of the FDS approach. Secondorder change actually began when the function and the dialectic meaning of the symptoms were explored. The anxiety served as a powerful means of communication in his relationship with himself and others (“I am weak but use my weakness to control my life”). The dialectic meaning of the symptoms (weakness is actually strength) made it possible to find its function and eased the change. Reuben’s awareness of the power gained by the symptom allowed him to give it up as a distressing behavior and to make it part of his behavioral repertoire. It appears that the major change occurred when Reuben realized that his anxiety was functional. This

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relieved the anxiety and allowed him to come to terms with it. The reduced anxiety allowed him to further explore his life and get him to a place where he was able to seek, find, and face his biological mother. Reuben’s ability to use the dialectic method in dealing with things was very important. When a person is looking for a different, more positive perspective, the current situation does not look so terrible. Being able to look for another explanation, a different and opposing angle, helps to moderate or even change our perception of events. THE WATER BOTTLE

Susan, thirty-two years old, married, no children, worked as a software programmer in a startup company for three years. Before that she had worked at a high-tech company, and she transferred to the new one after she received an offer she could not refuse. Her husband, Sam, also aged thirty-two, was an executive in a public relations agency. The couple had been married four years. Both Sam and Susan were very busy, spending many hours at work, and they saw each other mostly at night and on Sundays. Susan was referred by a former client and reported having panic attacks while driving her car, mostly outside the city. Apparently, as she left the city outskirts she experienced high-level anxiety, sweating, a racing heartbeat, and trembling legs. When this occurred she would pull over to the shoulder and call her husband. If she could locate him, he would reassure her, and then she continued driving. If she could not reach him, she would sit by herself, preoccupied by thoughts about what would happen if she could not continue and what would become of her if she could not pull herself together and move on. She might wait in the car for quite a long time until she got hold of Sam. These fears were so intense that she tried to stop driving altogether. Her difficulties hurt her job performance because she was required to drive to out-of-town meetings with her team. Susan denied having marital difficulties, stating that she loved her husband, that they had no problems with their sexual relations, and that they chose not to have children because their careers seemed more important at that time. Susan sought help for the anxiety problem only. There was no significant family or personal medical or psychiatric history. However, Susan recalled an incident when she was aged ten when her father had a car accident after he had driven all day. She was in the car at

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the time. Fortunately, neither of them suffered serious injuries, but the car was declared a total loss. I suspected that Susan and Sam used her fears as means of communication. Sam was the knight on the white horse, and Susan was the princess to be rescued. This symptom allowed them to express their mutual care. Susan did not feel alone, and Sam’s role as the stronger one was thus reinforced. Dialectically, it is possible that Susan protected and invigorated Sam, who may have felt inferior or lacking in self-esteem. With Susan’s request in mind, and after we had achieved good joining, I suggested that the symptoms she reported might indicate an anxiety reaction and might serve a purpose in her life. Susan asked me what I had in mind, and I suggested the likelihood that Susan wanted her husband to pay more attention to her and show her how much he cared and for her to let him know how much she needed him. Susan did not accept this interpretation (she insisted that this was her problem and that Sam has no part in it and thus need not be part of therapy, as I suggested), and we agreed on a behavioral program to deal with her anxiety. At this point I could have chosen to insist on couple therapy, terminate therapy, or continue working with Susan with the expectation that improvement in her condition would not solve the underlying problem (if I was right, of course), but a good joining would bring her back to therapy. Susan looked very thankful and relieved when I told her that despite my belief, and out of respect for her suffering, I had decided to try to help her. The intervention consisted of relaxation training and guided imagery focused on driving the car and controlling the anxiety. I also suggested that she take a bottle of water with her, and whenever she began to feel anxious she should to pull over, drink some water, do the relaxation, and then drive on. The intervention proved effective, and in a very short time Susan returned to driving and experienced no disabling anxiety. Two months later she was back for therapy. This time Susan told me that she noticed that after she recovered from her problem, her relationship with Sam became strained, and they were having more fights than usual. Susan was afraid that something was wrong in their marriage, and she recalled my suggestion that her initial problem may have had to do with that. The relief Susan felt after successfully dealing with her initial symptoms had not generalized to her marital relationship. In fact, the removal of the symptom

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as a means of communication necessitated finding another way of communication that would ensure closeness but also less intimacy, hence the fights. I inquired about how happy she was with her marriage. Susan replied that she knew the current situation was only temporary until they both achieved job security, and then she expected them to settle down and have children. When I pointed out that this did not seem likely in their current jobs, she began crying and said she was aware of that, and it was not what she wanted in their relationship. They did not spend much time together, and because it was she who made more money, she thought Sam was more dependent on her than she wanted. I suggested that this indicated a marital problem in which both Susan and Sam shared responsibility, and they needed to cope with it together. I then explained about FDS principles,2 and Susan asked whether I thought her anxiety attack was meant to draw Sam closer to her, but she did not know how in the world she could be of help to him. I agreed that it seemed a plausible explanation and that we would discuss it more deeply when they both came for therapy. Susan and Sam came together for the next session. I spent time joining with Sam, who had been a successful athlete in high school, served in a special unit in the army, completed his undergraduate studies in economics, and dreamed of getting a PhD in philosophy. He could not go back to school because he was afraid they did not have the means. At this point Susan gave him a bewildered look and said, “We never discussed it! We do have the means.” Apparently, Sam was thinking about having kids, and realizing he would have to be the one to support the family, he would not be able to pursue his goal. It turned out that Sam thought Susan would quit her job and spend most of her time with the kids. Sam did not want to pressure Susan and was waiting for the right moment. At this point it was clear that they did not feel safe enough with each other to discuss this sensitive issue. They needed the symptom (fights) to reassure themselves of each other’s caring, without getting too close and intimate. In this case the symptom represented the dialectic meaning of distance and closeness. The fights were both a mutual request for a distance and an expression of mutual emotional investment and caring used to ensure the stability of the relationship. Susan suspected that the threat of Sam withdrawing from her led to her

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use of the panic attacks to draw him back and to tell him how desperately she needed him. Sam saw it similarly. The symptom served both of them and helped their marriage. I pointed out that Susan’s problem could have helped Sam not to press forward with his plan so that he would not have to face the change. After some thought, they agreed that my interpretation sounded right. I then asked whether there was a way of expressing their mutual need for support and affection without using the symptom.3 Sam replied that he was afraid of getting too close to Susan because she might become too dependent on him, and he would not be able to deal with it. Sam thought he might lose his own identity if Susan became so dependent. So rescuing Susan over the phone did not present such a threat. Susan said she wanted to be closer to Sam because she needed him, and she was afraid she could not succeed in her job without his support. Susan added that she was afraid of losing Sam because he might not tolerate her dependency. At this point the picture became clear. Susan was dependent on Sam and was afraid of losing him. She used her anxiety to draw him back. Sam observed her attempts, and being fearful of the threatening closeness, he rejected her, but he also saved her from a distance. When the anxiety symptoms abated, fights replaced them. The two loved each other and wanted to stay together, but they got entangled in their own fears and consequently ran the risk of losing each other. From this point, only a short-term intervention was needed. Therapy was terminated after three sessions. In the follow-up, six months later, Susan was two months pregnant, and they appeared happy. Sam said that he intended to continue studying but was not sure about which direction he would take, to which Susan said, “Whatever he decides, he is going to succeed.” The intervention had begun with responding to the client’s immediate needs. However, the assumed function of the symptom was mentioned very early in therapy and might have led to the second phase. The closeness–distance mechanism that operated with this couple ensured that they stayed at a distance from each other, although they were strongly connected. When the anxiety eased off after the first intervention, the marital crisis erupted,

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leading eventually to reconciliation and strengthening of the relationship. The functional dialectic interpretation paved the way for the change that occurred in their marriage. THE GAS MASK

This intervention took place immediately after the first Persian Gulf war. Israel sustained daily attacks by Iraqi missiles, and people spent most of their time in fortified shelters in their homes. These shelters were usually small, and people had to wear gas masks designed to protect them from chemical weapons. The level of anxiety was very high at the beginning but decreased toward the end of the war when people realized that there was a pattern to the missile attacks, and the damage was actually sparse. A week after the end of the war, a family came for therapy. The family consisted of a bright ten-year-old boy, Jacob; his mother, Janice, a forty-fiveyear-old librarian; and his father, Alex, a fifty-five-year-old electrical engineer. The reason for referral was Jacob, who apparently refused to remove his gas mask while at home and insisted on sleeping in the sheltered area rather than in his room. After we got familiarized and I felt that I knew the family fairly well and had established joining, the following discussion took place. The symptom was unusual and quite disturbing for Jacob. My thoughts ran naturally to the issue of functionality. Because a gas mask is used to cleanse the air, I assumed that something was going in the family that was polluted for him, making him use the gas mask. A further assumption was that something had happened during the war that intensified his fears. Jacob was thus trying to cleanse the air and probably help his family. moshe: Jacob, did you feel that there was polluted air in the house that required the use of a gas mask? jacob: How did you know? moshe: That’s simple. The purpose of the mask is to clean the air, and since the war is over, it appears to me that you feel some dirty air is still left in your house. jacob [turning to his parents]: Tell him what’s going on between you. Both parents looked surprised and apprehensive. janice: We didn’t know that you had a problem with us.

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jacob [impatient]: Not with me; between the two of you. alex: Why didn’t you say you were concerned about us? jacob: I was afraid that if I said something you would separate. moshe: Jacob is obviously concerned about your marriage and decided to show it this way. alex: Why the mask? moshe: Jacob is very smart, and he used what he had at the moment, but it seems to me that you kind of agree with him. janice: We didn’t plan to talk about it, but do you think it is appropriate for him to hear this? jacob: I already know about it, I could see it in your faces when you had to stay in the sheltered area! I heard you talking about divorce! moshe: Jacob need not know the details [Jacob nodded earnestly], but he needs to know that things are going to be okay with you. janice: It’s very hard for me, I didn’t want to talk about it and thought that it might go away on its own, and things would return to normal again. alex: I don’t think we have anything to discuss. It’s too late for that. moshe [turning to Jacob]: Do you think that if your parents tried to talk things over it would be enough for you? jacob [desperate]: Do you think there’s any hope for them? janice: I hope and wish so. alex: I don’t know. moshe: Would you like to try? alex: For Jacob, I will. jacob: Not only for me, but also for yourself. alex: Okay. Near the end of the session, after it was agreed that I would see the couple for therapy, I turned to Jacob and thanked him for bringing his parents for therapy. I told him that I hoped they would make the best of it, while he resumed doing whatever he needed to do. Jacob’s problem was the “entry ticket” for the parents. They all knew what the real problem was and were afraid to approach it. Jacob took it upon himself to save his family, and he did so by developing the symptom. The symptom symbolized (as it usually does) the family problem. Jacob perceived the family atmosphere as polluted because of the secret, the uncertainty, and

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the fear. Jacob was fearful of losing the security and stability afforded by the system (representing loss of control) and wanted to correct it using a means of control that was appropriate for the situation (war and a danger of poisoning). Once this was uncovered, it was easy for them to enter therapy (“for Jacob’s sake,” but actually and obviously for their own sake) and for Jacob to give up the symptom. However, Jacob did not give up the symptom easily. He kept an eye on his parents, made sure they kept the appointments, and was careful not to ask anything except whether they attended it. I believe that his trust in me and the parents’ gradual improvement (at least their consistent appointment keeping) helped him finally abandon the symptom altogether. This took about four weeks. Jacob was never mentioned in therapy once the parents began working at it, and only through an oblique inquiry did I find out how well he was doing. Marital therapy took more than six months. Apparently, the relationship had been deteriorating for a long time. Alex had had an extramarital affair that lasted several years. Janice knew about it but decided not to bring it up. It appeared that Janice did not want to divorce Alex and thought that this might happen if she confronted him. She could see how this situation served her on several levels: Alex did not make demands on her, emotionally or sexually, and she could spend more time at work and advance her career and hobby (sculpting and volunteer work at the hospital). Also, she felt she had moral power over Alex because of his arrangement, which she used as she saw fit. Alex did not want to break up his marriage, in which he felt comfortable and secure, and he sensed that the extramarital affair helped to prevent too many fights and left both of them calm and comfortable. The two colluded in trying to keep the marriage working while not being too close and sincere with each other. The emotional distance–regulating mechanism had worked well until the war. Then they had to be with each other for an extended and highly intense period of time. The unexpected closeness found them unprepared. The forced closeness without the ability to vent tension by their usual means (work and the affair) led to an unbearable tension that threatened the integrity of the system. There were a lot of fights and a foul atmosphere at home. Jacob sensed this, and he reacted to it by developing symptomatic behavior. Janice and Alex ended therapy still married to each other, feeling much better about the relationship, and they were able to support each other.

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However, they decided they wanted to maintain their way of life, whereby they allowed each other ample space. At the follow-up session, six months after termination, they reported feeling much better and closer to each other. Jacob (who did not want to participate in the session because it was “their business” and not his) was doing very well at school and was quite sociable there and elsewhere. Alex came back two years later, with Janice’s permission, to work on an occupational crisis (inability to write reports) that brought up issues of the meaning of life. Apparently the extramarital affair was an attempt to seek excitement and meaning in life. Janice’s acceptance of the affair took the excitement out of it and left him empty. The emptiness drove him back to therapy. This intervention highlights a number of the issues discussed in chapter 1. We saw how Jacob assumed the role of a scapegoat (and also of the hero who sacrifices himself for the good of the system), and we saw the symptom’s symbolic nature and its function in calling for help and bringing the family for therapy. The emotional distance regulatory mechanism helped maintain a comfortable distance between the spouses while preserving the system. This mechanism failed when the situation did not allow distancing. It appears that working through the function of Jacob’s symptom, and later the function of the extramarital affair, helped reduce anxiety and distress. This, in turn, made it possible to work through emotionally laden issues to a satisfactory resolution. The couple’s solution was fairly unique. Few couples can survive a longterm extramarital affair and continue living together, and quite satisfactorily so. The acknowledgment of their shared responsibility and cooperation in creating and maintaining this situation, and their awareness of its functionality, contributed to the success of the intervention. Incidentally, the child called me a number of years later to ask for a referral and told me that he still remembered how I helped the family. He did not mention his problem, only the family one. DEPRESSION BY PROXY

The phone rang late Saturday night. On the line was a man who sounded agitated. Apologizing for the lateness of the hour, he asked whether I could see his wife, who was deeply depressed and not responding to medication. I

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asked how long she had been having difficulties, and he answered, “Three weeks.” To my question regarding the emergency, he said that he could not take it anymore. We scheduled an appointment for early the next week, and I asked him to bring his wife. “What will I do if she refuses?” he asked. I suggested that he try convincing her by saying that he needed her help because he was having difficulty handling himself, and he needed to learn how to care better for her.4 They came together for the session. The husband, Aaron, sixty-six years old, was a former CEO of a major corporation and was currently unemployed. Aaron appeared to be a self-sufficient, self-reliant person who always took care of himself and others. The wife, Rose, aged sixty-three, had been a homemaker since she married Aaron. Rose usually did volunteer and charity work. She was passive and dependent at home. She had been living in Aaron’s shadow. They had two children, thirty-nine and thirty-six, both married and with five children between them. They lived far away and were very busy with work and the kids. Aaron and Rose had been married forty years, and it was the first marriage for both. When I asked Rose how it was for her to come for therapy, she said, “No problem, Aaron asked me and I came.” Aaron said, “I was afraid she wouldn’t come. She hasn’t left the house for the last three weeks to go anywhere.” Apparently, Rose had begun feeling sad and depressed (no appetite, no interest in her volunteer and charity work) about two months before, but for the previous three weeks she had stopped taking care of the house and Aaron, had stopped making meals, had not returned calls, and had spent most of the time in bed with closed windows (“light disturbs me”), and she had disregarded her hygiene. There was no family history of any psychiatric disorder, although she remembered her mother getting into bed after she had had a fight with her father. Their medical history was unremarkable. The clinical picture looked grim. The couple had called in their family physician for a home visit, and he had prescribed antidepressant medication, which she refused to take (“I am afraid of side effects and getting addicted”). Hospitalization was out of question for them. I felt helpless, but before I decided to give up and insist on hospitalization, I asked what happened around the time the symptoms first appeared. The immediate response was “Nothing.” When I persisted, Aaron said that he had been released from his position

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after the company lost a great deal of money in questionable transactions. I asked him how he felt about it, and Aaron replied, “Nothing special; it happened before, and we got through it.” Aaron was referring to his previous job, which he had quit nine years before. As I inquired more into the issue, it became clear that this time his chances of getting another comparable job were fairly small, and he dreaded the idea of staying home not doing anything. I turned to Rose and asked her how it was for her. She answered, “I knew this was going to be very hard on Aaron, and I didn’t know how to help him. I told him to take their offer and quit. Now we’ve lost everything.” The pain, caring, anger, and disappointment were all evident. Having heard that, I began thinking that becoming depressed might have been Rose’s way of expressing her anger toward Aaron but also her way of helping him cope with his job loss (her depression thus expresses both anger and caring, distance and closeness). The need to take care of Rose in this difficult situation made Aaron’s difficulties pale in comparison. His need to take care of her diverted his attention from his situation and made him focus on hers. If my assumption was correct, the depression was reactive, even by proxy—actually, Aaron’s expected depression experienced by Rose. The lack of any significant psychiatric or medical history seemed to support the reactive nature of the disorder, and the coincidence of losing the job and the onset of the symptom was difficult to ignore. Quite possibly, the function of the depression was to help Aaron deal with his own loss by not confronting or experiencing it. Because Aaron was a highly responsible person, and because Rose remembered her mother becoming depressed after fights, the choice of depression as a means of expressing the multitude of feelings was understandable. I also realized that anger is followed by a feeling of helplessness and frustration and is based on a feeling of pain. I decided to test my assumption by putting it to them and seeing where they took it. Feeling that the joining between us was good, I cautiously proceeded: moshe: I know how much you care for each other and how difficult it is to lose a job. [They looked at me, expectantly.] Losing a job can make a person angry but also very depressed and pained. [They nodded in agreement. I turned to Rose.] I believe very much that you wish to help Aaron, and you are afraid he is not strong enough to get over losing his job this time. [Rose did not respond.] Knowing how much you love him, I think you are trying to help him even now. [Rose nodded in agreement. I turned

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to Aaron.] I understand that losing your job at your age makes life very difficult, and with the market the way it is, I believe it will be very difficult for you to find a new job, which makes its loss a substantial burden. [Aaron nodded vehemently.] I wonder whether there is a place or a person with whom you can share your anguish and sadness. aaron [looking at me]: How can I be depressed when Rose feels so badly? At this point I felt more confident about my initial assumption. It seemed to me that the time was right to proceed. My thought was that if Aaron allowed himself to experience his feelings and share them with Rose, she might be able to snap out of her depression. Experiencing sadness and grief was a sign that Aaron was strong enough to sustain them both. If this were the case, there was no further need to protect him. I did believe in Aaron’s strength, but I strongly hoped that if I was wrong, the joining would be good enough to keep them coming. We were close to the end of the session (our second), and I turned to them: moshe: Aaron, there is one thing I would like to ask you to do for the next session. I know how badly you feel about losing your job and about Rose’s condition. It is terrible and tormenting. Now, what I’d like you to do is to sit with Rose and tell her how you really feel about what is going on and what will be going on with you. I would like you to share with her your fears and anxieties, and please, spare nothing. I trust Rose and you very much and strongly believe you can do it. It turned out that I had to postpone the next session, which took place two weeks later. Aaron and Rose looked different as they entered my office. Their stride was firmer than I remembered. Rose looked me in the eye, and I could not believe what I saw: a hint of a smile on her face. After spending some time renewing the joining (e.g., asking about their health, their children), I asked what happened. aaron: After we got home, Rose went to bed and I went to fix dinner. As I was preparing dinner, I felt tremendously sad and began crying. I have never cried in my life, not even during the war. Rose heard me and came to the kitchen and began crying as well. We sat there, hugging each other and crying. I think we sat there forever. Then Rose told me that she had been afraid something terrible would happen to me. [At this point, he began crying. Rose moved her chair close to his and patted his head.]

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rose [looking at me]: He’s like a child; he doesn’t know how to deal with failure. He feels so bad, I have had to comfort him all the time. Something indeed happened. They had appropriately switched roles, and now Aaron expressed depression and Rose took care of him. Obviously, changing roles was effective in terms of relieving Rose’s depression, but depression still remained an issue, and consequently, they could not deal with the very pressing practical issue: the loss of Aaron’s job. I decided to respect the change they had made and wait. Two sessions later I suggested that if they felt like it, we could begin discussing what they were going to do with themselves in the future. Fortunately, the timing was right. They began talking about spending more time with their grandchildren, even moving to where their children lived. Aaron said he needed to talk to his friends and might serve on the boards of some companies. The assigned homework included drawing up a list of friends and Aaron’s calling them to express his readiness to take a position of board member. This he did, and he found that even though no position was immediately available, his friends seemed receptive. It took another five weeks until the first offer came. By this time Rose and Aaron were out of therapy, and they kept me informed over the phone. At the follow-up session, three months after termination, Aaron was already serving on one board and expecting another offer, and Rose had returned to her volunteer work. They did not look happy, but they were satisfied with the change and progress, and they expressed hope that it would continue. In a follow-up, almost five years after therapy, Aaron and Rose reported being active, although Aaron had quit his jobs and spent his time working in the garden, talking with family, and spending a lot of time on the Internet. Rose was very busy with her work and had no time for him. No further recurrences of depression were reported. This vignette is a very powerful one. I consider it a milestone case, one of those that impress me the most and are engraved in my memory. These cases help shape my views on therapy and psychopathology. I faced a devastating pathology that, under a different theoretical perspective, might have led me to recommend psychiatric care and might have had a different and time-consuming outcome. My belief in my approach and in the joining I had established with Aaron and Rose allowed me to experiment

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with an unusual approach. Success here encouraged me to keep using and expanding this approach. All the elements of FDS were present: the functionality of the symptom (depression) and the dialectics of the relationship (“strong” Aaron shifting to strong Rose and “weak” Rose shifting to weak Aaron). Here depression took on the dialectic role of expression of weakness and relief from responsibility. It forced Aaron to take responsibility for Rose. At the same time, Rose’s depression helped Aaron cope with his own devastating situation by diverting his attention to her situation. Depression helped Rose express her anger and pain and relieved Aaron’s guilt over his failure. Rose needed Aaron to take care of her, and helping her made him feel better about himself. The reformulation of the problem in terms of FDS created a secondorder change, which in a very short time brought about a change in the system. This began with the introduction of symptom meaning, which led to role reversal with respect to the symptom. Their awareness of the situation and its meaning with respect to their relationship (the mutual deep caring) helped to strengthen their bond and overcome the trauma. Had the situation been different, that is, if their life history had been different (e.g., a psychiatric history of major affective disorder; substance or alcohol abuse), the interpretation could have been different, and the intervention would have taken a different course. However, this case illuminates the various meanings of depression. Depression is a servant of many masters and takes on different meaning with different clients. I have heard clients describe depression as “a vacation,” “a strength,” “time out from reality,” and “restful.” All point to the function of depression as temporarily freeing one from responsibility for life and having others shoulder it. In this case, depression was also interpersonally directed. THE MASK OF DEPRESSION

David was twenty-four years old when he referred himself for therapy. David was of average height, a little overweight, and looked somewhat childish (he had begun shaving only two years before). David was the only son of his father, a fifty-five-year-old technician, and his mother, a fifty-two-year-old homemaker. David was a high school graduate who had tried working at various jobs: waiter, cashier, and gardener. David lived at home but would consider leaving home, after he found a suitable job, and living on his own.

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The presenting problem was depression. David described himself as unable to enjoy anything in his life, feeling dissatisfied with his ability to achieve anything, having a sad mood, and feeling hopeless about his chances of finding a job and moving out and about the possibility of change. His outlook on life was grim and pessimistic. David reported frequent suicidal ideation but with no specific plans. This had been going on for a long time, since he graduated from high school and began considering the option of going to college and leaving home. David described himself as completely different in high school. He remembered himself as friendly and outgoing, even though he did not excel in anything; he was an average student, not a great athlete, and he had some friends. His friends had left town for college, and he was left alone. David decided to go to therapy because he felt he needed to do something; his parents were profoundly concerned and extremely frightened after hearing him talking about the meaninglessness of his life and his wish to end it all. They encouraged him to seek help. David had no medical problems he was aware of; nonetheless, I recommended that he see a family physician for a checkup, which he later did, and it proved normal. David was an only child because his mother suffered from postpartum depression, and his parents decided they did not want to experience it again. Their life appeared to focus on David, and they said, according to David, that he was the “jewel in their crown.” They were devoted to him, acquiescing to his demands and wishes. David did not think his parents’ attitude was beneficial for him, but he admitted that it was convenient living at home. When I asked him why he thought he wanted to leave home, he answered, “Isn’t that what a guy my age is supposed to do?” When I insisted that he tell me what he wanted, he said, “I’m not sure what I want to do; it is scary to live on my own. I have never been alone in my life, and I feel very comfortable at home.” At this point I could feel David’s ambivalence. Living at home was easy and undemanding, but it did not accord with the societal expectations of independence as David experienced them. His parents had a similar ambivalence. They had told David that he could move when he felt ready for it, but until then he could stay at home. moshe: How do you know you are ready to leave home? david: It is irrelevant now since I am so depressed, I can’t even begin thinking of leaving home.

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The role of the depression was clear: to provide David with an excellent excuse for not leaving home. The onset of the depression (actually, dysthymia) had occurred when David was expected to move on to college, accept responsibility for his own life, and leave home. The threat of leaving home was too much for both David and his parents, and the depression was a neat way of solving the dilemma. The question was why David wanted to remain a child. What was it in the adult world that was so frightening for him? What was his hidden strength? It took another two sessions to get there. moshe: David, I was thinking that there is something else in what’s happening to you that I can’t fathom. I know you’re strong. I know you care about your parents. It seems to me that you’re trying to protect them and yourself from something. Can you help me figure this out? david: I’m not sure I want to talk about it. It’s true I feel much better now, and I don’t want to spoil it. I need more time. moshe: I think that’s fair; what I hear you saying is that you need more time before you can talk about it. Tell me this: do you need to feel safer with me? david [looked a little upset]: No, it has nothing to do with you; it’s just that I’m not ready yet. moshe: What do you think can help you become ready? david: I don’t know. I guess I’m afraid of what will happen after I tell you. moshe: You’re afraid of what will happen to you after you open up. I think that what you’re holding in is really scary, but I believe that getting it out will make you feel better, less tormented than you are now. David remained silent for a long time. I could see the struggle in his eyes. He seemed to want to talk, his mouth opened and closed several times. It was really very difficult for him. moshe: It’s is very difficult for you. david: I’m gay. moshe: I admire your courage and trust. The revelation, which was very difficult for David, led to a worsening of his depression. I held steadfastly to my respect and appreciation for his taking the risk and opening the issue of his sexual orientation, as well as my recognition of his courage to be true to himself. Gradually, David became

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less terrified of the revelation. He was highly concerned about his parents’ reaction. Nonetheless, he began experimenting with his sexuality. He was involved in several short-term relationships. He enrolled at a university and began to study philosophy. He was still afraid to tell his parents, and I thought it was because he was trying to protect them from the news but also to gather courage and confidence to face the consequences. David was sure that their response would be negative. Finally, the time came, and he found that his parents had suspected it and had prepared themselves for being told. So when David informed them, they were supportive and only asked whether he knew what he was getting into. David was aware, and frightened, but he was happy to know that his parents would be there for him. On this note, David was ready to go out into the world. Therapy ended several weeks later. David returned to therapy once in a while for a session or two, just to remind himself of how strong and wonderful he was. This was very important for him as he made me a significant part of his life. The trust that was formed in the therapeutic relationship made possible the rapid transition from working on the depressive symptoms to the underlying fear of dealing with his sexual orientation. Able to deal with it in the safety of the therapeutic relationship, David felt he could open the issue with his parents. My consistent and persistent faith in David’s ability to cope, and my showing again and again how he could turn the events to his benefit, paid off splendidly for him. After several sessions he was able to tell me that indeed there was a positive side to things. His boyfriend’s leaving him had been very painful, but it was also a blessing because they probably were not well matched, and that was a good experience for him. It was as if David had acquired a new skill, and this helped him to expand his view of things without harming his ability to feel and experience them. Here again, we explored the functional value of depression. In this case the depression was functional for David and his parents. It delayed David’s separation from his parents (and their separation from him). Furthermore, the depression diverted his attention from coping with being gay. His ability to share this with his parents gave them the opportunity to remain an important part of his new life. David needed their support, and they felt needed by him, but by the same token they could allow him to separate and lead an independent life.

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These vignettes demonstrate the use of FDS as a powerful tool in providing the client with a different outlook on his situation. First of all, using FDS thinking changes the nature of the presenting maladaptive behavior. It adds an alternative understanding: positive, adaptive, and altruistic. The dialectic meaning changes the view of pathology and makes it less frightening and debilitating. The client’s hopelessness, helplessness, and feelings of loss of control are replaced by a sense of control. Achieving control allows a renewed perception of choice. The person has the option to choose whether to use the old, previously maladaptive behavior in a more adaptive way or to abandon it altogether for alternative behaviors. Some patients adopt the dialectic view and are able to see other aspects of events in their lives. This skill is extremely important in changing their view of these events. The ability to see the positive side, or any other side, makes their thinking more complex but helps reduce the threat posed by the negativistic, optionless view that gave rise to the disabling symptoms.

PART V

SELECTED TREATMENT ISSUES

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11 INFIDELITY

People marry to ensure provision of their basic needs for safety, security, belongingness, and identity. They create a system based on mutual loyalty that is expected to last a lifetime. The marital bond is based on trust, which is crucial for closeness, safety, and intimacy. The marital bond is traditionally secured by a contract and a wedding ceremony. The contract is a private commitment, and the wedding is a public one. The marital vows are made so that each partner publicly abandons the option of quitting the relationship. To preserve the system, society imposes a variety of sanctions (e.g., religious, economic, social) to make it harder for people to break the marital bond. Nevertheless, the presumed stability of the system actually entails instability. People seek stability, but a substantial percentage of them have difficulty living with or in it. The high divorce rate (50 percent in the United States) indicates that the marital system is not shatterproof.1 The marital system is dialectic in meaning. It is created to provide stability, but a stable system is inherently unstable. The structure of the system is designed to ensure stability; people want it to be stable, but at the same time they are aware that they can break this stability whenever they want. The stability of a marriage is a wish and a goal that denotes the reality of its instability. Surveying numerous couples’ treatment files, I found a recurrent theme common to most of them. The theme was stability versus excitement. It appears that those who came to therapy were struggling with this dialectic. Marriage provides stability. Stability means order and predictability. We create a structure and recurrent behavioral patterns (habits, rituals) in order to maintain and preserve stability. Yet a 177

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good number of people cannot live with routine life or cannot achieve this stability. They seek the excitement that they cannot find in their marriage. They would like to have both in their marriage, but this seems impossible. It seems that people want the system to meet two irreconcilable needs: stability and excitement. People marry having hopes, expectations, and fantasies about a lasting marriage and their future in it. For some these expectations come to fruition. Others adjust or change their goals in a way that sustains the marital system. Still other people may conclude that they cannot live in the system the way it is; they believe they made the wrong choice, or that the pace of life has taken them to a different place, or that their own personal development failed to synchronize with their spouse’s, opening a gap they are unable to bridge. These people may look for a way to resolve the discord between the life they believe they have and the life they wish for or fantasize about. Infidelity is one of the ways people may choose. Infidelity is a violation of the contract between spouses that specifies exclusivity of the relationship. Infidelity is an element of instability brought into the system, sometimes with the purpose of stabilizing it. PREVALENCE OF INFIDELITY

Trust is the basic element of the marital relationship. The existence of trust allows the partners to be themselves, be vulnerable, and face together the hardships of life. Infidelity is a violation of this trust. About 97 percent of participants in a large survey agreed that extramarital affairs (EMAs) should not be allowed (Johnson et al. 2002), and 85 percent of respondents in the Sex in America survey expressed disapproval of infidelity (Laumann et al. 1994). Knox et al. (2000) found that 69.1 percent of their student participants reported that they would end a relationship with a cheating partner, and about half of them reported actually doing so. However, sexual fantasies with a nonmarital partner are quite normative: 98 percent of men and 78 percent of women in married or cohabitating relationships report at least one recent such fantasy (Hicks and Leitenberg 2001). Despite the overwhelming negative attitude, the rate of infidelity is quite high. Kinsey et al. (1953) found that 36 percent of husbands and 25 percent of wives reported marital infidelity. The National Health and Social Life

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Survey reports that 21 percent of men and 11 percent of women admitted extramarital involvement (Laumann et al. 1994). Glass and Wright (1997) report that 44 percent of married men and 25 percent of married women had at least one extramarital involvement. Whisman and Snyder (2007) report that only 1.08 percent of 4,884 women interviewed face to face reported infidelity, whereas 6.13 percent of those women interviewed later via computer reported infidelity. The difference was attributed to assessment method. Because infidelity is not a socially accepted behavior, underreporting is probable (Schwartz and Rutter 1998). Despite the overwhelming opposition to EMAs, a good portion of people have experienced them. From their review of the literature, Allen et al. (2005) conclude that one of the most consistent findings is that men are more likely to engage in extramarital relations or to have more extramarital partners than women. Men express more desire and tend to be more active in seeking an extramarital partner. Lusterman (1997) refers to societal factors (e.g., social sanctions are more severe for women than for men, sex is considered a status and power symbol for men but not for women). However, in terms of both attitudes and behavior, the gender gap appears to be shrinking in younger cohorts (Atkins, Baucom, and Jacobson 2001; Laumann et al. 1994; Oliver and Hyde 1993; Thornton and Young-DeMarco 2001). Marital infidelity has dire consequences. It is a major cause of divorce, spousal battery, and homicide (Daly and Wilson 1988). TYPES OF INFIDELITY

Infidelity can be divided into three main types: sexual, emotional, and virtual. A plethora of articles and books set forth theories explaining how infidelity is caused (see Allen et al. 2005 for an updated and comprehensive review of the literature). The distinction between emotional and sexual infidelity is reflected in the finding that a man is more likely than a woman to be unfaithful, to engage in one-night stands, to involve someone of limited acquaintance, and to perform coitus (Humphrey 1983). It is usually believed that women are more distressed by emotional infidelity and men more by sexual infidelity (Buss et al. 1992; Shackelford et al. 2004). A number of recent studies (DeSteno and Salovey 1996; Grice and Seely 2000; Sabini and Silver 2005;

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Schützwohl 2005) found no differences between men and women with respect to their reaction to either type of infidelity. These findings are controversial (Geary et al. 1995; Pietrzak et al. 2002). Sheets and Wolfe (2001) found that whereas heterosexual women, lesbians, and gays were more distressed by a partner’s emotional than sexual infidelity, heterosexual men were equally distressed by these two situations. Perel (2003) and Greenan and Tunnell (2003) point out that in the gay community it is not uncommon for couples to choose nonmonogamous sexual arrangements, with the commitment in the primary relationship being mostly about emotional fidelity, attachment, and dependability rather than sexual faithfulness. Sheets and Wolfe (2001) found that heterosexual men experienced greater distress in reaction to a partner’s sexual infidelity than heterosexual women, lesbians, or gays. Previti and Amato (2004) found that sexual infidelity was associated with anger and blame, but emotional infidelity was associated with hurt feelings. Becker et al. (2004) found that the jealousy response to an emotional infidelity best distinguishes women from men and that both women and participants in serious, committed relationships reported significantly greater intensity in their emotional reactions than men and those not in a committed relationship. Internet infidelity is a new phenomenon (Hertlein and Piercy 2006). The Internet offers an opportunity for complete anonymity, where a person can present himself in any way he wants. There is no need for a meeting in the flesh, so it is wide open to fantasy with an imaginary (albeit real) companion on the other side. Whitty (2005) reports that although not all participants in the study saw an Internet affair as a real act of betrayal, the majority did see it as real infidelity and as having as adverse an impact on the couple as a traditional offline affair. Again, the most important finding was that emotional infidelity was given as much attention as sexual infidelity. The major problem with Internet infidelity is the breach of trust, because it is kept secret and usually the people engaged in the affair share intimate fantasies and details. Another fear associated with the Internet affair is of its actual consummation or its becoming potentially actualized. All these are likely to make the virtual affair a real relationship problem.

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HOW DOES THE SYSTEM PROTECT ITSELF AGAINST INFIDELITY?

Whatever the cause, the outcome of infidelity is most often a severe marital crisis and trauma. Infidelity is a trauma of betrayal and a breach of trust. It introduces a clear and present danger to the integrity and existence of the system. To prevent such a trauma, the system uses several measures: t


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The most important barrier is the quality of the marital relationship. When the partners are satisfied, there is no need to turn outside. In this case the person neither sends nor reads signals inviting infidelity. Drigotas and Barta (2001) suggest that highly committed people are less likely to be unfaithful because they are motivated to derogate potential alternatives in order to protect the relationship (thus effectively keeping alternatives unattractive), and when tempted to be unfaithful they are likely to consider the long-term ramifications of such behavior for the relationship and the partner. Commitment reduces the frequency with which temptations arise and provides resources enabling the person to shift his or her focus from any potential short-term pleasure to the long-term consequences. The marital contract and religiosity. In some religions the penalty for breaking up the marriage is specified in the marital contract. This penalty may be financial (Jewish Ktuba) or spiritual (Catholic belief). Unfortunately, these customs are not actually applied, or they have lost their significance in our day. However, religious belief is negatively related to both permissive attitudes toward an EMA (Cochran and Beeghley 1991; Kraaykamp 2002; Scheepers, Grotenhuis, and Van Der Slik 2002; Smith 1994) and actual engagement in it (Amato and Rogers 1997; Atkins et al. 2001; Buunk 1980; Choi, Catania, and Dolcini 1994; Hunt 1976; Janus and Janus 1993; Kinsey et al. 1953; Lawson and Samson 1988). Social sanctions. Frayser (1985) studied sexuality in sixty-two present and past cultures and found that in twenty-six societies the husband was allowed to have extramarital sex but not the wife. In half of those, the husband was legally given the option to kill his

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unfaithful wife. In cultures that permitted adultery, none allowed it for women. Some cultures define adultery differently for men and women. In Jewish law, for example, it is still on the books that a married woman is guilty of adultery if she has sexual intercourse with any man other than her husband, whereas a married man is guilty only if he has sex with another man’s wife. What he is guilty of is not disloyalty to his own wife but of committing a property crime against another man. Under Muslim law, a man is allowed to have sex outside marriage and to kill or divorce his wife if she is found doing the same. In modern Saudi Arabia and other Arab countries, women are still stoned to death for adultery, but the male partner is not. Until the late 1970s in Brazil, men who were betrayed by their wives could kill them without legal consequences; their “crimes of passion” were considered justified. Only in 1979 did the famous case of Angela Diniz, murdered by her husband for infidelity, lead to a change in the law. Obviously, infidelity is a clear case of gender-discriminating standards. Laumann et al. (1994) found that in the United States men tend to divorce their wives for infidelity more often than wives divorce their husbands. These authors also point out that women are still more harshly punished if discovered; men are less forgiving and more prone to vengeance and acts of violence. Jealousy is another way to prevent attempts at infidelity. It is a mechanism used in dyadic relationships to ensure that the spouse will remain in the relationship. Buss and Haselton (2005) consider jealousy an emotion designed to alert a person to threats to a valued relationship. It is activated by the presence of interested and more desirable sexual rivals, and it functions, in part, as a motivational mechanism with negative behavioral consequences designed to deter infidelity and abandonment. Brad et al. (2003) argue, from an evolutionary angle, that male jealousy functions to reduce the risk of their female partners being impregnated by rival males, whereas female jealousy functions to reduce the risk of their male partners diverting resources to the children of rival females. Evolutionary psychologists hypothesize that jealousy is an evolved adaptation,

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activated by threats to a valuable relationship and functioning to protect it from partial or total loss (Buss et al. 1992; Daly, Wilson, and Weghorst 1982; Symons 1979). Jealousy occurs in the context of a relationship. It serves as a warning signal that the system is not safe enough. It reflects caring and emotional investment on the part of the jealous party, but it also indicates that the desired partner is experienced as sliding away. The intensity of jealousy is positively correlated with the experience of distance, emotional or physical. The more jealous the person is, the more distant the partner is. A self-intensifying cycle is created in which jealousy leads to feelings of being controlled (or “suffocated”); this leads to further distancing, which in turn increases the level of jealousy. In this respect jealousy operates as an emotional distance–regulating mechanism that is used for creating a distance while maintaining a relationship. This mechanism may be useful until the parties feel they can’t control it, and it limits them unbearably. At this point, the system enters a crisis that calls for an outside intervention (e.g., therapy). THE FUNCTION OF INFIDELITY

An EMA is a marital crisis, yet it can also be functional for the involved individual or couple. The motives for initiating infidelity highlight its functionality: t


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Self-esteem. Imber-Black (2005) argues that an EMA for men is based on a sense of entitlement or functions as a way of bolstering selfesteem. As for women, the motivation is often related to romantic expectations or disappointment with the marriage. Women want to feel desired and loved. Another related reason is a feeling of being constricted by the marital duties (e.g., breadwinning and domestic duties), which are likely to lead to a feeling of self-devaluation. This can lead to rebelliousness in the form of extramarital affairs. Missing the train (an adventure). At times a person may feel that she has not experienced life to the fullest. This is likely to happen to a person whose spouse was the first person she had a serious relationship with. It also may happen to those who feel that they are

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getting old and would like to delay the process by having an EMA, usually with a younger partner. This affair rejuvenates their life. The affair can be viewed as an emotional distance–regulating mechanism. The existence of an affair limits emotional involvement and prevents too much intimacy between the spouses. An EMA reduces fear of intimacy and also protects against loneliness. The affair may serve as a stress reduction mechanism in the relationship. The affair reduces pressure for sexual activity in the marriage. It allows the partner to be more patient and tolerant and may reduce fighting. The situation can be different when guilt feelings are associated with the EMA. In that case, stress at home may be intensified to justify the EMA. An EMA is a way to spice up the routine and stability provided by the family system with excitement and uncertainty. The involved person feels bound by the routine and safety of the marital system, which cannot meet his need for stimulation and risk. The realization that these two needs cannot be met by one system may lead the person to look for the chancier element outside the marital system. A classic dialectic situation is created in which the dialectic meaning of one system is given by the external one. Furthermore, the excitement can be experienced in the setting of routine and stability, and vice versa. A person seeks excitement out of boredom (stability and routine), but the excitement can be felt only in the context of stability and routine. The person involved in the affair chooses excitement. Following the crisis after the exposure of the EMA, the person who had the EMA may choose the excitement over the stability. However, once the transition is made, the person is likely to find that she needs stability or that the excitement of the new relationship in its turn gives way to stability and routine. This may increase the pressure to return to the old relationship, and a vicious cycle is formed.2 An EMA can serve as a way to express hostility toward a spouse or to exact revenge on a spouse. A spouse hurt by an act of infidelity or disrespect may choose an EMA as a means of getting back at the person who performed this act. There is no intention to break down the system, just to express anger and pain.

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Exit affairs. Sometimes an affair is the person’s way out of the marriage. She may feel trapped in the current relationship and build an extramarital relationship as a way out. Once the new system has stabilized, there is no need to remain in the old one. In this case a decision to leave home has been made before the actual act; the goal is break down the system. The partner who wants to quit the system usually leaves ample clues pointing to the EMA. In therapy this person usually wants to enlist the therapist in convincing her spouse that the decision is final and in helping the couple terminate the relationship as quickly and painlessly as possible. This type of EMA usually results in messy divorce proceedings that reflect the anger and hurt of the betrayed partner and the justification for leaving home of the person involved in the EMA.

EXTRAMARITAL AFFAIRS MAY HAVE A POSITIVE EFFECT ON A RELATIONSHIP

In view of the overwhelmingly negative attitudes toward infidelity, it may be surprising to realize that it may have a positive effect. Infidelity is traumatic and disastrous for a marriage, but it also presents an opportunity for change and growth. When explored, this opportunity can benefit the individual and the couple. My belief is that although infidelity is inherently wrong and poses a danger to the system and thus should be avoided, its consequences may be positive for the involved partners. This may be true when the spouses want to continue their marriage but also when marriage is terminated after a EMA. Reibstein and Martin (1993) believe that “affairs have brought people increased self esteem, more sexual confidence, more insight into how one is with the opposite sex, a wisdom about relationships, and a greater sense of autonomy” (145). “Affairs can also produce reconsideration of the purpose of marriage: through affairs, a redefinition of marriage can evolve; and there may also be a revaluation of what is possible and desired” (147). This discussion of the functionality of the EMA points to its additional potentially positive effects: emotional distance regulation and stress reduction. The EMA can provide stress reduction when one of the partners feels that he is not satisfied with their sexual life and sees no possibility of improving it. Turning to somebody else for sexual satisfaction (e.g., a

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prostitute, an EMA) may reduce the stress, reduce friction, and help sustain the marriage. Of course, this person risks adverse consequences if the EMA is discovered. Also, an EMA can reduce the pressure for intimacy by distancing the spouses. However, this breach of trust may not endanger the marriage as long as it is hidden (sometimes the spouse is aware of the EMA but decides not to act on it because she may similarly benefit from it). When this situation is made clear to the spouses after the secret has come to light, it is possible to repair the relationship and even take the couple to a higher level of contentment in their marriage. Being aware of the possible functional effects of the affair helps both the therapist and clients experience less fear and distress over its consequences. It may also help the couple and therapist use it to identify problem areas and improve relationships so that they become more durable and satisfying. THERAPY: STRUCTURE (GROUND RULES)

Couples who come for therapy are in a state of crisis and trauma, but they also hope for reconciliation. Their distress is also an indication of interpersonal involvement and caring and is a good prognostic sign.3 The major injury is that of betrayal and loss of trust. Some couples who have undergone such a trauma terminate the relationship on the spot and do not come for therapy. Others may come to therapy already resolved to terminate the relationship, but they want to make it less painful for their spouse and themselves. However, most couples who come to therapy want to end the crisis, restore the relationship, and make sure it will not happen again. Rarely do they see therapy as an opportunity to improve the relationship. Despite the potential for therapy to improve a couple’s relationship after an EMA, I strongly believe that infidelity is harmful to relationships. Infidelity is a trauma that behaves like a trauma. It will never disappear, be resolved, or be forgotten. It is merely denied and put to rest on a back shelf of our memory. Whenever a direct or indirect association presents itself, the trauma resurfaces. The context for its recall determines how quickly it will be put back on the shelf. Unlike Pittman (1989), who does not believe that the betrayed spouse should ever take any responsibility, I believe that the person involved in an EMA has crossed a line, but this transgression is a product of the couple’s relationship. I fully appreciate the hurt and pain, which deserve their due

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place in therapy, but ultimately I prefer to focus on shared responsibility. Reaching the stage of shared responsibility makes it possible to work more closely and more productively on the conditions that led to the crisis and to try to correct them in order to avoid future transgressions. Like Pittman (1989), I believe very strongly that honesty and transparency are central to close, intimate relationships.4 I tend to agree with Brown (1999), who argues that affairs have little to do with sex; they are mostly about fears, disappointments, anger, and emptiness. They are also about love and acceptance. Spring (1996) presents a different view. She recognizes that transparency may not be appropriate for all couples and that telling the truth may not always be healing or productive: “For some couples the truth can have adverse, even destructive, consequences. For others it’s essential for restoring a damaged relationship . . . so in grappling with the best strategy, it may help to ask, ‘Best for whom?’” (257). Lusterman (1997) agrees with Spring that there are situations in which it is better not to tell. He claims that sometimes honesty backfires, sometimes certain information overloads a particular marriage, sometimes the partner is dangerous, and sometimes there is an implicit mutual agreement not to talk about the affair but instead to concentrate on improving the marriage. In talking directly to couples, he repeatedly stresses “how important it is to focus on the marriage itself, away from the infidelity” (88). This is an excellent point, but I believe that even though truth may be destructive, it needs to be told. Decisions can be made only when the available and relevant information is imparted. The amount of information disclosed depends on the needs of the injured person (the person who was involved in EMA is almost always reluctant to divulge information, in an attempt to protect the injured person, to get past it, or for self-defense). Intimacy is based on trust. Although trust cannot be restored to a pre-EMA level, it needs to be built to a livable level. Keeping secrets, especially at this time, is more harmful than revealing them. Also, truth may be difficult to accept and may have dire effects on the marriage, but it needs to be told and faced. If the marriage cannot survive it, it may not be worth saving. There are a few exceptions to the rule (Lusterman 1997), such as when the partner is potentially or actually dangerous. In that case one may weigh the consequences of keeping a secret against revealing it. However, if a

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partner is dangerous, then something is really wrong in the relationship, and terminating it may be a better solution than living in fear that the secret will be revealed (which probably will happen), at which time the consequences may be even worse. If the couple wants to continue living together and to resolve the issue, there is no alternative to honesty. If the couple wants to maintain the system without testing it further, I believe that they are just paving the way for future infidelity. The risks of revealing an EMA include divorce and other serious acts of retaliation, such as violence or even murder (Laumann et al. 1994). If a therapist suspects that violence is likely, she must take steps to make sure it does not happen. A rule I strictly keep is that the affair should be ended before the beginning of therapy. If this is not the case, I suggest setting a deadline for ending it. The deadline may be set a few weeks ahead but no later. There is no point being in therapy when the commitment to marriage is marred by an ongoing affair. The spouses need to start fresh. One of the major issues in working with infidelity is forgiveness and compassion. Shackelford, Buss, and Bennett (2002) found that men, unlike women, find it more difficult to forgive sexual infidelity than emotional infidelity and are more likely to terminate a current relationship as a result of the partner’s sexual infidelity than her emotional infidelity. Forgiveness and compassion are important in helping the couple cope with the EMA without spending too much time and energy on venting anger, frustration, and hurt. These are likely to appear at the beginning of therapy, but once they are replaced by forgiveness and compassion, it is easier to work on the relationship. I need to mention again that I will discuss here only clients who are willing to work on their relationship and situations in which the infidelity is not a secret. THERAPY: PROCESS

Therapy actually begins before the couple appears at the clinic. It began when the affair was uncovered, with the ensuing crisis and trauma. The sense of betrayal and loss of trust is at its peak. The betrayed partner usually feels angry, injured, and pained. It seems as if the world has collapsed and shattered. The familiar partner now looks like a stranger. The familiar environment—the house, the bedroom—seems foreign. You feel as if you

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have no place, and the last person you want to turn to is the one you would automatically have gone to earlier; your spouse is no longer there. The anger, humiliation, and disappointment are enormous. You feel lost, helpless, and hopeless. You want everything to disappear; you hope you will fall asleep and then wake up from the nightmare to find that your world has returned to normal. You know it is a reality and that the world you thought you lived in is no longer there. You feel alone, lonely, and terrified. Most of all, you feel anger and humiliation at this point. You cry and scream to shut out reality and try to banish the dread that engulfs you. After you calm down a little and are able to think slightly more rationally, you ask yourself what you did wrong. How come this happened to you? Where do you go from here? It is your decision. Your partner stays; he or she has not left you and insists on staying. Right now you hate your spouse and want him or her to disappear, but you have to consider the future. You want to hear every detail, and you hate yourself and your spouse for it. At this point you decide that you had better seek therapy. Most of the time (especially if you are the wife), it is you who has to look for a therapist, which makes you even angrier, feeling not only that you were hurt but now that you have to take responsibility for it. The partner who was involved in EMA is terrified: the affair that was kept secret is now uncovered. The safe and predictable world has become unsafe, chaotic, and dangerous. Feelings of power and excitement are now replaced by fear and shame. You are the one who betrayed your spouse, you are the perpetrator, and there is nothing you can say, except for being sorry for yourself and your spouse, that will change it. You experience the anger and the pain, and you know you are responsible. You can deny it, even blame your spouse, but inside you know you blew it. You want the affair to disappear and you and your spouse to go back to square one, before the affair was discovered. You want to continue the relationship but are afraid that your spouse will not cooperate. You promise heaven and earth to restore it, but everything now depends on your spouse. You begin to feel anxious and helpless. You promise to end the affair immediately and are torn between protecting your lover and satisfying your spouse. You feel you cannot just end the affair; you have somebody else’s feelings to consider. You watch helplessly as your spouse gets angrier and more pained as you say this. When you suggest counseling or hear about counseling, you may become

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more fearful. Here you are invited to a court where you will be crucified for your sin. You agree because there is no alternative, and it seems as if it is never going to end. The idea that something good may come out of it seems like a distant fantasy; you don’t dare think about it. The couple arrives at the clinic door anxious for work. They are distressed, sad, fearful, and pained. They will undergo a long process and several stages before they reach the wished-for outcome: joining with the therapist and learning the rules of the new game they will be taking part in, they will work on building trust, explore the dialectic functional aspects of the EMA, and learn how they both can benefit from it. Then they will work on restoring their relationship, and then will come the time for ending therapy and for a follow-up. Joining and Rule Setting

The first step for the therapist and clients is to join. This is not an easy task. The therapist cannot be judgmental or take sides. The therapist must avoid the offender–victim perception and connect with both. This is a very delicate process. When you join with the offended spouse, the other may think you are conspiring against him. When you join with the offender, the injured spouse may wonder how you dare treat him so nicely. So you begin by asking neutral questions and being careful not to touch on any sensitive issue, even if the clients want you to get there as soon as possible. It is important to spend as much time as necessary at this point to ensure that the clients realize that they are being accepted and respected as human beings. After the therapist feels connected, he may advance to talk about the affair. The therapist must be highly respectful of the trauma and the pain associated with it. There is no need to minimize it or even put it in perspective. The issue is the pain and hurt, and the betrayed person needs to feel that his reaction is fully appropriate and accepted, and the betraying partner needs to face up to the painful consequences of EMA. At this point the therapist can be one-sided but needs to be careful not to lose the other side. This may take some time, and therapist should not rush it. Then, when joining has been achieved, the therapist can ask what the spouses want to gain from therapy. At this point, the spouses and the therapist may be in different places. The betrayed spouse may still be very angry,

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and as long as there is anger there is power over the other side (and a need to hurt and take revenge). At this point it is not an equal-level position. The injured partner exercises power over the other that is based on guilt, fear, and shame. The betraying partner wants to end all of this as soon as possible and feels ashamed and guilty. She may also feel frustrated that the process takes a long time. The therapist needs to be aware and contain the various emotions while keeping the relationship in focus. The therapist needs to bring the parties together to a point where they agree that they would like to continue working on the relationship. The appropriate question (e.g., “Would you like to work on your problem?”) is addressed to the couple, not the individual. The therapist must secure willingness to work together on the problem in therapy. In cases of extreme resistance, the therapist may negotiate the number of sessions the couple will agree to attend before making a decision. It is also a time for the clients to become aware that the EMA is a trauma that will not go away and to be realistic about the fantasy that everything will be as before. It is possible for the relationship to eventually get back to normal. Realistically, the partners are likely to be in different places. It is analogous to physical trauma. The body that sustained a physical trauma (illness, loss of limb, or even curable disease) carries the scars forever; it may look a little different, or even the same, but the body may not become stronger and more immune to future trauma. Yet the trauma will stay. It will be hidden, but the injured spouse remains on guard, and if an event involving a lack of credibility occurs (e.g., being late or telling a lie, even a “white lie”), or if the unfaithful partner shows interest in somebody who is a potential candidate for an affair (or somebody of the opposite sex shows interest in her), the trauma will resurface, and the person’s reaction will be based on the trauma, not the actual event. This stage can take one to three sessions. Building Trust

Once a commitment to therapy is obtained, the therapist may share with the couple his views of disclosure and transparency. I tell my clients that it is appropriate for the injured spouse to feel betrayed, to lose trust, and to be plagued with uncertainties and questions. These questions may relate to

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every major or minor detail of what happened: the circumstances, the act, the setting, and so on. The person responsible for the betrayal needs to be very patient and answer every question, even if it is for the thousandth time. This process is difficult for both sides. The injured one hears again and again about the affair and feels the need to keep hearing it. The reason is that the injured person is trying to renew his or her trust, and the inquiry, which may be very difficult for that person, is a credibility test for the partner. The questions are asked again and again, and consistency, or rather a lack of it, is sought in an attempt to show whether the betraying partner deserves the renewed trust. Moreover, there is also a need to know what went wrong with the relationship (“What was wrong with me? In what way was the lover better than me?”) and an ambivalent and compulsive need to hear what went wrong along with a wish not to hear it. This process may take a long time. Sometimes months may elapse before the questioning stops. When it does, it usually indicates that the couple’s stress level is reduced. When the therapist feels that joining is strong, the spouses are committed to working on the problem, and the anger is mostly spent, it is time to cautiously inquire into the functional aspect of the EMA. This stage can take a long time, depending on the couple’s reaction to the EMA, the intensity of injury, and the type of interaction between the spouses and between them and the therapist. Functionality and Responsibility

The functional dialectic system approach views infidelity as functional for the system and the people involved. Infidelity is an act signifying the importance of the system. The person engaged in infidelity does not intend to break down the system, only to find a way to satisfy needs while keeping the system intact. An EMA may bolster self-esteem or regulate emotional distance. At other times the EMA serves as a warning or a cry for help intended to eventually strengthen the system. The therapist can begin inquiring about the functionality of the EMA by first asking the person who was engaged in it what he expected to gain thereby. The answer will give a clue as how the system needs to change. The therapist must ensure that understanding the motives for an EMA

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does not indicate its acceptance. Understanding the functionality of an EMA helps one to gain a better understanding of the system. Note that even the presentation of the issue may cause a negative reaction, especially on the part of the betrayed person. This reaction can take that person back to the place of hurt and pain. The therapist needs to be aware of this and adjust her attitude and presentation to the particular couple. After clarifying the functionality of the EMA with the partner who carried it out, the therapist turns to the other partner with the same question. When one partner looks for excitement, the other may be expected to hold on to stability and routine. This is likely to be the dialectic that led up to the affair. Both spouses are likely to emphasize the pole that attracted or served them. It is safe to assume that the affair had a stabilizing effect on the system as long as it was kept secret. No wonder that in most cases the partner who was not involved in the EMA is usually the last to know about it. The need for stability is so strong that it leads to denial until the facts stare one in the face. Exploring functionality enables the couple to see the effects of the EMA on their marriage and to realize what they need to do in order to change it. It is surprising to see how the spouses react to the functionality question. The question breaks the offender–victim cycle and suggests that both spouses share responsibility for the EMA. Nonetheless, the answer to this question is very telling, and it further elaborates the conditions under which the EMA took place. The spouse involved in the EMA may enjoy the increased self-esteem, or will not feel pressure to get more intimate, or will have more freedom to do her own things (e.g., concentrate on a career or child rearing). Instead of asking each spouse individually about the functionality of the EMA, the therapist can put the question into the space between them. This is a bolder way of communicating the shared responsibility for the EMA and more likely to generate initial resistance, but it is also a better way to communicate that although they are unacceptable and immoral, EMAs can be beneficial for the system. Incidentally, the beneficial effects of an EMA can be seen during the period in which it was a secret. When this stage is concluded, the spouses are well aware of what led up to the EMA and their shared responsibility for it. This is a turning point

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in therapy because it changes the rules of the game (i.e., second-order change). No longer are the spouses an aggressor and a victim; they are two partners who communicated their needs through the EMA. At this point the couple is faced with the option of making a change in their life so that such a painful situation will not recur. This stage can take two or three sessions. Restoring the Relationship

Once the couple accepts responsibility for the affair, it is time to move on to rebuild their relationship in a better way. Two tasks are involved in this process. The first is restoring trust. This is an almost impossible task. The couple needs to realize that a certain amount of distrust will always remain in the system. Recognition of shared responsibility is helpful in restoring trust because both partners cooperate in it. Nonetheless, the hurt and pain caused by the betrayal are highly traumatic. There is no need to ease the trauma; it may serve as a warning signal. (It is much more difficult, if possible at all, to recover from a second case of infidelity after therapy.) The second issue is finding a new balance between stability and excitement. The couple’s first inclination is to go back to the old routine as a way to perpetuate the perception of stability in the relationship. However, that routine was the cause of the EMA. The therapist’s role here is to help the couple establish a practice that balances the two. Countless techniques are available to help spouses accomplish the goal of rebuilding their relationship. My experience tells me that most couples are aware of them but have not found the courage or the need to do so. For example, the couple may decide to schedule mandatory time together (e.g., going dancing together or taking trips). The couple needs to learn that they must keep a balance between routine and excitement and that the major threat to the marriage is slipping back into a boring routine. At this point, when the couple begins working on their new relationship pattern, sessions can be more widely spaced (I usually hold a biweekly session a few times and then every three weeks for another two sessions). At this stage it is time for therapy to end. By now client and therapist feel the need for it. This step can take five or six sessions.

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Ending Therapy and Follow-Up

Ending therapy in cases of infidelity does not need to be worked through in therapy (see chapter 14). The ending of therapy consists of formal steps indicating that the couple is able to continue on their own. The critical time is the follow-up. In this case I use multiple follow-up sessions. The first is usually set for three months after the ending of therapy. At the follow-up session the couple reports on how well they feel with their current relationship, and the therapist inquires about the changes they have made compared with life before the exposure of the EMA. If the spouses report that they feel at ease with their relationship, that their level of openness is comfortable, and that they can communicate about troubling issues tranquilly and calmly, and if they appear to have developed a practice that allows them to balance routine and excitement, then the next follow-up is set for six months thereafter. If the couple reports that they have gone back to the pre-EMA routine or that they still have problems with communication, the therapist needs to decide, with the couple, how to proceed. These decisions may involve a change of therapist or referral to an enrichment program. It may also be possible that working on the EMA has unearthed other problems that need further work or counseling. This step can take three to five sessions. The whole process can take eleven to seventeen sessions, not counting the stage of building trust. The length of this stage depends on the specific couple and can take one to nine months, possibly more.

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12 ADOLESCENT SUICIDE

A chill engulfs the therapist who hears the word “suicide” or the sentence “I want to kill myself.” The mind shifts to emergency mode. Priorities are changed, the wait list is waived, and the person is moved to the front of the line. The removal of the threat becomes the primary goal for the intervention. This is a life-or-death situation that is not taken lightly. We are in a profession that aims to improve life, ease suffering and distress, and make people happy. The idea of suicide sharply contrasts with these goals. As in medicine, we view suicide as a failure, as a breach of our promise to save and improve life. When a child or adolescent threatens suicide, it is even more horrible than an adult making such a decision. For the adolescent, it is different in that once the child comes out of the crisis, options in life will open and there will be hope for a better life. When the child fails to understand and accept this hope, we feel helpless, frustrated, and very sad. When the child attempts suicide and succeeds, everyone feels like a failure. It is very difficult, if not impossible, to justify a child’s or adolescent’s suicide. Obviously our first priority is to prevent suicidal behavior of any kind. However, clients come to us more often after they have attempted suicide, or they tell us about suicidal ideation and plans before they actually make the attempt. To consider suicide as an opportunity or as a functional behavior seems unthinkable, and yet, as we shall see later, it is. Another aspect of the challenge is to determine the implications of assigning positive meaning to a behavior that is consensually negative. Do we encourage dysfunctional behavior because it is functional? Obviously and absolutely not. If we could control reality we would prevent or avoid any 197

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behavior that is destructive, disastrous, painful, or criminal. Because we cannot control life and destiny, we may try to deal with its consequences; we need to look for its positive aspects and try to channel it to avenues that will make life better. SUICIDE

Suicide is the deliberate act of killing oneself. Although the colloquial use of the term is quite clear, a precise definition is more complex. Holinger (1979) and Jessor (1991, 1998) suggest a continuum of behaviors that fit the definition of intentional self-destruction, ranging from the less obvious cigarette smoking, substance abuse, and unprotected sexual activity to reckless driving, self-mutilation, and suicide attempts. Berman, Jobes, and Silverman (2006) analyzed adolescent suicide statistics and found that it is the third leading cause of death (after unintentional injury and homicide). The suicide rate rose between 1950 and 2000 (National Center for Health Statistics 2001). Adolescent girls attempt suicide more than boys, but boys have a higher rate of completed suicide (Bingham et al. 1994). Woods et al. (1997) provide empirical support for the relationship between suicidal ideation or attempts and potentially health-endangering behaviors such as regular tobacco use, lack of seatbelt use, gun carrying, and substance use. Similar findings were reported by Sosin et al. (1995), Orpinas et al. (1995), and King et al. (2001). McIntosh (2000) reports that firearms account for approximately 63 percent of suicides, followed by hanging and poisoning. Drug overdose is used mostly by adolescents attempting suicide. Overdose is most common for adolescent girls and firearms for boys (McIntosh 2000). Suicide is examined from sociological, psychological, genetic, and neurobiological perspectives. Durkheim (1897) argues that suicide results from feelings of alienation (egoistic, altruistic, anomic, and fatalistic). All these types reflect the relationship (or lack of it) between the person and society: the person is not part of society, and he or she is neither connected to nor dependent on it (egotistical). The person may be identified with society to the point where he feels that sacrificing life for the greater good is noble (altruistic, e.g., a war hero). The person may see suicide as a solution to his problem (anomic). A person may regard suicide as a way to free himself from society’s restrictions (fatalistic). The major point is that

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suicide is a relational behavior reflecting the quality of the relationship between the person and society. Suicide may stem from identification with or alienation from society. Petzel and Riddle (1981) propose that adolescent suicide may involve social factors (family conflict, school adjustment, and social relationships) and cognitive factors such as hopelessness, intention, motivation, and conception of death. Joiner (2003, as cited in Berman et al. 2006) contends that suicidal behavior has predisposing elements: a capacity for self-injury, a sense of burdening loved ones, and lack of connectedness to a group or relationships. Kirkcady, Brown, and Siefen (2007) found that schizoid compulsion, anxiety, and depression were the major characteristics of self-injurious behavior. Boden, Fergusson, and Horwood (2007) found that anxiety disorder was the best predictor for attempting suicide. Nrugham, Larsson, and Sund (2008) report that depressive symptoms are associated with suicidal behavior. All these finding suggest that adolescents attempting suicide feel demoralized (Tellegen et al. 2003). Psychodynamic theories (Freud 1917) view suicide as hostility turned inward against the self. Zilboorg (1936) argues that suicide is a manifestation of unconscious hostility combined with lack of capacity to love, and he associates it with the effect of a broken home. Other psychodynamic theorists such as Sullivan, Horney, and Jung view suicide an individual failure to relate to others, a failure in individual growth, or regression toward rebirth, respectively. It can be seen as a resolution for separation–individuation conflicts (Wade 1987). The cognitive–behavior therapy (CBT) approach considers suicide a reaction to helplessness (Brown et al. 2000). Rudd, Joiner, and Rajab (2001) outline CBT-oriented individual therapy with adolescents as aimed at explaining the suicidal behavior (client-specific), emphasizing its transient nature and predisposing pathology, and triggering events in order to help the individual. Richman (1986) sees suicide from a system structural point of view (Minuchin 1974), as resulting from a disruptive family structure: role conflicts, unclear boundaries, failure in communication, and consequent difficulty in accepting change or coping with stress. All this may lead to suicide. Sabbath (1969) sees the suicidal child as an “expendable” child who

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is driven to killing himself by a pathological family system. Wagner (1997) reviews findings indicating that poor parent–child communication, loss of a caregiver (separation or death), and psychopathology of close relatives are all associated with adolescent suicide. However, these are merely correlations that do not support causal relations. The association between stressful life events and suicidal ideation is suggested by several studies (e.g., Cohen-Sandler, Berman, and King 1982; Dubow et al. 1989). Studies also suggest an association with a lack of social support (Dubow et al. 1989; Pfeffer 1989a) and family dysfunction (Fergusson and Lynskey 1995; Joffe, Offord, and Boyle 1988; Orbach 2007). King et al. (2001) found that family difficulties, as manifested in the caretaker’s low satisfaction with the family environment, low parental monitoring, and parental history of psychiatric disorder, were associated with suicidal ideation and attempts, as were negative life events. Unlike King et al. (2001), Dubow et al. (1989) found that marital discord, use of physical discipline, and poor school grades were associated with suicidal ideation and attempts. Fergusson, Woodward, and Horwood (2000) found that socioeconomic adversity, marital disruption, poor parent–child attachment, and exposure to sexual abuse were associated with adolescent suicidal behavior. Family characteristics are the third major risk factor in adolescent suicide and include separation from parents, family history of psychiatric pathology, family history of suicidal behavior, and childhood maltreatment (Stoelb and Chiriboga 1998). The association between conduct disorder, substance abuse, and attempted or completed youth suicide has been demonstrated repeatedly (Shaffer, Gould, and Fisher 1996). These studies provide support for the system viewpoint, which associates a disruptive family environment, manifested by marital discord and difficulties in setting limits and maintaining parental authority (family hierarchy), with disruptive behavior. This may affect the child’s performance in major areas of life, including academic performance, interpersonal relationships, and self-destructive behavior (e.g., conduct disorder, aberrant sexual activity, substance abuse). In the extreme, these lead to suicidal ideation and attempts. King (1997) found that adolescents have the highest ratio of suicide attempts to completion, which can be as high as 800:1 for self-reported attempts and 350:1 for hospitalization (Berman et al. 2006). This may indicate that most of these adolescents do not actually mean to kill themselves. To

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cope with the impending danger, some become model children, and others take a more dangerous and desperate course. King and Apter (1996) and Orbach (1996) suggest that suicidal ideation and attempts can be traced to failures in parental care and concern for the child’s physical well-being. Recent studies of protective measures against suicide threats and other deviant behaviors suggest increased parental monitoring of their children. However, effective parental monitoring is not simply a product of close, active parental surveillance but also reflects a parent–child relationship that facilitates open communication and disclosure by the child (Stattin and Kerr 2000). Jessor (1991, 1998) suggests that orientation toward and involvement in family and community values and activities underlie the various personality and social environmental variables that protect against risk behaviors. These studies provide further support for the importance of the family system in facilitating and preventing suicidal behavior. This issue is so compelling and disturbing that our use of academic, neutral language makes it very difficult sometimes to remember that we deal with human beings. FUNCTIONAL DIALECTIC SYSTEM VIEW OF SUICIDE

The family system approach views suicide as a means to protect and preserve the system (family or society) or to break away from it. However, a decision or wish to terminate life in consequence of the person’s interaction with the familial or societal system indicates how closely the person is connected to the system. It is interesting to note that viewing suicide from a system point of view is not common in research and theory concerning suicide, specifically adolescent suicide (Bongar et al. 2000). A PsycNet search on the term suicide (any field) between 1985 and 2010 yielded 27,432 publications; suicide and adolescence produced 6,917 citations. However, the combination of system theory or family theory and suicide produced no studies. Any reference to family and suicide produced 5,050 citations. These data show that viewing suicide as part of family system theory is quite rare, whereas the association between suicide and the family is well documented. The functional dialectic system (FDS) approach views adolescent suicide in a systemic, interpersonal context. The family system is created to provide for its members’ needs. These needs include stability (order),

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safety, belongingness, and identity. Whenever there is a threat to the integrity of the system (and hence to its ability to provide these needs), family members (especially the identified patient) take measures to maintain or restore the system’s stability. A good number of studies, including those cited earlier, have found that the families of adolescents who attempted or succeeded in suicide were characterized by marital discord, parental separation, death, poor communication, rigidity, conflict avoidance, unclear boundaries, psychiatric disorders, or a history of suicide (Asarnow 1992; Davidson and Linnoila 1990; King et al. 2001; Mitchell and Rosenthal 1992; Pfeffer 1981, 1986, 1989b). These studies support the assertion made earlier with respect to the role of the perceived threat to system integrity. An adolescent facing such a threat, at a time in her life when a stable family is essential, feels the need to do something about it. The adolescent may become a model child as a way to avert blame or may turn to antisocial behavior (e.g., drugs, violence, aggression, juvenile delinquency, promiscuity, school failure, interpersonal difficulties). Suicidal ideation is part of this behavioral repertoire, used to alert the system to a greater danger. A failure to elicit help drives the child to more extreme behaviors, including suicide. The choice of suicide behavior can be based on multiple factors, including family history, publicity, TV, books, music, and movies. The adolescent contemplates suicide as a cry for help, a solution to her misery, anger at significant others, or relief from a feeling of helplessness. The triggering event can be anything that tips the scale. It can be a fight with parents or friends, a failure in school, an offensive remark, a reprimand, or the like. The triggering event is important in elucidating the behavior or pointing to the source of the problem (e.g., family, peers), but in itself it is immaterial. The success of the suicide attempt depends on the seriousness of the intent and measures used (e.g., firearm, drugs, dosage used, time for potential rescue). In most cases success, is actually an accident (unless measures that have an immediate and irreversible effect, such as a firearm or hanging, are used). Despite the common perception of the person committing suicide as disturbed or problematic, I believe that the decision to commit suicide is

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an indication of the strength and bravery of the adolescent and of his caring for his family. The readiness to take your life in your own hands, to go against nature and common attitudes (just imagine climbing over a bridge rail!), attests to the person’s strength. This is an act that most people (even distressed ones) will not perform and fear even thinking about. It also indicates how much the person is part of the system and how important the system is for him, to the extent that he is willing to sacrifice his life for it. Suicide can be viewed as a form of communication, a message from the adolescent who cares about the family and does not want to disappoint it or who wants to change it or punish it. In that case it can be used to facilitate a second-order change in the family. Suicide in the family is an extremely traumatic event. It puts everything in a different perspective. It forces an immediate change in the system. The occurrence of such an event, signifying the end of life, is a cry for help, a plea to change the situation so that life will not be wasted. Its consequences are terrible for the family. It is a failure that nobody can deny. The family is disrupted and broken, and it is impossible to recover. However, when dealt with appropriately, it can be a uniting, renewing, and rehabilitating experience for the family. THERAPY: STRUCTURE AND PROCESS

Reviewing my files, I was astonished to see how many of my clients have struggled with the issue of suicide. Selecting one of them was difficult. Each client was unique in terms of familial context, motive, and function. I decided to choose the most challenging and difficult client. I believe this intervention highlights the major issues involved in working with adolescents who attempt suicide. A few years ago I received a call from a school counselor who told me she wanted to refer a family to me, but she thought she needed to tell me that this was a fine but extremely difficult family. When I asked what she meant by that, she said that outwardly the family was very nice, concerned, and cooperative, but there was a rigid and unrelenting attitude toward the school. They tended to blame the school for everything that happened to their daughter. Before she went further I asked her whether she had permission from the family to talk

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to me. She said she had not yet talked with the family, but she needed to be sure that I would take them on. I asked her not to tell me any more until she got their permission, but I would accept the family for therapy. An hour later the mother, Ilene, called. She sounded distressed and worried. When I scheduled the appointment for three weeks later she burst into tears and told me that this was an emergency because her daughter had threatened to kill herself and had attempted it before. I asked whether they thought about going to the emergency room or getting psychiatric help. Ilene replied that her daughter warned them that if they did that she would certainly kill herself and nothing would stop her. I was intrigued. Was the child (Dana, age seventeen) pushing them to family therapy? I asked whether Dana knew about me. Ilene said that the only thing she told Dana was that I was a clinical psychologist and worked with families. Yes, I told myself, she already knows where the problem is. I rescheduled the meeting for a few days later and asked all family members to be present. Ilene asked whether it would be enough for just her and her husband to come with Dana, but I was insistent, and she promised to bring them all. The family came to the intake session together. The father, Jason, fifty-five years old, was an executive of a software startup company. The mother, Ilene, fifty-five, was a homemaker and an honors college graduate. Jeff, twenty-five, was a sociology senior at a nearby university. Hannah, twenty-one, was a mathematics sophomore at the same university. Dana, seventeen, was a senior high school student. Jason had been in high-tech even before he graduated as an electrical engineer from a reputable university. He had worked very hard and for long hours since then. He became friends with Ilene during college, and they married after graduation. Because Jason was working so hard and his career looked so promising, they decided to postpone having kids, and Ilene decided that she did not want a career of her own. Later, after Jeff was born, she decided to stay home so that their children would experience having their parents present in their lives. She said she had felt good about it because it enabled her to spend so much time with the kids. But recently, when Dana was about to graduate from high school, she began thinking about a career (Jason sneered at this point). Jeff was doing very well in his field. He chose sociology because he did not want to study anything related to computers, like his father, and said that

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seeing his father he could not understand what was so rewarding about a job that takes you away from home and gives you no chance to enjoy life. Jason responded that this was incorrect: he traveled around the globe and did things he liked, and he enjoyed solving all the programming and design problems he had dealt with over the years. Hannah corrected him at once: true, he traveled all over the globe, but because he stayed in those places for a short time and for work only, he didn’t actually see or enjoy anything. Hannah also enjoyed what she did and wanted to work with her father in his company and “develop new and interesting things.” Dana looked bored all this time and said, when her turn came, that she was bored with school, she didn’t want to be there, she was not a good student and didn’t want to be one, and she didn’t need to be one if she was going to end up dead sooner or later anyway. Her last suicide attempt, which brought the family in, “was not serious” because she took some pills but not enough (according to Dana’s report) to cause serious harm, and she did it because she felt “bored.” After she said that, the office was dead silent. Nobody uttered a word. Everybody stared at Dana incredulously. Jason was the first to snap out of it, and he told Dana that she was really crazy if she wanted to kill herself out of boredom. Ilene looked at Dana, and the anger she was trying to control was evident on her face. The siblings looked at her with dismay. hannah: I don’t believe you; you are too smart and clever to think that way. You want to shock us, and you’ve succeeded wonderfully. jeff: If you want to say something, why don’t you say it straight out? [Dana did not respond and just sat sullenly.] jeff [turning to me]: This is not the first time. She tried to kill herself twice before. ilene [immediately responding]: That’s not true; the first time she just swallowed aspirin! The second time she tried to cut her wrist with a Japanese knife, and we had to take her to the hospital, but that wasn’t very serious either. jason: She just wants to get attention and get off school legitimately. hannah: Everybody knows she doesn’t like to study, and she doesn’t need to do anything to prove it. School has already given up on her! I kept silent. I was aware of the latest suicide attempt and the previous ones. I heard the exchange and was perturbed by the intense denial Jason and Ilene used, and I was afraid that Dana would interpret this as a lack of

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caring on their part. I was acutely aware of the intellectual, seemingly cold, detached, and somewhat cynical approach Jason took and the immense fear Ilene felt, which was translated into her attempt to downplay the danger. Clearly, something had to be done, and the danger of further suicide attempts loomed. What should I do? Start by contracting with respect to the suicide? Put it aside until the problem definition became clearer and see whether there was a point where the dialectic functional meaning of the attempt became evident? Was there a dialectic meaning to a wish to die? Did I have a good enough joining even to bring it up? What would happen if my timing proved wrong? I was fearful almost to the point of immobility. But they sat there, and I felt I needed to say something. In fact, I said nothing for a few more minutes. Then I decided I had to test the joining before going anywhere else. moshe [turning to Jason]: I heard you saying that you think Dana is trying to get attention and leave school. Did I hear it right? jason: Yes, you heard me right; she wants to get her friends’ attention so she will be the star of the group. hannah: Dad!!! ilene: She always needed to be at the center. jeff: You’re crazy, all of you. What are you talking about? She tried to kill herself! moshe: I’m impressed by how much you care about Dana. It’s frightening to think that she really wanted to kill herself. I know you try very hard to understand it, and it’s very hard when Dana doesn’t cooperate. I believe Dana cares a lot about you [Dana curtly dismissed me]. I believe that Dana wants to live very much. I also believe that Dana is trying to do and say something through the attempts, and I’m afraid she’s not being listened to, or she’s not understood the way she intended. My intervention appeared out of place and context, but it changed the course of the session because I introduced an FDS element that made them stop and rethink. jeff: What do you think she wants to tell us? [He turned to Dana.] Is he right? Do you want to say something that we don’t hear? jason: She doesn’t want anything but to cause us pain. I don’t understand it at all; it doesn’t make any sense, to kill yourself so people will hear you. Maybe they’ll hear, but you’ll be dead and not hear it yourself!

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moshe: How do you explain the fact that Dana planned these attempts so that she would not die and you would have ample time to save her? jason [He looked at me, and for the first time I saw a look of appreciation in his eyes.]: If you’re right, what do you think she wanted? moshe: Why don’t you ask her? dana: I don’t want to talk to him. I’m bored, and can we leave now? I’ve got something to do at home. moshe: I feel how frustrated you are. It’s very difficult when you want to say something and nobody seems to hear you. dana: It’ll never work; they don’t hear anybody but themselves. hannah: You mean Dad and Mom? dana: I don’t want to talk about it. moshe [turning to Jeff and Hannah]: Do you have the same experience? hannah: It’s true that Dad is very busy and doesn’t have much time for us, but with the job he has, what else can he do? jeff: You learn to do things on your own. I think I felt that I needed to do things by myself very early in life. ilene: Right. He made his own bed when he was four years old. This response revealed that Dana was right. The parents did not show a lot of empathy for their kids and expected them to grow up fast. That was odd because Ilene said she dedicated herself to raising them. So did Dana want to kill herself so she could live her life like every other child? So that her parents would care for her and show it? Would it let her be a child and not make her independent so quickly? If so, why wait so long and do it so intensely? Was it possible that there was another function to her cry? It seemed that I needed to learn more about the familial situation. moshe [to the parents]: Dana is almost at the age when she is expected to leave home. Can you envision your life with Dana out of the house? jason: Why should it be different? What are you getting at? ilene: You mean that we will not need to worry about Dana? moshe: Not really. What I had in mind is how will the two of you get by when Dana is out of the house? ilene: I don’t see Jason making any changes. I’ll probably look for a job. moshe: Have you given a lot of thought to that? ilene: No. I have other things to worry about [looking in Dana’s direction].

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hannah: I believe she’ll go crazy with Dad away so much. And besides, I’m not sure they still have much in common. Hannah’s remark supported my assumption about the parents’ marital difficulties. I needed to expand on that and see where it was going. The suicide attempt seemed to lose some of its urgency at this point. moshe: I heard you saying that you don’t believe your parents have much in common now. jason: What are you talking about? We’ve been together since we were in high school! ilene: It’s true that Jason is away most of the time, but he may change as we grow older. jeff: You’re naïve; don’t you see that his work is the center of his life? jason: No, you are the most important ones. hannah: Yes, I still remember the time I had a car accident, and you couldn’t get away from a meeting to help me! At this point, they began shouting and crying, which conveyed feelings of neglect and abandonment. Ilene was silent and then began crying soundlessly. moshe [to Ilene]: It’s very hard for you to listen to the kids’ pain. ilene: I feel the same way, as if I’m all alone and dying. That was a sad and painful statement. The mention of death turned attention back to Dana. Everyone was silent at this point. moshe: It’s very difficult to hear you mentioning death. It is like Dana telling you how you feel. ilene [nodding but not speaking]. moshe: Dana seems to tell you that you need to do something if you want to live. dana [suddenly sat up, looked around]: This is all a piece of crap. I don’t care about her. She can be lonely for the rest of her life. Who cares? moshe: You care, and you care so much that you were willing to do something about it, even if it cost you dearly. jeff: Are you telling us that Dana did what she did in order to tell Mom that she needs to do something so Mom can live differently? That’s hard to believe. hannah: I know it sounds crazy, but when was the last time we had a family discussion about anything? jeff: Never, you know that.

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hannah: See, it’s because of Dana that we sit here and talk about our relationships. jason: I don’t like it. Can we discuss this at home? hannah: No, we can’t do it at home. See how hard it is for you even to admit we have a problem? jason [to Ilene]: Do you really think we have a problem? I think Dana has a big problem, and we should concentrate on that. ilene: I think the kids are right. We do have a problem, although I’m not sure what it is. The rest of the session was devoted to definition of the family problem. The family problem was consensually (except by Dana, who sat quietly throughout the discussion) defined as a communication problem. They never talked about issues; they could not express their emotions, fearing that their parents would not be able to take it. Nobody talked about the parents’ marital problem, and neither did I. I thought that the highest priority was to change the problem definition from suicide to something else, believing that later we could focus on the parents. I was also afraid that if we focused on the parents at this point, they would not cooperate and would drop out of therapy. At this point I turned to Dana. moshe: I think you did a great job in bringing the family in. I believe that without you it would have been more difficult for everyone. Don’t you agree? dana: I think you don’t know what you are talking about. I don’t want to be at school, and I would like to leave home. I don’t care about them. moshe: I understand you. You say you don’t care about anybody, and all you want is to get out of school and home. dana: Exactly. moshe: Can we talk about how you do it at the next session? It’s getting late, and I think you deserve the time and attention to plan these things. dana: You think they’ll let me? moshe: I believe we can talk about it. [Turning to the parents] Would you agree with that? [Ilene nodded affirmatively, but Jason did not respond.] dana: You see, Dad isn’t ready. jason: I think you have other problems that you need to work out before you leave home. It was getting late. I was already late for the next client, and Jason had

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opened a new can of worms. I could not end the session without some closure for Dana; otherwise, we took the risk of another manipulative attempt. I told the family that we needed to continue the session, and I needed to let the next client know that we were running late. I exited to the waiting area and told the client that I had an emergency and she would have to wait. The client agreed to wait, and I returned to the session. In the meantime, they were able to tell each other how important the session was and that they needed to continue. Dana said she would not come if her father kept saying she had problems. jason: I still think you have problems, but I agree that we need to talk about our relationship. I’m ready to come to the next session. moshe: I want to make sure you understand that the issue we’ll talk about next time is the family relationship. [Everybody nodded in affirmation.] moshe [to Dana]: Do you agree not to do anything that endangers your life while we are in therapy? I would like you to have my phone number so you can call me even if you just begin thinking about doing anything; is that okay? Do we have an agreement? [Dana nodded affirmatively and stood up.] On their way out, on the doorstep, Dana led the way out. Jason turned to me and said quietly, “I think she needs individual therapy.” Dana looked back very angrily and said, “He didn’t get anything!” and ran off. I stood at the door feeling numb, angry, and very sad. I looked at Jason and said, “I think you should watch Dana very carefully. She’s not sure the message that you have a family problem has sunk in, and I’m terribly afraid she will do something. I urge you to watch her very closely and give me a call if anything happens.” I am sure it was very difficult for them to hear this. I could not sleep at night worrying about Dana. I decided to call in the morning to make sure everything was all right and to make sure they were taking my warning seriously. Unfortunately, I did not have to. Their call came at 7:00 a.m., and it was from the emergency room. Jason told me that Dana had made another suicide attempt and swallowed a large number of acetaminophen tablets. They were worried about possible liver damage. I expressed my sympathy and sadness and pointed out that, fortunately and deliberately, Dana did not use lethal means. I asked them to call me when they were discharged so we could make a new appointment. They called three hours later from home, and we agreed to meet at the set time because it was only three days hence.

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They all came together and on time. Their faces conveyed no worry. They entered cheerfully, including Dana, and sat in their places. The only change was that Dana placed herself nearer to her siblings. After inquiring how they felt I asked, “Tell me what happened.” jason: After we got back home we sat for dinner and talked about the session and why Dana did what she did, and everybody was telling me how dreadful I was in the meeting. jeff: Not dreadful, just insensitive. jason: Anyway, we watched TV and Dana went to her room. She turned on her sound system, and at that time it was okay. But after a while, when we went to bed and the house became quiet, it was very loud, so I went in to ask her to lower the volume. She was lying on the sofa, very pale. I got alarmed and tried to wake her, but I couldn’t. I immediately carried her to my car and drove to the ER, and the others followed me. We were seen immediately after I told them I suspected a suicide attempt. The doctor told us that they pumped her stomach and that she swallowed a large number of pills. We didn’t know what kind of pills since we have none in the house after the previous attempts. After a while they told us it was Tylenol, and she was in no danger, but they needed to run tests to check liver functions. The tests indicated that there was no damage, and they sent us home after we told them we were in therapy. I empathized with their fear and alarm and reflected how calm they looked. hannah: We talked about it while we were waiting at the ER and decided Dana was trying to teach Dad a lesson after he said that she needed individual therapy and because she didn’t use anything lethal. And after you suggested that she could have been sending a message this way, we figured that was what she was doing. Dad went to her and said he was sorry for not understanding what she meant. moshe [to Dana]: Is this how you read it? dana: Yes, he didn’t listen! He always thinks I’m the problem. From this point on, the session went on to discuss other issues, and the suicide attempt never appeared again. It was as if it served its purpose and was no longer needed. The family was able to discuss how close they wanted to be, and they were sorry they had missed the chance to be closer earlier. Now that they were going their separate ways, they had to set new priorities for themselves.

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Two sessions later the discussion turned to the marital relationship. Hannah brought it up, and she asked her mom why she had not made a career of her own. Ilene talked about devoting herself to Jason’s career and child rearing but also said she felt sorry for not pursuing her own interests because now she felt very lonely. She had very few friends and nothing to do. I pointed out how much she cared for Jason and how much he cared for her. At this point Jeff turned to me and asked, “I understand the first part, but how do you figure Dad’s caring for Mom?” ilene: I don’t think he cares as much about me as he cares about his job. I think he’s married to his job, not to me. That’s what makes me so miserable, that I don’t feel appreciated at all. jason: I always told you to do something with yourself. Don’t blame me for not doing anything! ilene [to Moshe]: I think we have things to discuss, and I am not sure the kids should be part of it. jeff: Thank God, I never thought you would come to this. I certainly agree. hannah: I also think you need to discuss your things without us. dana: I don’t believe they can do it. They could, and they did. The ensuing sessions included only Jason and Ilene. The sessions began with the history of their relationship. They were high school sweethearts and married early. Both were in college during the first years of their marriage and had severe financial problems. Jason worked at odd jobs to support them. After graduation Jason joined a high-tech startup company, and from that point on he spent many hours at work. The couple grew apart over time. Ilene felt neglected, unappreciated, and mostly lonely. She felt sullen and bitter, and this led to further distancing. The distance appeared to be functional for both of them. Jason was permitted to focus on his career, and his absence from home helped them avoid conflicts (his career and the monetary benefits became overridingly important). Ilene felt lonely but used the distance in order to avoid closeness, intimacy, and sexual relations, which were quite unsatisfactory for her. Also, nurturing her anger helped her overcome her disappointment over missed career opportunities. It also gave her more time with the children, which helped alleviate her loneliness. Both had difficulty with intimate relationships. The underlying fear of each was of losing their identity (Jason was afraid that being close to Ilene would

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necessitate giving up his career, and Ilene was afraid that getting closer to Jason would lead to her losing her identity). This process took about three sessions. In the fourth session Ilene asked me, “In one of the first sessions you mentioned that Dana wanted to give me life by attempting suicide. It sounded crazy to me then, but can you tell me now what you meant?” moshe: Yes. I don’t think Dana really wanted to kill herself. She wanted to draw your attention to a question we often ask when we encounter death and dying: was it worth it? Life is so short and can end so quickly; do I really live it? What will I say to myself when my time comes? Did I live my life well, or did I waste it? [This line of thought usually leads to a reevaluation of our priorities, although not necessarily to a behavioral change.] ilene: This is exactly what I thought after each of her attempts, but I never followed it through. moshe: And? ilene: I think she’s right. I need to do something with myself. But isn’t it too late? I’m quite old to begin working. jason: Why do you need to work? You can volunteer somewhere. ilene: I also want a career. It’s time I took care of myself and did something I’m good at. Jason did not want to change the situation. Apparently any change was threatening for him because he was aware that it would require a change on his part. He felt this way even though it was clear to him that Dana and all of them would have to pay the price for it. Consequently, Ilene became more assertive and took steps to find a job. Surprisingly, she found a job as executive assistant to a company CEO. Jason accepted the change with no overt resistance, and he even seemed to enjoy Ilene’s success. The next phase, in my opinion, was to keep working on their relationship and improve their level of intimacy. Jason and Ilene did not see it this way and said that the atmosphere at home had improved dramatically. The family met every weekend, and they talked to each other. Dana was still in school and doing better, and they all agreed that she needed to find a place of her own outside the parents’ house and probably go to college. I asked only that we meet together with the kids to sum up treatment. They gladly agreed. A week later they all came for the last session. They smiled as they entered

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the office as if I were a close relative. They sat in the places they had sat in during the intake, but closer together. They reported that their relationship had improved, and the atmosphere at home was quite pleasant. They did not feel overly close to each other, but they were closer than they had been before therapy. They tried to meet once a week or so for dinner, and Dana joined in. Dana said that she was back at school and intended to graduate, go to college, and get out of the house. I asked the family how they viewed Dana’s past behavior. They all agreed that her behavior served as a message for all to shape up and change their ways. They thought that she was extremely successful in this, but they would have felt better if she had done things differently, without the suicide attempts and the damage and injury that Dana took upon herself. Jason even thanked Dana for what she had done, and he expressed regret that they needed to have such a traumatic experience in order to make a change that was beneficial for everybody. Follow-up was done informally in this case. Dana came back to see me six months later when she experienced a crisis in her relationship with her new (and first) boyfriend. She came for consultation and said she had talked with her parents but was afraid they still remembered the suicide attempts and were too afraid to offer her sound advice. She wanted to hear my opinion. Apparently, she was able to evaluate her relationship in a mature way and decided that even though she liked her boyfriend, he was not mature enough to provide her with a shoulder she could lean on and was too dependent on her. She told me she believed she needed someone more mature, whom she could rely on and who could support her emotionally when she felt low. I commended her on the way she handled her relationship and told her she was doing it so appropriately that I was not sure what she really wanted from me. I suggested that she might have come to tell me that she did not need help. She said that she had indeed come to make sure she did not need me, and she reported that the family was doing very well and that her mother was very successful in her new job; her parents were planning a long trip to South America. This case illustrates the advantage of FDS very well. The symptom was highly functional for the family in terms of bringing them to therapy and facilitating change. The dialectic meaning of suicide as a life-directing and enhancing message was accepted by Ilene and the family, and it expedited

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a second-order change. I believe that using FDS helped reduce the fear and anxiety over the threat of suicide and then helped the family look at the communicative aspect of the suicidal behavior. Their ability to relate to the positive and functional aspects helped them avoid stigmatizing Dana as the identified patient or scapegoat and made her the facilitator of a muchdesired cohesive process that helped each member redefine herself or himself. This led to improvement in the relationships between all of them and to a highly stable change.

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13 ENRICHMENT AND FACILITATION OF THERAPY The functional dialectic system’s construal of reality is not trivial and may be counterintuitive. Rarely do we find ourselves in a situation where we need to attend to the complexity of an issue and to the myriad possibilities emanating from extending and expanding our view of the issues. In fact, we often try to shy away from situations that appear complex, and we fear that they may complicate our lives. We usually leave the complex and complicated views to the experts. Only in times of dire need or when we are challenged do we resort to complex thinking. We want our world to be as simple as possible and avoid complications as much as we possibly can. The reason for this is simple and consistent with our expectations of our world: we want it to be simply ordered so that predictions will be easy to make and we will have a sense of control of our lives. Complex, multifaceted thinking threatens this simplicity and generates an element of uncertainty and insecurity. We have developed mental shortcuts to ensure the desired simplicity (e.g., stereotypes, beliefs). These heuristics affect our attitudes, perceptions, emotions, and behavior. People maintain these attitudes as a way of ensuring their own positive sense of self (“I am correct” or “You are the bad person”) by devaluing the other, holding her responsible for the problems, or portraying her as incompetent (Moskowitz 2005). Moreover, they tend to be self-preserving, like self-fulfilling prophecies (Pomerantz and Dong 2006). We see others in a certain way and expect them to behave accordingly. When they do, it reconfirms and reinforces our initial attitude. When they do not behave according to our expectations, we prefer not to change our 217

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attitude but to explain their behavior in a way that keeps the initial belief intact (cognitive dissonance; Festinger 1957, 1964). People facing the necessity to change their attitudes usually are not willing to spend the energy needed for an optimal and probably better evaluation of the issue (Wegner and Carlson 2005). Attitude change comes only as a last resort. In fact, the willingness to change one’s attitude is moderated by people’s motivation to process information not necessarily congruent with their initial beliefs and attitudes (Wegner and Carlson 2005) or the authority of the source for change (Jordan 1953; Osgood and Tennenbaum 1955), among other variables. When people come to therapy they usually hold nonadaptive beliefs and attitudes. However, they are willing and motivated to change their attitudes. (Obviously, we need to take into account the phenomenon of resistance, which involves reluctance to change attitudes so as to block the process of therapy and avoid making changes in life for the reason indicated earlier.) As they are introduced to the therapist’s way of thinking or therapeutic approach, the clients can be helped in making that change (Frank 1973). The client’s changed view of reality helps put life back on track and makes it more meaningful and presumably more controlled. Thus, the functional dialectic system approach offers clients, and people in general, the opportunity to expand their negative view of their world in a richer, more varied, and optimistic way. The dialectic method is an easy way of changing one’s attitudes and beliefs about anything. But it is a skill that needs to be learned and practiced in order to be useful. To help master this skill, in therapy or in everyday life, the functional dialectic system approach offers a number of useful techniques. The advantage of the dialectic approach is that it enables people who have no theoretical knowledge of the issue to speculate and inquire about it. An interesting study was recently completed by Samai and Almagor (2011), who asked participants in the study to write down their definition of depression. Earlier they had completed a questionnaire measuring anxiety and well-being. After the description, the participants were given a short description of dialectic thinking and were asked to write their definition of depression once again. This time the description included significantly more positive statements. They were tested again at one-week and two-week intervals. The findings indicated that the change occurring

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at the end of the experiment lasted until the last measurement. Introducing dialectic thinking resulted in a change in attitude, manifested in the change of the participants’ views of depression. In therapy such an effect is even more pronounced because the therapist continues using dialectic thinking throughout therapy. The art of dialectic dialogue began with Socrates. He believed that through the process of dialogue, in which participants are forced to clarify their ideas, the meaning of the issue under discussion will come out. The continued dialogue ensures a process of correction and clarification that will bring out the truth. Therefore, some dialogues may end inconclusively (http://www.studyguide.org/socratic_seminar.htm). Although I have reservations about finding the truth, I do believe that uncovering different meanings, sometimes conflicting and discordant, is important for a more comprehensive understanding of the issue. The dialectic dialogue can be used to improve communication and understanding between people and gain a better understanding of their behavior. Furthermore, the use of the dialectic method, in the form of a dialogue or a monologue, facilitates better understanding of the problem the person deals with and can help both client and therapist in exploring and defining the problem to be worked on in therapy. THE DIALECTIC DIALOGUE: EXERCISES

The following exercises are designed for couples or people who want to learn the skill of dialectic thinking.1 They are designed mostly as dyadic assignments, but they can be done individually as well. When dyadic work seems inappropriate, the couple or family members can work individually and compare notes after completing the exercise or share it with the therapist in the session. The therapist is able then to help the clients see the similarities and differences in their views and use the exercise to gain understanding of the problem. To make the practice more enjoyable, I organize it hierarchically in terms of how personally close or emotionally laden the issues are. The first step relates to intellectual, impersonal issues, the next is interpersonal issues related to other people, and then interpersonal issues related to the couple. This way the practice begins as an impersonal, intellectual exercise and moves on to more personal and emotionally loaded issues. However,

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this order is not mandatory, and the exercises can be assigned in a different order or independently, as seems appropriate. These exercises can be done individually even though, as stated, the preferable mode is a couple or even a family or group setting. Working on these exercises imparts the skill to clients and also enables them to use it as an aid to understanding the difficulty and the goals of the intervention. The ability to see both sides of the coin allows identification of the source of the problem and also suggests the course for change. Exercise 1: An Impersonal and Intellectual Issue

Step 1: Choose a topic for discussion. It can be drawn from newspaper articles, books, and the like. However, it is important that neither partner feels strongly about the issue. Step 2: With the flip of a coin one partner is elected to begin with the negative or the positive pole and to discuss, for five minutes, these aspects of the issue. The other partner may help in identifying more points or elaborating the points mentioned. When this step is completed, it is advisable to write down the main points in a table. It has two columns, one for the negative and the other for the positive aspects. Step 3: The other partner discusses the positive or negative aspects of the chosen issue in the same way, and the appropriate column in the table is filled out. When this exercise is repeated, the roles and the order (who begins and which pole) are reversed. An Example The couple sits in the living room watching TV and decides to discuss Hurricane Katrina. Hurricane Katrina struck New Orleans in 2006. The devastation was enormous: thousands of people fled their homes, a vast number of houses were flooded and destroyed, and masses of people were relocated and unable to return home for a long time. The hurricane had been expected, and there should have been enough time to prepare for it. Still, it struck as if without warning, and help and support came very late. Most of the devastation occurred because the levees did not hold, and most

Negative

Positive

Destruction.

An opportunity to rebuild a poor neighborhood.

People dying.

An opportunity to show care and support. Feeling alive.

Helplessness and hopelessness.

The anguish prompted better and speedier help. There is vast room for improvement.

Financial loss.

An opportunity for rebuilding, renovating, creating new businesses. A second chance.

Neglect of human life.

There was a dire need to rethink the way people are treated and looked on, in view of the need to see them as equal human beings.

Loss of face for a democratic, caring country.

May lead to a more modest view of self.

Once again, the poor suffer. Examples of Dialectical Meaning.

of the damage was concentrated in areas close to the destroyed levees, where mostly poor people lived. One partner begins with negative pole, and then the other continues with the positive pole. The various points made are summarized in the figure above. Clearly, although Hurricane Katrina was a monstrous disaster, it highlighted some issues that carried positive consequences. These, when acknowledged, mitigate some of the negative aspects of the situation and add an optimistic element to it. Exercise 2: Interpersonal Issue—Others

Offering help and advice to other people is entirely different from actually experiencing the given issue. Helping or advising others puts the helper in an external, objective position, uninvolved and free of responsibility for the help and its consequences. However, the advice and help can be highly

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valuable to the person being helped. This person may have difficulty seeing or attending to various aspects of the situation or the issue because of his or her involvement. Accordingly, the following exercise is designed to deal with issues relating to and involving other people, where the practicing partners are merely observers. The exercise can be done in one of two ways: •

•

The partners can discuss an event or an issue pertaining to people they know (e.g., divorce, marriage). The discussion will then follow the steps outlined in Exercise 1. While being with a group of people who discuss an issue, one can play devil’s advocate and present the dialectic pole of the issue under discussion. Then the person can sit back and watch (and perhaps even enjoy) how the discussion continues.

An Example Abortion is a highly controversial and a hotly debated issue. In a group of people who mostly share the same view (e.g., they support abortion rights), you can present the opposing view (in a polite, respectful, yet assertive manner). Then you can sit by and watch how your different view affects the conversation. Exercise 3: Personal—Emotional

After completing the first two exercises a number of times, or when the couple thinks they have mastered the principles of the dialectic dialogue, they are ready to deal with more personal, emotionally laden issues. This exercise can be done by the couple or individually. When they do it individually, the partners can share it or bring it to the next session and share it with the therapist. The procedure is the same as in Exercise 1. The couple face each other, choose an issue, and decide who begins and with which pole. Example 1: Adolescent Child’s Behavior

The boy has just turned fifteen and manifested a sudden change in behavior. There have been many more arguments and more intense fighting

Negative

Positive

He hates us.

He tries to establish his own identity by opposing us.

He does not respect us.

He challenges our belief system to test how strongly we adhere to it.

He does not like spending time with us.

He wants to try new things in order to learn more about himself.

We may lose him.

The fact that he is still at home indicates he does not want to leave home.

He may get into drugs.

He is trying to assert himself among his peers.

He leaves us.

The fact that he is defiant and uses us as a model indicates how important we are for him.

His friends are more important.

We are working as team to help our child.

He does not care anymore. Examples of Dialectical Meaning (Negative Turns Positive).

over almost every issue: school performance, attitude toward authority figures (e.g., teachers), household chores, curfew, challenging of parents’ moral behavior (actually, the discrepancy between their behavior and moral values), unwillingness to take part in family activities, spending too much time in his room with music blaring, smoking, and a generally defiant, sullen attitude. The parents become extremely worried and share their fears with their son, who tells them not to worry because he does not do drugs, steal, or do anything else against the law, so they should leave him alone. The parents sit together and try to shed light on their child’s behavior (see above figure). Having compiled the list, the parents are able to express their fears and then check them using the dialectic approach. Their anxiety has decreased because they became aware of the possibility that their son’s behavior might reveal something positive about him.

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Example 2: Marital Problems

The couple has been fighting for quite some time. The fighting involves much shouting and some verbal abuse (cursing, below-the-belt remarks) but no more than that. The couple decides that it bothers them, and they need to think and discuss it. Using the dialectic dialogue, they sit together and begin the exercise shown in the figure on the facing page. This list suggests to the couple that the fights have a function for them. They are based on feelings of security and mutual trust. Therefore, they allow themselves to fight. It is also a way of trying to convey something they cannot do differently, and they need to figure out what it is. If the couple decides to use the dialectic dialogue to explore this problem, they can ask themselves the following questions: • • • •

When do we fight? What will happen if we do not fight? What will we do instead? What will happen if we become very close to each other? What is so frightening about closeness that we try so hard to avoid it?

The answers to these questions are likely to help them identify the underlying source of the fighting, and then they can decide how they would like to go about eliminating it. These exercises can be given parallel to the sessions as homework assignments, and the couple’s responses, difficulties, and successes can be described or used in the session. As in working with a behavioral hierarchy, the transition from one step to the next is based on the client’s success in dealing with previous steps. When a difficulty is experienced in some of the advanced steps, the couple can go back to a previous successfully completed step and repeat it until they feel comfortable and ready to move to the next one. Exercise 4: A Couple in Crisis

When a couple is in crisis, it is not always effective to use a dialectic dialogue. If the spouses are unable or unwilling to do it together, they can do it individually. In this case they bring their assignment to therapy, and the therapist can use it to help the couple identify their difficulties and the

Positive

Negative

We feel very secure and safe, so we can allow ourselves to put some distance between us.

My spouse hates me.

We need more personal space.

My spouse does not respect me.

We endure tension that we bring home and need to vent it.

My spouse does not want to be with me.

Home is a safe place.

My spouse is getting more distant and difficult to communicate with.

We try to say something that we cannot say in any other way.

I may lose my spouse.

We are sitting together in an attempt to solve the problem; we are together.

My spouse may leave me.

No sex tonight. Examples of Dialectical Meaning (Positive Turns Negative).

things that are common and that unite them. In this case I refer to the task as a dialectic monologue. Each spouse sits alone in a quiet place and answers for himself or herself the following questions: • • • •

What is the best possible situation I would like to be in? What is the worst situation I can be in? Between these two points, where would I position myself now? What is the smallest step I can take in order to move from where I am to where I want to be? Now that I have considered this step, can I double it?

In the next session, the therapist can ask who did the exercise and whether that person is ready to share it with the other. If they have not done it, the therapist can encourage them to do it. They may not yet be ready for it, but they will be in a few sessions. If they are willing to share, this may mean that the partners have made some strides in the right directions (of course, the contents of the response must be checked first).

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FACILITATING DIALECTICS: FAMILY SCULPTING

Another technique, family sculpting, can be used to explore the dialectic meaning of relationships and situations. Family sculpting is a nonverbal portrayal of family relationships and roles in a physical space (Bischof and Helmke 2005; Constantine 1978; Duhl, Kantor, and Duhl 1973; Papp, Silverstein, and Carter 1973). The physical space is used as a metaphor for family relationships. The concept of boundaries extends beyond physical features (e.g., the skin) to emotional ones. People tend to define a territory that forms a space around them. Any violation of this space creates unpleasant feelings and a tendency to reestablish distance. The size of this space depends on several factors: the level of closeness with other people (the more intimate the relationship, the smaller the preferred space), the affective state of the person (some people, when they feel sad or blue, prefer either more or less interpersonal space than when they are in a different mood), the physical situation (the physical space, e.g., elevator, crowd), and the characteristics of the other person (e.g., cold or warm, attractive). The sensitivity of interpersonal space to emotional states makes it an excellent metaphor for the quality of relationship in the family. When family members feel close they will try to reduce the space, but when they feel negatively about each other they will try to increase it. This is one of the best techniques to allow both client and therapist experientially to view the dialectic meaning of behavior. In sculpting, the dialectic relationships can be acted out. Family members are asked to sculpt the situation as they see it. However, the way they see it also conveys the dialectic meaning of that situation. Sculpting is done mostly with families but can also be applied to couples. Each participant is requested to position the other participants anywhere in the clinic, in any posture she wants, and expressing any mood she feels is appropriate. After everybody is situated, she is asked whether she is satisfied with the product. If the answer is positive, the person is asked to position herself in the sculpture. The addition of the emotional posture to the sculpture is rooted in psychodrama (Moreno 1946) and hence represents a scene in the family relationship. The sculpting is usually done at the clinic and requires some space. During the process, the therapist stays at the sculptor’s side, taking notes on the various arrangements. After everyone completes the tasks, the participants

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discuss the sculptures they have seen and try to draw conclusions and gain insight into the reason for a particular sculpture or for the common theme appearing in the various designs. Who will go first? I usually ask for volunteers, and the first to offer is the first to go. Otherwise, the decision is based on gut feelings, with no clear rule as to who begins. L’Abate, Ganahl, and Hansen (1986) suggest that it is preferable not to choose parents to begin the sculpting so that they will not limit the children in later sculpture. It is my experience that the first sculpture sets the tone for the others, and often the successive sculptures constitute a dialogue with the first one. For example, if the first sculpture depicts a highly negative interaction between family members, others may try to moderate this presentation (e.g., in an attempt to protect the parents). A friend of mine asked me to see one of his colleagues, who was having marital problems, and added that this colleague has had a long experience in individual therapy with the best therapists. I agreed, and he called me almost immediately and we set up a time; then I asked whether there were other family members, and he replied that they had three children. I asked him to bring everybody for the first session. He asked whether this was necessary, and I said that I thought the more information we could get, the more effective the intervention would be. He doubted this and said, “If you insist; nobody has ever asked for that.” The family came for the first session: father, Isaac, fifty-four years old, second marriage; mother, Louise, forty-eight, first marriage; Ron, sixteen, high school sophomore; Kathy, fourteen, junior high; and David, twelve. When asked about the reason for coming, they all described their family as the perfect family where everybody was free to do and be whatever he or she wanted, and the parents were caring and permissive. I decided to try the family sculpture, and David volunteered to go first. He decided that they would be on a bus. He reserved the front seat for the driver. He put his siblings in the second row and his parents in the third row. I asked him whether he was satisfied with the arrangement, and he said yes, so I asked him to position himself in the sculpture. He placed himself in a row between his siblings and his parents. Amazingly, everybody else accepted the bus situation and made only minor changes in the seating arrangements. They all left the driver’s seat free, and

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everybody positioned the parents at the rear of the bus. After the various sculptures were completed, I asked them why they chose the bus situation. The response was that this was the only way to keep everybody together. (This meant, of course, that they were not together, they didn’t feel together, and there was nobody who wanted them to be together. Actually, they had to be forced to be together.) Then I asked whether they noticed that there was no driver in the bus. They looked at me in surprise. Apparently nobody noticed that there was no driver! It did not take long to figure out that the parents were too busy with their own lives and difficulties and did not play a significant part in their children’s lives. This sparked anger, hurt, and pain when the children expressed their fears about their parents’ marital discord. The parents were astonished to learn how much the children knew about their problems. By the end of the session it was very clear to the parents that marital therapy was indicated, so a contract was made for couple therapy. Couple therapy took almost two years and was very difficult. The spouses struggled hard with their fear of intimacy and rejection, but after that the relationship appeared to be very good, and we gladly agreed this was the time to end therapy. I asked again for the whole family to come to that session so we would end at the point where we had begun. They all came and looked quite happy. I asked them to do the family sculpture again. Louise was the first to go. She positioned Isaac outside my office and the kids around herself, hugging her while she was at the center. When this was done Isaac asked her why she put him outside, and Louise answered, “Maybe I don’t want you in my life.” Stunned silence. Nobody said anything. After a very long silence Isaac said, “It seems that we have nothing more to talk about,” and he stormed out. I sat there shocked, not knowing what to do or say. Louise said, “Well, this is not what I expected, but this is what needs to be,” and then she and kids were gone. Three months later they were divorced. That is how powerful this technique can be! Such dramatic events are rare, but others are more common. In another case a family came for therapy with their thirteen-year-old son, who was having severe problems in school (e.g., truancy, disobedience). During the intake session I asked them to do the family sculpture. The boy went first and positioned his parents at opposite sides of the room, facing the

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walls. And then he put himself in the middle, exactly between his parents. The parents made a different sculpture in which they hugged each other and the boy, whom they positioned between the two of them (the parents’ sculpture was dialectic to their son’s). When I asked them to discuss the sculptures, it became very clear to them that the child was afraid that they were going to get divorced, and he was trying his best to divert their attention to him so they would not have to face each other (and their relationship). The parents became clearly aware that they needed their child to connect them and to help them avoid communicating with each other. They were both afraid of any communication that was likely to lead to anger, fighting, and separation. As a result, the parents went into couple therapy. A variation of this technique can be used involving the addition of another sculpture. The original instructions refer to the current situation even if this is not expressly stated. But another sculpture can be added, namely, “How I would like to see my family in the future.” This instruction leads to sculpting of the future desired relationship. When this is done, a comparison is made between the current and future situations. This discussion highlights the dialectic meaning of the current situation and points to the desired or expected goal of the intervention. Most times the futuristic sculpture is optimistic, but occasionally it is quite sad and reflects a pessimistic attitude about the future of the family.

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PART VI

TERMINATION AND FOLLOW - UP

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14 ENDING THERAPY AND FOLLOW-UP

The therapeutic relationship is a significant interpersonal encounter. As in any other significant interpersonal situation that we come across throughout our lives, we meet new people whom we happen to know quite intimately for a short or a long time. When the time for separation arrives (e.g., graduation, moving, changing jobs or workplace), we move on with our lives. We may stay in touch with some people or lose touch with most of them regardless of how significant or intimate the relationship was. The separation is not done without sadness and feelings of grief and mourning, but we accept and learn to cherish what we gave to and received from the relationship. Sometimes we connect to people intensely, then separate for a long time and then meet again. We may find that the time passed has not affected the relationship. Sometimes we meet a person for a very short time (e.g., on a flight) and find ourselves in a deep and intimate interaction. When this interaction terminates we may never see that person again, but its effect stays with us for a long time. This is the nature of everyday relationships, and therapeutic relationships are no different. Every therapeutic intervention, like everything else in life, comes to an end. The end of therapy is present from the start, and client and therapist alike are acutely aware of it, especially in the case of a time-limited intervention in which the number of sessions is restricted at the outset of therapy. Furthermore, and unlike any other kind of relationship, therapeutic relationships are expected to end, and the end is an essential part of the process. Awareness of the end of therapy may encourage the client and therapist to make better use of the time (Gilbert and Shmukler 1996). The time limit and awareness of its end do not make the interaction 233

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less significant or important. Within the time boundaries, a close, intimate, and highly meaningful interaction takes place between people who care a lot about each other. When the interaction ends, something very important lingers much longer: the memory of the interaction and of the caring and the insights gained. The end of therapy is usually and commonly called termination. I don’t feel comfortable using that word because its connotation is death. Termination is associated with something final and irrevocable. I prefer to use the word end. Ending is not that final; while it suggests that something has concluded, it can be changed and begin anew, like the end of a chapter or a story. The word termination has its roots in the psychoanalytic tradition. In psychoanalysis and psychodynamically oriented psychotherapy, termination is associated with mourning and loss of the client–therapist relationship (Scharff and Scharff 2008; Tyson 1996). Psychoanalytic psychotherapy is a long-term process in which client and therapist meet several times a week. Evidently, the therapist and the therapeutic interaction become foremost in the client’s life (and the therapist’s). Also, in the early days of psychoanalysis, it was agreed that once the client terminated therapy he could not return to the same analyst, so that the work on separation and loss would not be impaired by the possibility of a renewed relationship. However, termination may involve mixed feelings because it also represents joy, relief, and opportunities to use the money and time for other purposes (Tyson 1996). Work on termination is crucial in psychoanalytic, psychodynamic psychotherapy in that it enables the client to work on separation and individuation and consolidates the changes gained in therapy. An incomplete work on termination renders a crucial aspect of therapy incomplete (Glover 1955) and can adversely affect the outcome of therapy. In time-limited or problem-focused interventions that are more task oriented than process oriented, the emphasis on termination is not as central as it in psychoanalysis or psychodynamic therapy. Consequently, working through termination is not crucial. However, at times there will be a need to work on termination, especially when termination appears necessary (Davis and Younggren 2009). This does not mean that the interaction between client and therapist is not important; it is indeed important and significant. However, therapy is viewed as a significant encounter in the midst of the flow of life. It is an encounter that is likely to bring about a change in the

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client’s and the therapist’s lives, like any other significant interaction. The relationship is seen as a means to a goal and not a goal in itself. This is more apparent when therapy is focused on specific, well-defined problems. In time-limited or problem-focused therapy, the end of therapy does not necessarily mean the end of the client–therapist relationship. There are follow-up sessions, and it is within the bounds of the therapeutic contract that the client may go back to the same therapist. So the end of therapy does not mean termination. The functional dialectic system (FDS) approach views the end of therapy as the beginning of a new stage in life. The end is a point in time that is also a beginning. The end of therapy indicates that both client and therapist believe that the client has acquired the skills necessary for her to view her life from a new perspective. Although specific goals are set and achieved before the end of therapy, the most important thing is the acquisition of the new dialectic perspective. In this respect, the end of therapy actually begins when the client accepts the dialectic functional view and applies it to various areas of life. The client is now equipped with a different way of construing reality. This change is associated with altered cognitions and beliefs. These alterations will interact with varying life situations and interaction with others. These will have to be dealt with using the skills acquired in therapy. The FDS view is that therapy is a turning point where the client learns how to expand her view of reality in a more optimistic, positive way (compared with the negative view that brought about her difficulties). This change of outlook enables her to look at her life from multiple viewpoints and make decisions that are broadly reasoned. Being able to consider the functionality of the “problem” and the underlying needs it serves, along with the altered meaning of behavior, is likely to contribute to the change. WHEN DOES THERAPY END?

The most important question is when therapy ends. The answer is usually found in the therapeutic contract. The contract specifies the criteria for ending therapy, and once these criteria are met, therapy ends. This type of ending brings mixed feelings. On one hand, it is time to let go and for the client to move on, but on the other hand it is sad. You must separate from a client with whom you have had close relationship. It is like letting a child

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go: you are proud of the child’s achievement, but you hate sending him away. In this case the follow-up delays the separation, giving the partners time to adjust to the idea. However, there may be other conditions under which therapy can end (see Davis and Younggren 2009 for ethical considerations): t


t


t


'PSDFE
UFSNJOBUJPO (or circumstantial termination; Weiner 1986) as a consequence of external forces (e.g., relocation, unemployment). Therapy is terminated, and, if necessary, provisions for its continuation with another therapist must be made. The therapist may provide clients with the name of another therapist and ask permission to share information with the prospective therapist. Sometimes there is enough time to process the termination and separation. In this case the effect of termination on the current therapy must be discussed. This is the case when the therapist is leaving for a long period of time. &OGPSDFE
UFSNJOBUJPO (Weiner 1986) or ending. This is a case in which the therapist decides to terminate or end therapy. This is a rare event. The therapist may conclude that he has not been effective or conducive to therapy. This usually results from countertransference issues. If the therapist finds that some issues are too difficult for him to work on as they come up in therapy, he might decide to terminate therapy. These issues can include death (e.g., the therapist experiences a death in his family) or abuse.1 The reader may remember the couple I described in chapter 9. In this case I believed I needed to terminate therapy because I felt that my joining was faltering, and I could not be part of a therapeutic process when I had lost my confidence in my client’s integrity. 1SFNBUVSF
FOEJOH (poor fit between therapist and client; Weiner 1986). Premature ending occurs when therapy ends before the contractual goals have been achieved. The client may have a poor joining or working alliance with the therapist (Sharf, Primavera, and Diener 2010). The client may decide to end therapy because she feels that no more progress can be expected, or because she resists further changes, or because she feels that she can move on with current gains. The first two motives are related to resistance

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and indicate fear or unwillingness to cope with the change. These various endings indicate that the client actually understands the problem and knows how to solve it. The client may want to go ahead and work it through on her own, thus saving time and money, or the client is not ready to do it, and the actual change will come later. This does not mean that therapy is not effective or successful. Figuring it out can be done in the follow-up session. I had a number of cases in which, after I set out the FDS interpretation, people asked to end therapy (but agreed to follow up). At first I was perturbed and thought maybe I had done something wrong; perhaps the timing for the interpretation was off? Did I come on too strong with the interpretation? I was reassured by their agreement to a follow-up session that something positive would result, but I was concerned about letting them go without really understanding what happened. I was not able to find this out until the follow-up session. Then I was told that they felt the interpretation was enough for them to act on their own. They even said they had told me so at the time but were not sure I accepted it (and they were right; I did not want to hear it then). Apparently they were doing quite well, and it taught me a very good lesson: listen to your clients and do not impose your agenda on them. This example reaffirms what I said earlier: the change actually occurs when the FDS view is adopted. From that point on it is up to the client to decide when to end therapy, regardless of the initial contract. Therapy usually ends as agreed by the partners when the contractual goals have been achieved, or it is terminated as a result of external circumstances or by a unilateral decision of the therapist or client. From the FDS viewpoint, the real question is whether the client has acquired the new perspective before ending therapy. Obviously, it is easier when the end of therapy is consensual and follows the contract, but it is not crucial. HOW DOES THERAPY END?

Should the end of therapy be discussed and processed in therapy? It should. The therapeutic encounter is a significant interaction that leads to a change in the client’s life and involves a close, intimate relationship between the

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client and therapist. This interaction should not end hastily but must be part of the process. However, its weight should be proportional to length of therapy. Most often, the actual ending of therapy may take a session or two to complete. After an agreement has been reached that the time is right for ending therapy, a date is set for ending. Usually, two sessions are devoted to ending, although it may take less or more, depending on the client. In the ending session the client is asked to review the process of therapy, beginning with the referral problem and outlining the course of therapy and change. This enables both the client and the therapist to outline therapy from the client’s point of view. The therapist can learn how therapy is perceived and the changes that took place. Then the client is asked what the most important gain from therapy was and how this gain manifests itself in his life. Also, the client is asked how the actual outcome compares with his initial expectations of therapy. At times therapy is concluded successfully, but the change may occur in other areas of life, or not in accord with the initial expectations (e.g., the initial identified patient was a child, but the problem turned out to be a marital problem that was successfully dealt with in therapy). If there is more than one client, each of them is expected to follow the same process. If all agree about the process of change and the outcome, this part is concluded. If there is disagreement, it can be discussed if necessary. Quite often, different system members point out different gains that are manifested in different areas of their lives. It becomes more complex when some do not see the changes that they or others have undergone. In that case the ensuing discussion will probably focus on the attempt to convince the unconvinced (and reassure the convinced) that a change has indeed taken place. If this process results in disagreement, there is no need to resolve it in the session; it must wait until the follow-up session. After the client has finished reviewing therapy, the therapist does the same. The therapist reviews the process from her point of view. Again, disagreement can be addressed during follow-up. At this point therapy ends, and the client and therapist part company. It is not the formal ending because a follow-up session is already scheduled. Ending is a sad event for both therapist and client, and the fact that this sadness is mixed with happiness does not lessen the respect for it.

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The therapist should respect and acknowledge sadness. This sadness underscores the importance of the relationship, the opportunity for growth, the beginning of a new era, and the continued presence of the therapist in the background. Ending therapy, like ending any other close relationship, is not easy. Clients and therapists alike may attempt to delay or avert the end of therapy. Clients may manifest their dislike of ending by developing new or relapsing symptoms and difficulties. They may deny change and progress. Conversely, they may try to speed up the process and end therapy immediately and prematurely the moment ending is mentioned. Ending therapy, even a short-term one, may bring back memories of past sad endings. All of these can be seen as attempts to deny something that has already happened; there is a change, and there is awareness of it. The client’s denial is an affirmation of the change. However, these issues cannot be addressed in therapy because the client is not present. In this case I would write a letter to the client in which I review therapy and the outcome as I see it, repeat the main dialectic understanding of behavior (including the ending), and invite the client to a follow-up session. It is expected that for some clients, immediately after therapy ends a regression period may set in when some of the initial problems recur (often less intensely). This is a common phenomenon attributed to the negative feelings aroused by the end of therapy. The period after the end of therapy is a testing time for the client. The client continues life without active participation and monitoring of the therapist. The client needs to use the skills learned in therapy in real life. This may lead to a regression that could last a short while, and the client is expected to improve after that regressive period and move closer to the expected end-of-therapy functioning (Wolberg 1998). The regression can be conceptualized as part of self-testing; the client reenacts the symptoms and then uses the skills acquired or learned in therapy to treat them. Quite possibly, mentioning the possibility of relapse will help prevent it by enabling the client to make sense of the regressive behavior when it occurs (“My therapist said that it is part of the process, so I don’t have to worry about it”). The therapist, who is a part of the therapeutic relationship, is likely to develop affection for the client and may derive much satisfaction from therapy and the relationship and might like it to continue. In this case the

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therapist will collude with the client in the attempt to delay the end of therapy. The therapist might agree with the client that there are more difficulties to address, or he might accept deterioration in the client’s condition as an indication for continuing therapy. My recommendation is to stick with the initial contract and defer the decision to the follow-up session. By this time both client and therapist will have had time to see how the client copes in real life and will be better equipped and situated to make further decisions about therapy. FOLLOW-UP

The follow-up session is one of the most important parts of therapy. The time between the end of therapy and the follow-up is the time when the gains from therapy are expected to be consolidated. The period between the end of therapy and its evaluation enables both therapist and client to appreciate the quality of the intervention. It provides the client with a better sense of her ability to use the skills learned in therapy in real-life, therapy-free situations. It enables the therapist to evaluate his therapeutic work and identify the factors that contributed to the change or lack of it. Assessment of therapeutic outcomes is quite complex. When it is done at the end of therapy, the therapist can learn about the immediate effect of therapy (post-treatment effect; Kazdin 2004). This effect is usually positive and reflects a reduction in distress and demoralization. The long-term efficacy of the intervention can be assessed only weeks or months after the end of therapy. Obviously, the longer the interval between the end of therapy and follow-up, the better the ability to assess long-term stability of the therapeutic gains. However, this evaluation can be marred by events unconnected to the intervention that affect the outcome. I recommend a three-month interval for the first follow-up. Additional follow-up sessions can be scheduled as needed. A related question is the source of data used for the follow-up evaluation. The most commonly used source is the client’s self-report (Hill and Lambert 2004), which is the most practical and meaningful. The client is the consumer. His perception of the outcome influences his attitudes, feelings, and behavior. This is even more true when the client is a couple or family, and participants agree about the outcome of therapy. Other sources of information (e.g., significant others, school) can be used when available.

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The follow-up is designed to evaluate the outcome of therapy and to identify its curative (or noncurative) factors. Whereas the former is mainly for the benefit of the client, the latter is more for therapist’s benefit. The scheduling of the follow-up session gives the client a feeling that even though therapy has ended, he is still being monitored and not left alone. The therapist is still in the picture, though not on a regular basis. There are no formal sessions, but there is the awareness of the presence and availability of the therapist. The follow-up session is usually set at the beginning of therapy as part of the therapeutic contract. It is scheduled for about three months after the last session. When therapy ends as agreed, setting the follow-up is expected. However, if therapy ends differently, the therapist may want to call the client and try to set up a follow-up meeting. The follow-up can reveal various outcomes: t
t


t


t


The client is happy or satisfied with the outcome, and therapy ends at this point. The client is satisfied with the outcome, but the therapist (or client) thinks more time is needed to evaluate therapy gains. In this case another follow-up session is scheduled. The client might want to have the option to call on the therapist from time to time for reinforcement. This is an acceptable arrangement. The client is not be satisfied with the outcome and feels that there has been little or no change. In this case the therapist and client need to consider the following options: take more time and schedule another follow-up session to see whether a gain has occurred; resume therapy to deal with the unresolved difficulties, with a thorough reexamination of the problem and intervention and a new contract; or resume therapy, but with a different therapist. It is quite possible that the negative feelings about the outcome will hurt the joining between therapist and client. Also, it is possible that a new approach to therapy is needed. For both reasons, it may be better to refer the client to a different therapist. Different system members feel differently about therapy; some are satisfied and some are not. This effect can occur when a number of participants are in therapy (e.g., family members). In this case

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several options can be explored: take more time for evaluation and schedule another session; resume therapy in order to deal with the unresolved issues; or refer the interested member for additional therapy. It is possible that therapy led to a realization that more work is needed for that member. In this case, this person is referred to a different therapist. The reason is that the therapist works with the system, and her loyalty is to the system. Working with an individual member of the system may lead to not seeing the person from the system point of view or developing loyalty to that person, which is likely to interfere with the therapist’s ability to work with the system. To maintain her position in the context of the original contract, the therapist cannot work with individual members. SAYING GOODBYE

Therapy can end, but it is not terminated; therapist and client merely say goodbye to each other. This can be done in various ways. Some of my clients have brought food and presents to the last session as a gesture of appreciation. Other clients wanted to celebrate the end of therapy by our having dinner together. Still other clients were afraid of ending therapy: they parted saying thanks and goodbye, but they implied that they reserved the right to come again, and they avoided anything that might mean termination. In my experience, ending therapy does indeed convey the impression that this is not a termination, and we are about to meet in the future. So there is no need to make a big deal out of it. Just say, “Goodbye.”

CLOSING COMMENT

This book introduces a unique approach, albeit not necessarily new in all respects, integrating individual, couple, and family approaches in a way that makes the differences between them less distinct and enables the therapist to shift from one to the other with conceptual ease. That is not to say that the various approaches become equally easy to carry out. There are differences between the approaches that result from the different client constellations. Nevertheless, with the use of the functional dialectic system (FDS) approach, problem conceptualization is similar for all these approaches. The basic premise is that behavior is functional and dialectic in meaning, and it conforms to the clients’ fundamental goals: order, safety, belongingness, and identity. The goal of FDS is to help clients, within the context of loving and caring therapeutic relationships, to recognize the function of their behavior and help them choose their way of coping with the seemingly debilitating situation. This book represents an attempt to put the various approaches to system therapy along with individual approaches, cognitive–behavioral therapy in particular, under the same roof. The first part of the book illustrates how our life is meaningfully organized to provide these fundamental needs. In 2006, I was fortunate enough to receive a teaching position at Yeshiva University (Ferkauf Graduate School of Psychology). I was asked to teach an introduction to social psychology. Although my research interests are more in testing and personality, and my clinical work strongly emphasizes the systemic, dialectic, and functional aspects of behavior, I agreed to face this challenge. As I prepared my classes I realized that if I began with the FDS view of behavior, I might be able to put 243

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the various issues under the same umbrella. Social cognition, perception, attribution, self-knowledge, attitudes, conformity, prejudice, and prosocial behavior all harmonize very nicely with the goals of a social system. I was happy to learn that the students enjoyed the class as much as I did. In retrospect, no wonder that all this converges to the same metaprinciple: the person is part of a social system and simultaneously influences and is influenced by it. For people to be able to receive from the system what they need, they must build, preserve, and protect the system by every means. The use of symptomatic behavior is only one of the means people use to do this. The preservation of the system is more important than the life or well-being of the individual. Once we understand and accept this presumption, all the rest follows; behavior, abnormal or not, is functional toward this goal. How can we learn about the function of a behavior? Dialectics is our vehicle to do it. The idea that everything has its opposite inherent in it helps us find out the meaning of behavior. Once we figure this out, anxiety diminishes. We now understand our behavior better and become less afraid of it or its consequences. We are in control. This essentially is what FDS therapy is all about. It aims to extend people’s view, thereby enabling them better to use their cognitive, emotional, and behavioral repertoires. The client does not learn new behavior, only how better to use what he or she already has and knows. It does not necessarily mean that treatment will be short, but it does changes the scope and atmosphere. Dealing with “When do I use my symptom?” differs from dealing with “How terrible and painful it is to have the symptom.” FDS is the basis for understanding and changing behavior. This optimistic view of abnormal behavior creates a tremendous change in both client and therapist. Suddenly we feel that we are in control of our behavior, and the sense of hopelessness and helplessness is replaced by a sense of control and vigor. When I first introduced this approach to my students, you could see the doubt in their eyes. Is it really possible? How will clients react when we take the symptom away from them? More seasoned therapists were asking about the pace of the process. Isn’t it too quick? How will clients react to such a rapid intervention? Somehow they had forgotten that most improvement in

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therapy occurs in the first six to eight sessions (Lambert and Ogles 2004). Interestingly, most clients do not ask these questions, and they appear quite relieved when they are able to ease their misery and find hope and change. As I became more assured and articulate in my view, I found myself happily applying it to all areas of life. I found that my view of things has changed (even though at times I am inclined to return to the one-way, black-and-white view, because I feel more secure in it at the time and only later return to FDS to find solace or to learn more about the complexity of that situation). This book represents the culmination of long and arduous journey, a finale that is the beginning of a new period. I do not expect that those who read the book will change their orientation and quickly adopt mine. I will feel blessed if those who read the book just think about it. I am sure that even a thought is enough to make a change. This is all I wish for!

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APPENDIX THE AMERICAN ASSOCIATION FOR MARRIAGE AND FAMILY THERAPY CODE OF ETHICS 1. RESPONSIBILITY TO CLIENTS

Marriage and family therapists advance the welfare of families and individuals. They respect the rights of those persons seeking their assistance, and make reasonable efforts to ensure that their services are used appropriately. 1.1 Marriage and family therapists do not discriminate against or refuse professional service to anyone on the basis of race, gender, religion, national origin, or sexual orientation. 1.2 Marriage and family therapists are aware of their influential position with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid dual relationships with clients that could impair professional judgment or increase the risk of exploitation. When a dual relationship cannot be avoided, therapists take appropriate professional precautions to ensure judgment is not impaired and no exploitation occurs. Examples of such dual relationships include, but are not limited to, business or close personal relationships with clients. Sexual intimacy with clients is prohibited. Sexual intimacy with former clients for two years following the termination of therapy is prohibited. 1.3 Marriage and family therapists do not use their professional relationships with clients to further their own interests. 1.4 Marriage and family therapists respect the right of clients to make 247

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1.5

1.6

1.7

1.8

decisions and help them to understand the consequences of these decisions. Therapists clearly advise a client that a decision on marital status is the responsibility of the client. Marriage and family therapists continue therapeutic relationships only so long as it is reasonably clear that clients are benefiting from the relationship. Marriage and family therapists assist persons in obtaining other therapeutic services if the therapist is unable or unwilling, for appropriate reasons, to provide professional help. Marriage and family therapists do not abandon or neglect clients in treatment without making reasonable arrangements for the continuation of such treatment. Marriage and family therapists obtain written informed consent from clients before videotaping, audio recording, or permitting third party observation.

2. CONFIDENTIALITY

Marriage and family therapists have unique confidentiality concerns because the client in a therapeutic relationship may be more than one person. Therapists respect and guard confidences of each individual client. 2.1 Marriage and family therapists may not disclose client confidences except: (a) as mandated by law; (b) to prevent a clear and immediate danger to a person or persons; (c) where the therapist is a defendant in a civil, criminal, or disciplinary action arising from the therapy (in which case client confidences may be disclosed only in the course of that action); or (d) if there is a waiver previously obtained in writing, and then such information may be revealed only in accordance with the terms of the waiver. In circumstances where more than one person in a family receives therapy, each such family member who is legally competent to execute a waiver must agree to the waiver required by subparagraph (d). Without such a waiver from each family member legally competent to execute a waiver, a therapist cannot disclose information received from any family member. 2.2 Marriage and family therapists use client and/or clinical materials in teaching, writing, and public presentations only if a written waiver has been obtained in accordance with Subprinciple 2.1(d), or when

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2.3

appropriate steps have been taken to protect client identity and confidentiality. Marriage and family therapists store or dispose of client records in ways that maintain confidentiality.

3. PROFESSIONAL COMPETENCE AND INTEGRITY

Marriage and family therapists maintain high standards of professional competence and integrity. 3.1 Marriage and family therapists are in violation of this Code and subject to termination of membership or other appropriate action if they: (a) are convicted of any felony; (b) are convicted of a misdemeanor related to their qualifications or functions; (c) engage in conduct which could lead to conviction of a felony, or a misdemeanor related to their qualifications or functions; (d) are expelled from or disciplined by other professional organizations; (e) have their licenses or certificates suspended or revoked or are otherwise disciplined by regulatory bodies; (f) are no longer competent to practice marriage and family therapy because they are impaired due to physical or mental causes or the abuse of alcohol or other substances; or (g) fail to cooperate with the Association at any point from the inception of an ethical complaint through the completion of all proceedings regarding that complaint. 3.2 Marriage and family therapists seek appropriate professional assistance for their personal problems or conflicts that may impair work performance or clinical judgment. 3.3 Marriage and family therapists, as teachers, supervisors, and researchers, are dedicated to high standards of scholarship and present accurate information. 3.4 Marriage and family therapists remain abreast of new developments in family therapy knowledge and practice through educational activities. 3.5 Marriage and family therapists do not engage in sexual or other harassment or exploitation of clients, students, trainees, supervisees, employees, colleagues, research subjects, or actual or potential witnesses or complainants in investigations and ethical proceedings. 3.6 Marriage and family therapists do not diagnose, treat, or advise on

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3.7 3.8

problems outside the recognized boundaries of their competence. Marriage and family therapists make efforts to prevent the distortion or misuse of their clinical and research findings. Marriage and family therapists, because of their ability to influence and alter the lives of others, exercise special care when making public their professional recommendations and opinions through testimony or other public statements.

4. RESPONSIBILITY TO STUDENTS, EMPLOYEES, AND SUPERVISEES

Marriage and family therapists do not exploit the trust and dependency of students, employees, and supervisees. 4.1 Marriage and family therapists are aware of their influential position with respect to students, employees, and supervisees, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid dual relationships that could impair professional judgment or increase the risk of exploitation. When a dual relationship cannot be avoided, therapists take appropriate professional precautions to ensure judgment is not impaired and no exploitation occurs. Examples of such dual relationships include, but are not limited to, business or close personal relationships with students, employees, or supervisees. Provision of therapy to students, employees, or supervisees is prohibited. Sexual intimacy with students or supervisees is prohibited. 4.2 Marriage and family therapists do not permit students, employees, or supervisees to perform or to hold themselves out as competent to perform professional services beyond their training, level of experience, and competence. 4.3 Marriage and family therapists do not disclose supervisee confidences except: (a) as mandated by law; (b) to prevent a clear and immediate danger to a person or persons; (c) where the therapist is a defendant in a civil, criminal, or disciplinary action arising from the supervision (in which case supervisee confidences may be disclosed only in the course of that action); (d) in educational or training settings where there are multiple supervisors, and then only to other professional colleagues who share responsibility for the training of the supervisee;

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or (e) if there is a waiver previously obtained in writing, and then such information may be revealed only in accordance with the terms of the waiver. 5. RESPONSIBILITY TO RESEARCH PARTICIPANTS

Investigators respect the dignity and protect the welfare of participants in research and are aware of federal and state laws and regulations and professional standards governing the conduct of research. 5.1 Investigators are responsible for making careful examinations of ethical acceptability in planning studies. To the extent that services to research participants may be compromised by participation in research, investigators seek the ethical advice of qualified professionals not directly involved in the investigation and observe safeguards to protect the rights of research participants. 5.2 Investigators requesting participants’ involvement in research inform them of all aspects of the research that might reasonably be expected to influence willingness to participate. Investigators are especially sensitive to the possibility of diminished consent when participants are also receiving clinical services, have impairments which limit understanding and/or communication, or when participants are children. 5.3 Investigators respect participants’ freedom to decline participation in or to withdraw from a research study at any time. This obligation requires special thought and consideration when investigators or other members of the research team are in positions of authority or influence over participants. Marriage and family therapists, therefore, make every effort to avoid dual relationships with research participants that could impair professional judgment or increase the risk of exploitation. 5.4 Information obtained about a research participant during the course of an investigation is confidential unless there is a waiver previously obtained in writing. When the possibility exists that others, including family members, may obtain access to such information, this possibility, together with the plan for protecting confidentiality, is explained as part of the procedure for obtaining informed consent.

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6. RESPONSIBILITY TO THE PROFESSION

Marriage and family therapists respect the rights and responsibilities of professional colleagues and participate in activities which advance the goals of the profession. 6.1 Marriage and family therapists remain accountable to the standards of the profession when acting as members or employees of organizations. 6.2 Marriage and family therapists assign publication credit to those who have contributed to a publication in proportion to their contributions and in accordance with customary professional publication practices. 6.3 Marriage and family therapists who are the authors of books or other materials that are published or distributed cite persons to whom credit for original ideas is due. 6.4 Marriage and family therapists who are the authors of books or other materials published or distributed by an organization take reasonable precautions to ensure that the organization promotes and advertises the materials accurately and factually. 6.5 Marriage and family therapists participate in activities that contribute to a better community and society, including devoting a portion of their professional activity to services for which there is little or no financial return. 6.6 Marriage and family therapists are concerned with developing laws and regulations pertaining to marriage and family therapy that serve the public interest, and with altering such laws and regulations that are not in the public interest. 6.7 Marriage and family therapists encourage public participation in the design and delivery of professional services and in the regulation of practitioners.

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7. FINANCIAL ARRANGEMENTS

Marriage and family therapists make financial arrangements with clients, third party payers, and supervisees that are reasonably understandable and conform to accepted professional practices. 7.1 Marriage and family therapists do not offer or accept payment for referrals. 7.2 Marriage and family therapists do not charge excessive fees for services. 7.3 Marriage and family therapists disclose their fees to clients and supervisees at the beginning of services. 7.4 Marriage and family therapists represent facts truthfully to clients, third party payers, and supervisees regarding services rendered. This Code is published by: American Association for Marriage and Family Therapy 112 South Alfred Street, Alexandria, VA 22314 Phone: (703) 839808 · Fax: (703) 838-9805 www.aamft.org

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NOTES

Introduction 1. One statement often heard in therapy is, “I don’t know what I live for.” This is a very difficult statement to respond to because the sense of goal and purpose is strongly rooted in us. At times of distress when this statement is made, we are left with nothing clear and satisfactory to say. The response we have appears empty and irrelevant at that moment, although it is so meaningful at other, nondistressed times. We then hope that the person will somehow find the answer for himself or herself, which is often the case. 2. Compassion is defined as active caring rather than pity or sympathy (Gyatso 1994). 3. Hegel was incorporated into Japanese philosophy, which is a blend of Hegel and Zen (Kim 1952). 1. System 1. Olson (1993) developed the Circumplex model, which involves categorizing families along three basic axes: cohesion, adaptability, and communication. Research supports the dimension of cohesion, whose meaning is close to that of boundary (Anderson 1986; Markevitz 2002). Olson hypothesized that families high on the dimension of disengaged or enmeshed boundaries will be less adaptive than families low on this dimension. 2. Dialectics 1. Freud did not think dialectically. His dialectical structure evolved over time and is not a product of dialectically related philosophy.

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6. Joining and Establishing Therapeutic Alliance 1. Suppose a client presents with a symptom of panic disorder, and through the FDS approach it is found that client uses panic attacks to avoid being held responsible for his behavior. Discovering this, the therapist knows that the panic attacks have become a means to an end and not the end. In the case of FDS, the inquiry will shift to encourage responsibility-taking behaviors that will replace panic attacks. 7. The Envelope 1. In a supervisor’s training session, I saw how the relationship between the group leader and the supervisor affected the latter’s relationship with the therapist and the therapist’s relationship with the family. In one session we dealt with the supervisor’s difficulty in asserting herself to the therapist, who in turn could not help the client deal with her own lack of assertiveness. The ability to open up the issue in the supervisor’s training (fear of losing the love and support of an authority) enabled the supervisor to do it with the therapist, who, later on, did it with the family. 2. In immigrant families where the predominant language is different, the children are likely to be the first to adopt the new language. Having achieved this, they may serve as family representatives in the outside world. This gives them much power over their parents and weakens the family structure by changing its hierarchy. 8. Disclosure 1. This is a sensitive issue. The therapist uses information provided by the client. Aside from looking for inconsistencies or revelations by the client, the therapist has no way of knowing when or what information is not disclosed. One source of knowledge is out-of-therapy information provided inadvertently or deliberately by other people. In such cases, I believe it is better that therapist not have this information. 2. Whereas the client’s self-disclosure confidentiality is protected by the ethical code, that of the therapist is not. Clients can disclose whatever they wish, but the therapist can’t. The code of ethics protects the client but not the therapist in this regard. 9. Resistance 1. I prefer the term ending to termination. Termination has the connotation of finality and death as it is used in traditional psychoanalysis. Ending

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means something less final, like the end of a chapter or a book, which suggests reversibility and temporality. 2. We need to remember that both spouses want to save their marriage, and they feel afraid and vulnerable. They would like to trust the therapist with their marriage. They need to feel safe and secure, and only after testing the therapist (hence the power struggle) can they do this. This is only one of countless examples that can go other ways as well. 3. The literature is replete with studies on this issue. A search yielded 423 studies since 2000 alone. The most notable researcher in the field is Elizabeth F. Loftus (Loftus 2005; Loftus and Bernstein 2005; Nourkova, Bernstein, and Loftus 2004). 10. Functional Dialectic System View of Symptom and Psychopathology 1. Tellegen et al. (2003) prefer the term demoralization to distress, but I believe that distress represents more closely the client’s clinical condition and is also closer to its lexical meaning (Waite 2002). Demoralization may be confused with another, unrelated meaning, namely corruption of morals. 2. When I explain FDS to my clients, I emphasize the importance of the relationship to ensure safety, belongingness, and identity, and I elucidate how we find ways to ensure the existence of the system so as to facilitate both distance and closeness. This brings me to dialectics and emotional distance–regulating mechanisms. Incidentally, this explanation helps reduce anxiety and prepares the ground for the later change in perspective and perception. 3. Introducing the idea that the symptom is used to prevent dealing with intimacy is usually enough to persuade the couple to quit using it and, within the safety net of the therapeutic relationship, to delve into this crucial issue. 4. I have found that there are several ways to help bring into therapy those who refuse: (1) Just tell the referring person that you are confident she knows how to do it. (2) Ask the referring person to tell the refusing one how much she is concerned about him. (3) Tell the refusing person that you need his help because you have a problem. This last way is most helpful with children and adolescents who are afraid to be seen as the problem. It is also quite correct because systemically everyone shares responsibility for the problem.

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11. Infidelity 1. The high divorce rate is not an indication of the weakness of the marital institution. The high rate of second marriages is a sign of its strength. The high divorce rate is an indication that marriage, especially the first one, has turned into just another means of mate selection. 2. Interestingly, in such a triad (individual, spouse, and lover) experience has taught me that the person standing between the lover and the spouse is the least capable of resolving the situation (the vicious cycle). The solution usually comes when either the partner or the lover seriously considers terminating the relationship. 3. Atkins et al. (2005) conducted a randomized clinical trial of marital therapy. Results show that infidelity couples began treatment more distressed than noninfidelity couples; however, evidence suggests that couples who had an affair and who revealed this affair before or during therapy showed greater improvement in satisfaction than noninfidelity couples. 4. I do not believe in absolute, unconditional honesty. There are times when “white lies” are needed in relationship in order to avoid hurting the other person. These “white lies” are acceptable in honest, intimate relationships where there is underlying trust and understanding that the partners care for each other and will not do anything intentionally to hurt each other. 13. Enrichment and Facilitation of Therapy 1. The underlying assumption is that the event discussed is a historical one or one that the partners had no control of. Nonetheless, when used for future events, the dialectic dialogue can be very instrumental in helping the partners anticipate several consequences of their actions. Obviously, this exercise has no significant predictive value. But regarding future events, the use of this approach may increase confusion by suggesting a number of possible conflicting ways of dealing with the situation. 14. Termination and Follow-Up 1. The therapist is permitted to admit her limitations. However, when discussing it with the client, the therapist needs to make sure the client understands that this is the therapist’s problem, and the client is not responsible for it.

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AUTHOR INDEX

Ackerman, N. W., 40 Ahern, F. M., 17 Akert, R. M., 14, 111 Allen, E. S., 179 Almagor, M., 31, 48, 54, 93, 147, 218 Amato, P. R., 180, 181 Ambrose, T. K., 138 American Association for Marriage and Family Therapy, iv, 96, 122, 247 American Psychiatric Association, 93, 150 American Psychological Association, 122 Andersen, D. T., xxvi, xxviii Anderson, S. A., 255 Apter, A., 201 Aron, A., 57, 60, 65 Aronson, E,. 14, 111, 118 Asarnow, J. R., 202 Atkins, D. C., 179, 181, 258

Beavin, J. H., 20 Beck, A. T., 31 Becker, D. V., 180 Bedeian, A. C., 9 Bedi, R. P., 78 Beeghley, L., 181 Bell, N. W., 47 Belmont, L., 17 Belsky, J., 60 Bennett, K., 188 Ben-Porath, Y. S., xvii Bergner, R. M., 14 Berland, H. M., 17 Berman, A. L., 198, 199, 200 Bernstein, D. M., 257 Berscheid, E., 46, 53, 54 Betancourt, H., 133 Beutler, L. E., 93, 119, 125 Biddle, B. J., 14 Bingham, C. R., 198 Bischof, G. H., 226 Bischoff, M. M., 125 Bischoff, R. J., 78 Blair, I., 133 Blass, R., 61 Blatt, S. J., 61 Bobo, L. D., 111 Boden, M., 199 Bongar, B., 93, 201

Bank, L., 109 Barnes, M. L., 54 Barta, W., 181 Bateson, G., 21, 70 Baucom, D. H., 179 Baum, M. C., 14 Baxter, L. A., 44 293

294 | AUTHOR INDEX

Booth, A., 66 Borys, D. S., 122 Boszormenyi-Nagy, I., 14 Bow, J. N., 89 Bowen, M., 40 Boyle, M. H., 200 Brad, J., 182 Braginsky, B. M., 120 Braginsky, D. D., 120 Brainerd, C. J., 140 Bretherton, K., 61 Bridges, N. A., 120 Brown, E. M., 187 Brown, G. K., 199 Brown, L. S., 122 Brown, P. M., 46 Bumpass, L. L., 57 Burkard, A. W., 122 Burckell, L. A., 120 Buss, A. H., 179, 183 Buss, A. R., 26, 27, 28 Buss, D. M., 53, 54, 182, 188 Buunk, B. P., 181 Byrne, D., 53 Cade, R., xxxi Carlson, D. E., 218 Carter, E., 226 Carter, E. A., 52, 65 Catania, J. A., 181 Chandler, C., 133 Charny, I. W., 44, 51, 54 Choi, K., 181 Chiriboga, J., 200 Claiborn, C. D., 31 Clark, L. A., 147 Clarkin, J. F., 93 Clore, G. L., 53 Cochran, J. K., 181 Cohen, E. D., 113 Cohen-Sandler, R., 200 Coll, K. M., 9 Combs, M. P., 113

Comtois, K. A., xxx Condon, J. W., 53 Conoley, C. W., 31 Constantine, L. L., 226 Constantine, M. G., 122 Conte, R., 135 Cook, D. A., 57, 122 Cook, J. M., 53 Cookson, D., 9 Copleston, F., 26 Corsini, J., 94 Costa, Jr., P. T., 147 Cox, D. L., 136 Crano, W. D., 53 Crits-Christoph, P., 78 Daly, M., 179, 183 Daniels, D., 17 Danser, D. B., 31 Davidson, L., 202 Davis, D. D., 234, 236 Davis, K. E., 56 Descutner, C. J., 46 DeSteno, D. A., 179 Deutsch, C. J., 135 DeVoe, E. R., 89 Diamond, L. M., 57 Dickerson, V., 73, 291 Diener, M. J., 236 Dion, K. K., 110 Dion, K. L., 110 Dlugolecki, D. W., 118 Doherty, K., 118 Dolcini, M. M., 181 Dong, W., 217 Dowd, E. T., 31, 126 Downey, D. B., 9 Drigotas, S. M., 181 Duane, C., 77 Dubow, E. F., 200 Duck, S. W., 53 Duhl, B. S., 226 Duhl, F. J., 226

AUTHOR INDEX | 295

Durkheim, E., 198 Duvall, E. M., 52 Eubanker-Carter, C., 120 Eckstein, D., 71 Effrein, E. A., 118 Ehrlich, S., 147 Ekerdt, D. J., 66 Ellsworth, P. C., 133 Erikson, E. H., xxiii, 46 Eysenck, H. J., 9 Falender, V. J., 118 Faller, K. C., 89 Farber, B. A., 135 Fazio, R. H., 118 Feeney, J. A., 44 Feingold, A., 53 Feldman, D. A., 31 Fergusson, D. M., 200 Fergusson, M. L., 53, 200 Ferreira, A., 20 Festinger, L., 118, 218 Fisch, R., 69 Fischer, E. F., 110 Fischer, G. W., 111 Fisher, C. D., 121 Fisher, P., 200 Fishman, H. C., 14 Flaskas, C., 77 Folkman, S., 115 Forer, L. K., 17 Fox, C., 111 Frank, J. D., xxii, 147, 218 Frayser, S., 181 Freud, S., xxiii, 22, 25, 28, 199, 255 Gabbard, G. O., 120 Ganahl, G., 227 Gao, G., 110 Garber, R. A., 31 Geary, D. C., 180 Gelles, R. J., 134

Gergen, K. J., 118 Gerson, R., 51 Gerstein, L. H., 46 Gilbert, M., 233 Gill, M. M., 25 Glass, J. F., xxi Glass, S., 179 Glick, I. D., 110, 113 Glover, E., 234 Goldberg, L. R., 54 Goldfried, M. R., 120, 121 Goldston, D. B., 89 Goodheart, C. D., 94 Gould, M. S., 200 Graham, S., 133 Greenan, D. E., 180 Greenson, R. R., 77, 120, 125 Grice, J. W., 179 Gridley, B., 46 Grosse, M., 120 Grotenhuis, M., 181 Guarnaccia, P. J., 150 Guendouzi, J., 66 Guerin, K., 39 Guerin, P. J., 39 Gutheil, T. G., 120 Gutierrez, M., 111 Guttman-Baumgold, S., 9 Gyatso, T., xxvii Hadley, T., 51 Haley, J., 13, 47, 51 Hampton, R. L., xii Hansen, J., 227 Harker, K., 111 Haselton, M., 182 Hatfield, E., 46 Hayes-Roth, F., 93 Hazan, C., 57 Hauser, R. M., 9 Heard, H. L., 9 Hegel, xxix, 26, 27, 28, 255 Helms, J. E., 122

296 | AUTHOR INDEX

Hendrix, H., 55 Hertlein, K. M., 180 Hicks, T. V., 178 Hill, C. E., 77, 82, 240 Hoffman, L., 129 Hofmeister, H., 66 Holinger, P. C., 198 Holtzworth-Munroe, A., 134 Hook, M. K., 46 Hook, S., 26 Horvath, A. O., 78, 82 Hoyt, D. R., 18 Hughes, P. M., 44 Hull, C. L., 25 Humphrey, F. G., 179 Hunt, M., 181 Hyde, J. S., 179 Imber-Black, E., 137, 183 Jacobson, N. S., 179 Jackson, D. D., 15, 19 Jackson, D. N., 20, 47, 54, 56 Jackson, J. H., 56 Jaffe, P. E., 120, 121 Jankowiak, W. R., 110 Janus, S. S., 181 Janus, C. L., 181 Jasjnskaja-Lahti, I., 111 Jaycox, L. H., 111 Jessor, R., 198, 201 Jobes, D. A., 198 Joffe, R. T., 200 Johnson, C. A., 178 Johnson, D. R., 66 Joiner, T. E., 199 Jordan, N., 218 Jourard, S. M., 120, 121 Kahn, J. H., 117 Kantor, D., 43, 226 Karasu, T. B., 135 Karp, E. S., 56

Kassinove, H., 135 Katherine, A., 122 Kazdin, A. E., 95, 240 Keefe, R. C., 54 Keith-Spiegel, P., 122 Kelly, A. E., 117, 118 Kelly, G. A., 25 Kennedy, G. E., 18 Kenrick, D. T., 54 Kerckhoff, A. C., 56 Kerr, M., 201 Khouri, P., 22 Kidwel, J. S., 9 Kim, H. T., xxix, 255 Kim, J. E., 66 King, C. A., 200 King, R. A., 198, 200, 201, 202 Kim, H. T., xxix, 255 Kim, J. E., 66 Kirkcady, B. D., 199 Kirmayer, L. J., 150 Kinsey, A., 178, 181 Knobloch, L. K., 66 Knott, A. E., 89 Knox, D., 178 Kooiman, C. G., 89 Kraaykamp, G., 181 Kraft, R. G., 31 Krasner, B. R., 14 Ktsanes, T., 56 Ktsanes, V., 56 Kuho, H. H. D., 9 Kvale, S., 30 Kwong-Liem, K. K., 122 L’Abate, L., 126, 227 Lackie, B., 14 Laird, J. D., 111, 112 Lambert, M. J., xxi, 82, 106, 113, 240, 245 Lang, C., 121 Langlois, J. H., 53 Larsson, B., 199

AUTHOR INDEX | 297

Laumann, E., 178, 179, 182, 188 Lawson, A., 181 Lay, C. H., 54 Lea, M., 53 Lehr, W., 43 Leitenberg, H., 178 Lester, D., 56 Levinger, G., 110 Levis, D. J., 89 Lewin, K., 25 Lieberman, S., 44 Liebkind, K., 111 Lindenboim, N., xxx Linehan, M. M., xxvi, xxix, xxx Linnoila, M., 202 Linville, P. W., 111 Lipsitz, J. D., 61 Little, A. C., 53 Lock, T. G., 89 Loftus, E. F., 140, 257 Long, A. G., 9 Longabaugh, R., 93 Lopez, S. R., 150 Luborsky, L., 82 Lusterman, D., 179, 187 Lykken, D. T., 56 Lynch, T. R., xxvi, xxx Lynskey, M. T., 200 Macaskill, A., 44 MacCallum, R. C., 9 Machado, P. P. P., 119 Madanes, C., 47 Mahler, M., 61 Makover, R. B., 93 Marcus, A. C., 150 Marcuse, H., 26 Markevitz, A., 255 Markus, G. B., 17 Martin, R., 185 Marx, K., 28, 29 Mason, M. J., 138 Masters, J. C., xii

Mayne, T. J., 138 McCrae, R. R., 147 McGoldrick, M., 52, 65, 113 McIntosh, J. L., 198 McPherson, M., 53 Meara, N. M., 118 Meyer, J. P., 56 Michalski, R. L., 9 Mika, P., 14 Miller, A. L., xxxi Miller, J. B., 136 Milne, C. R., 126 Minnes, P., 115 Minuchin, S., 12, 13, 14, 77, 82, 199 Mitchell, M. G., 202 Modai, I., 111 Moen, P., 66 Moleiro, C., 125 Monach, J. H., 44 Montalvo, B., 111 Moreno, J. L., 226 Moskowitz, G. B., 217 Moskowitz, J. T., 115 Mowrer, O. H., 148 Munholland, K. A., 61 Murray, A. A., 56 Murray, H. A., 56 Nachshen, J. S., 114 Neufeldt, S. A., 119 Newcomb, T. M., 53 Nichols, M. P., 15, 20, 71 Nisbett, R. E., 26, 28 Norman, W. T., 54 Nourkova, V., 257 Nrugham, L., 199 Offord, D. R., 200 Ogles, B. M., xxi, 82, 245 Olinsky, D. E., 126 Oliver, M., xxxi Oliver, M. B., 179 Olson, D. H., 255

298 | AUTHOR INDEX

Omer, H., 133 Omi, M. A., 112 Orbach, I., 200, 201 Orpinas, P. K., 198 Osgood, C. E., 218 Ouwehand, A. W., 89 Paivio, S. C., 134 Pallak, M. S., 57 Papp, P., 226 Pappas, P. A., 106 Passini, F. T., 54 Paulhus, D. L., 17 Peng, K., 26, 28 Pere, L. E., 180 Pepper, S., 56 Perrett, D. I., 53 Pervin, L. A., 25 Petzel, S. V., 199 Pfeffer, C. R., 200, 202 Phillips, A. S., 9 Piercy, F. P., 180 Pietrzak, R. H., 180 Pittman, F., 186, 187 Pittman, G., 53 Plomin, R., 17 Plutchik, R., 135 Pomerantz, E. M., 217 Pong, S. K., 9 Pope, K. S., 122, 135 Post, D., 9 Popper, K. R., 27 Potter-Efron, R. T., 136 Poznovsky, A., 111 Prager, K. J., 47 Previti, D., 180 Primavera, L. H., 236 Quintana, S. M., 118 Rajab, H., 199 Range, L. M., 89

Rangell, L., 147 Ransom, D. C., 70 Rapaport, D., 25 Rapson, R. L., 46 Rasmussen, P. R., 129 Regan, P. C., 53, 54 Reis, H. T., 53 Reibstein, J. A., 185 Reyne, V., 140 Richman, J., 199 Riddle, M., 199 Rieckmann, T., 115 Riegel, K. F., 26 Rimm, D. C., xii Ring, K., 120 Ritsner, M., 111 Robbins, J. M., 150 Robertiello, R. C., 126 Robins C. J., xxix, xxviii Rodgers, J. L., 9 Rodriguez-Hanley, A., 108 Rogers, C., 23, 28, 109 Rogers, S. J., 181 Rosenbaum, M. E., 53 Rosenthal, D. M., 202 Ronnestad, M. H., 126 Rosen, L. V., 121 Rourke, P. A., 89 Rudd, M. D., 199 Russell, D. E., 122 Rutter, V., 179 Ryback, R., 93 Rychlak, J. F., 26, 28, 29 Sabbath, J. C., 199 Sabini, J., 179 Salovey, P., 111, 179 Samai, S., 31, 218 Samson, C., 181 Sand, A. M., 53 Sayers, S., 27 Scaturo, D. J., 121, 125, 129

AUTHOR INDEX | 299

Scharff, J. S., 234 Scharff, D. E., 234 Scheel, M. J., 115 Scheepers, P., 181 Schlenker, B. R., 118 Schmidt, M. H., 53 Schoener, R. G., 121 Schoenewolf, G., 126 Schützwohl, A., 180 Schwartz, P., 179 Schwartz, R. C., 15, 20 Schwoeri, L. D., 113 Seely, E., 179 Siefen, G. R., 199 Selvini Palazzoli, M., 48 Shackelford, T. K., 9, 178, 179 Shaffer, D., 200 Shapiro, D. A., 118 Sharf, J., 236 Sheets, V. L., 180 Shmukler, D., 233 Shoham, V., 126 Sholevar, G. P., 113 Silove, D., 61 Silver, M., 179 Silverman, M. M., 198 Silverstein, O., 226 Simon, R. I., 121 Simons, E. P., 44 Skynner, A. C. R., 21 Sluzki, C. E., 70 Smetana, J. G., 133 Smith, C. A., 133 Smith, T. W., 181 Smith-Lovin, L., 53 Smoot, M., 43, 103 Snyder, D. K., 179 Snyder, R. C., 108 Socrates, 31, 219 Solomon, M., 65 Sosin, D. M., 198 Spearman, C., 147

Spears, R., 53 Sprenkle, D. H., 78 Spring, J. A., 187 Stansbury, V. K., 188 Stattin, H., 201 Sternberg, R. J., 95 Stierlin, H., 20 Stiles, W. B., 118 Stiver, I. P., 136 Stoolmiller, M., 125 Straus, M. A., 134 Strawbridge, W. J., 18 Strong, S. R., 31 Sullivan, J., 57, 199 Sulloway, F. J., 9, 17 Surkin, E., 134 Swales, M. A., 24, 30 Sweet, J. A., 57 Symons, D., 183 Szinovacs, M., 66 Tabachnick, B. G., 122, 135 Tafrate, R. C., 135 Talebi, H., 125 Tatar, M., 111 Taunt, H. M., 115 Taylor, S. E., 115 Tellegen, A., 17, 56, 93, 147, 199, 257 Tennenbaum, P. H., 218 Ter-Kuile, M. M., 89 Thelen, M. H., 46 Thornton, A., 179 Thrangu, K., 27 Toman, W., 16, 17 Tracey, T. J. G., 125 Trebitch, E., 17 Trivers, R. L., 53 Tucker, P., 60, 65 Tunnell, G., 180 Turner, R. H., 14 Tyler, K. A., 18 Tyson, H. A., 234

300 | AUTHOR INDEX

Ullman, H., 111 Van Der Slik, F., 181 Van Lear, C. A., 44 Van Velsor, P., 136 Vinick, B. H., 66 Vogel, E. F., 47 Wachtel, P. L., 121 Wade, N. L., 199 Wagner, B. M., 200 Waite, M., 257 Walsh, F., 51 Wampold, B. E., 78 Watson, D., 73, 147 Watzlawick, P., 20, 69 Weakland, J., 69 Wedding, D., 94 Weeks, G., 126 Weghorst, S. J., 183 Wegner, T. D., 218 Weiner, B., 4, 26, 29, 30, 133 Weiner, M. F., 236 Whisman, M. A., 179 Whitbeck, L. B., 18 Whitty, M. T., 180

Wichman, A. L., 9 Williams, A., 66 Williams, I. C., 121 Williams, M. A., 122 Willutzki, U., 126 Winch, R. F., 56 Wise, S. L., 126 Wolberg, L. R., 239 Wolfe, M. D., 180 Wood, A. W., 26 Wong, M., 28, 29 Woods, E. R., 198 Woody, G. E., 63 Wright, T. L., 179 Wynne, L. C., 20 Young, A., 150 Young-DeMarco, L., 179 Younggren, J. N., 234, 236 Zajonc, R. B., 9, 17 Zilbach, J. J., 51 Zilboorg, G., 199 Zimmerman, 73 Zuberi, T., 110

SUBJECT INDEX

American Association for Marriage and Family Therapy, code of ethics, 247–53 abuse: child, 50, 98; domestic, 5; emotional, 152; physical, 6, 45, 91, 134; sexual, 12, 89, 136, 139, 140, 200; substance, 78, 89, 152, 170, 198, 200, 249; verbal, 224 adaptation, 51, 182 adolescence: xvi, 62–64, 201; and suicide, xvi, 197–216 adoption, 152, 156 adultery, 182 aggression, 8, 71, 89, 133–34, 202 alliance, therapeutic, 74, 77–82, 121, 135, 137, 145, 236 anger, xvi, 33, 35, 36, 45, 59, 108, 122, 125, 133–36, 142, 151, 153, 156, 164, 167, 170, 180, 181, 184, 185, 187–89, 191, 192, 202, 205, 212, 228, 229 antithesis, xxvi, xxix, 28, 29. See also thesis, antithesis, and synthesis attachment, xxiii, 57, 180, 200 autonomy, 44, 86, 120, 121, 140, 185

blame, 40, 80, 116, 180, 189, 202 boundaries: xv, xxvii,12–13, 20, 60, 62, 103, 122, 123, 130, 133, 137, 146, 199, 202, 226, 234, 250; disengaged, 12 13, 43, 255; enmeshed, 12, 13, 43, 255; impermeable, 12; permeable, 12; semi-permeable, 12–13 cathexis, 25 causality: xix, 4, 5; circular, 4, 5; linear, 4, 5 change: first-order, xxvi, 69–71; second-order, 60, 69–71, 79, 94, 104, 126, 145, 155, 194, 203, 215; process, xxix, 23, 28, 29, 97, 112, 125 chaos, xxii child abuse, 50, 98 childhood, 14, 55, 61, 200 children: xiii, 9–11, 13–18, 39, 43, 44, 49, 50, 60, 62–65, 67, 70, 72, 79–81, 83, 114, 122, 134, 182, 201, 227; eldest, 17, 43; grandchildren, 18, 65, 67; only, 17, 43, 171; youngest, 14, 55, 61, 20 circumplex model, 255 “click,” romantic, 55–56 closeness, 44, 46, 51, 60, 122, 123,

belief system, xxiii, 7, 72, 223 belongingness, xv, xiii, xxix, 108, 149, 177, 202, 243, 257 301

302 | SUBJECT INDEX

126, 131, 135, 137, 141, 142, 160, 161, 164, 167, 177, 212, 224, 226, 257 cognitive–behavior therapy, xii, xiii, xxi, xix, 95, 199, 243 cognitive dissonance, 118, 218 coalition, 39, 80 cognition: xxii, 69, 140, 235, 244; and meta-cognition, 19 collusion, 137 compassion, xxviii, 188, 255 communication: xv, 6, 12, 13, 20n, 23, 24, 47, 66, 70, 83, 85, 88, 89, 121, 129, 146, 149–51, 157, 159, 160, 195, 199–203, 209, 219, 229: intellectual, 23, 24; emotional, 23, 24; kinesthetical, 23, 24; nonverbal, 21, 29; verbal, 21, 23, 29 complementarity, 15, 27, 56 confidentiality, 79, 98 conflict, xv, xxiv, xxix, 6, 15, 16, 20, 21, 26–28, 30, 32, 40, 44, 47, 51, 54, 63, 65, 70–73, 104, 108, 109, 129, 199, 202, 212, 219 confrontation, 29, 59, 108 constructivism, xxi context, xv, xxi, xxiii, xxvi, xxvii, 8, 26, 28, 30, 32, 56, 73, 74, 79, 86, 104, 110, 111–13, 126, 129, 134, 142, 149, 150, 183, 184, 186, 201, 202, 206, 242, 243 contract, xv, 27, 38, 49, 52, 74, 79, 96–99, 103, 115, 126, 129, 177, 178, 181, 206, 228, 235, 236, 237, 240–42 contradiction, xiii, xxix, 21, 26–30 control, xiii, xxii, xxiii, 7, 9, 10, 13, 19, 21, 23, 26, 31, 34, 37, 42, 44, 59, 63, 70, 71, 84, 89, 90, 114, 115, 121, 131, 133–35, 138–40, 146, 148, 150, 153, 157, 159, 164, 174, 183, 197, 198, 205, 217, 218, 244;

loss of, 31, 34, 50, 133, 134, 125, 138, 146–48, 164, 174 co-therapy, xiii, 36, 104, 116 counter-transference, 82, 106, 107, 236 couple therapy, 42, 48, 92, 94–97, 131, 159, 228, 229 crisis: 46, 51, 52, 58, 59, 66, 126, 146, 183, 184, 186–88, 197, 214, 224; marital, 161, 181, 183; occupational, 165 cry for help, 40, 126, 127, 138, 192, 202, 203 demoralization, 93, 145, 147, 240, 257 dependency, xxiii, 5, 32, 33, 66, 105, 110, 131, 161, 247 depression by proxy, 165–70 development: xxiii, xxxi, 10, 12, 13, 16, 21, 26, 28, 29, 30, 32, 38, 43, 51, 52, 61, 71, 74, 133; emotional, 39, 40; family, 51, 52; goal, 70; intellectual, 9; personal, 32, 44, 178; stage of, 51 dialectic behavior therapy (DBT), xxvi dialectics: xv, xxiv, xxv, xxvi, xxviii, xxix–xxxi, 26–36, 44, 51, 57, 71, 92, 120, 141, 145, 170, 244, 255, 257; method of, 31–32, 33; and dialogue, 36, 219, 222, 224, 258 dialogue, 34, 36, 118, 219, 222, 224, 227, 258 differentiation, 12, 17, 40 disability, xii, 14, 40, 43, 109, 113, 120 distress, xxvi, xxx, 47, 54, 86, 93, 114, 118, 145–47, 149, 150, 152, 165, 180, 186, 197, 240 divorce, 39, 42, 48, 49, 52, 65, 71, 119, 123, 128, 139, 163, 164, 177, 179, 182, 185, 188, 222, 258 double bind, 21, 22, 70 double message, 21

SUBJECT INDEX | 303

drugs, 6, 10, 37, 63, 137, 152, 198, 203, 223 overdose, 198 dyad, 13, 39–41, 58–62, 137, 182, 219 ego: 25, 127; dystonic, 73; syntonic, 72, 73 emotional: closeness, 35, 43, 44, 70, 131; distance, 23, 126, 131, 132, 185, 192; investment, 131, 135, 160, 183; involvement, 95, 121, 184; regulation, xxx, 37, 69 emotional distance regulatory mechanism, xv, 43–47, 70, 135, 164, 165, 183, 187, 257 empathy, ccviii, xxx, 207 empowerment, xv, 114–16, 134 empty-nest, 64 ending(s): xv, xvi, 67, 74, 129, 137, 188, 190, 234–39, 242, 249; premature, 78, 239. See also termination of therapy enmeshment. See boundaries equal-level situation, 105 ethics: 96, 98, 122; American Association of Marriage and Family Therapists, code of, 247–57 ethnicity, 110, 113 expectations, 5, 8, 10, 14, 30, 54, 57, 60, 88, 94–96, 111, 118, 140, 171, 178, 217, 238 exploration, xii, 78, 86, 120, 145, 151 externalization, 72–73 extramarital affair (EMA), 138–40, 146, 164, 165, 178, 179, 181, 183, 185 family: atmosphere, 47, 163; belief system, xxiii, 7, 72, 223; development, 52; dysfunction, 200; environment, xxiii, xxvi, xxviii, 12, 17, 146–48, 188, 200, 201; extended, 3, 7, 59, 146;

hierarchy, 13–14, 48, 64, 79, 81, 110, 200, 224, 256; history, 6, 11, 19, 20, 74, 78, 87, 88, 149, 166, 200, 202; homeostasis, 22, 47, 70; markers, 51, 53; myths, 20; niche, 9, 10, 17; of origin, 64; projection process, 40; secrets, 20, 46, 57, 119, 137–40, 182, 187; single-parent, 152; size, 9; system, 12–15, 19, 20, 39, 43, 44, 52, 67, 80, 184, 200, 201; therapy, xii, xv, xxi, xxiii, xxi, 20, 48, 88, 95, 96, 127, 140, 151, 204; traditional, 14, 16 feedback: 22–23, 62, 83; negative, 22; positive, 22, 28 follow-up, xvi, xxv, 42, 97, 98, 161, 165, 169, 190, 195, 214, 235–39, 242 forgiveness, 185 functionality (of behavior or symptom), 31, 153, 154, 162, 165, 170, 183, 185, 192–93, 235 gain: 14, 17, 46, 48, 55, 90, 114, 135, 148, 150, 190, 192, 219, 227, 234, 236, 238, 240, 241; secondary, 111, 120 gender, 9, 109, 110–13, 179, 182, 247 gestalt, xxi, 4 grandparents, 16, 18, 80 heuristics, 217 hierarchy, 13–14, 48, 64, 79, 81, 110, 200, 224, 256 history: 6, 11, 19, 20, 74, 78, 87, 104, 200, 212; educational, 88; family, 149, 166, 200, 202; medical, 88, 152, 166, 167; psychiatric, 91, 158, 170, 202 homeostasis, 22, 47, 70 honesty, 54, 98, 187, 188, 250 hope, xxii, xxv, 58, 94, 107, 108, 114, 115, 125, 127, 150, 157, 163, 168,

304 | SUBJECT INDEX

169, 178, 186, 189, 197, 245, 255 hopelessness, 48, 151, 171, 174, 189, 199, 221, 244 hostility, 49, 133–34, 184, 199 husband, xxv, 6, 15, 16, 21, 41, 42, 44, 60, 61, 70, 132, 139, 150, 137, 158, 159, 166, 178, 181, 182, 204 Identified patient (IP), xxi, 18, 40–43, 87, 146, 202, 215, 238 identity, xv, xxiii, xxiv, xxv, xvii, xxviii, xxix, 7, 10, 13, 15, 29, 32, 37, 44, 59, 61, 69, 73, 87, 108, 110, 111, 112, 138, 148, 149, 156, 161, 177, 202, 212, 213, 223, 243, 249, 257 individual, xiii, xv, xxi, xiii, xxv, xxvi, xxx, xxxi, 7–11, 13, 15, 19, 22, 28, 37, 41, 42, 44, 47, 48, 49, 51, 52, 61, 69, 80, 89, 92, 93, 95–97, 111, 130, 134, 137, 140, 149, 151, 155, 183, 185, 191, 193, 199, 219, 220, 224, 227, 242–44 individuality, 52, 59 individuation, 32, 44, 61, 64, 199, 234 infidelity: 50, 137, 178–82, 184–88, 192, 194, 195, 258; and betrayal, 180, 181, 186, 188, 192, 194; and “missing the train,” 183–184; prevalence of, 178–79; and selfesteem, 183; and “exit affair,” 185; and stress reduction, 184; and excitement seeking, 184; and revenge, 184; and social sanctions, 179, 181; and trauma, 181, 185, 186, 188, 190, 191, 194 infidelity, types of: sexual, 179, 180, 188; emotional, 179, 180, 188; virtual-Internet, 180 interlocking family pathology, 40 Internet, xix, 63, 169 interpersonal encounter, 14, 105 interpersonal space, 44, 226

interpretation, 29, 31, 34, 70, 82, 104, 122, 151, 156, 159, 161, 162, 170, 237 intervention, xii, 11, 41, 49, 71, 74, 79, 85, 92, 97, 103, 104, 108, 126, 127, 142, 159, 161, 162, 165, 170, 183, 197, 203, 206, 220, 222, 229, 233, 234, 240, 241, 244 intimacy, 42, 44, 46, 59, 83, 108, 121, 131, 141, 155, 160, 177, 184, 186, 187, 212, 213, 228, 247, 250, 257 jealousy, 180, 182–83 joining, xv, 34, 74, 77, 78, 79–86, 95, 103–7, 109, 110, 113, 116, 117, 119–21, 123, 126, 129, 142, 145, 159, 160, 162, 167–69, 190, 192, 206, 236, 241, 256 Kybalion, xix law of non-contradiction, xxix, 26, 27 libido, 25 life cycle, 18, 32, 51, 52, 64, 67, 71, 88 life events, 51, 200 living together, 57, 165 love, romantic, 110 machine metaphor, 4, 29 marital discord, 11, 39, 40, 42, 47, 48, 200, 202, 228 marriage, xxv, 13, 35, 38, 49, 52–55, 57–60, 65, 66, 77, 80, 88, 91, 94, 96, 108, 111, 119, 122, 132, 138, 153, 154, 160–64, 166, 177, 178, 181–88, 193, 194, 212, 222, 227, 257, 258 measure of last resort, 142, 218 mental short cuts. See heuristics meta-analysis, 17, 53, 78, 82 meta-cognition, 19 meta-principle, 244 metaphor, 4, 29, 103, 112, 149, 226

SUBJECT INDEX | 305

mindfulness, xxviii, xxix, xxx minority group, 111, 112 mourning, 92, 123, 233, 234 multigenerational process, 53, 63 narrative, 19–20, 33 negotiation, 11 object relation theory, xxiii, 120 opposition, 10, 26, 179 ordeal, xiv outcome, 8, 9, 16, 27, 71, 78, 82, 94, 113, 119, 126, 130, 135, 136, 165, 181, 190, 234, 238–41 paradoxical intervention, xiii, xxix, 26, 126 parents, 10, 11, 13–15, 16, 20, 39, 40, 42–44, 48–50, 55, 60–66, 70–73, 79–81, 85, 88–92, 97, 114, 122, 127, 128, 140, 150, 152, 154, 156, 162–64, 171–73, 200, 202, 206–9, 213, 214, 223, 227–29, 256 pathology, xvi, xxv, 22, 29, 40, 41, 61, 78, 110 112, 151, 169, 174, 199, 200 payment, 79, 96, 98, 99, 126 personality, xxvi, 9–11, 15–18, 25, 54, 64, 67, 72, 79, 96, 98, 99, 126, 118, 201, 243; Big Five characteristics, 147; Big Seven characteristics, 147; lexical structure, 147; testing, xiii, xxiii; theory, 8; traits, 9, 17, 54 personality questionnaires: 56; Minnesota Multiphasic Personality Inventory (MMPI), 147; Personality Research Form (PRF), 56 physical attraction, 53, 54 power struggle, xvi, 5, 38, 39, 63, 79, 125, 128, 129–33, 257 predictability, xxii, 7, 29, 30, 73, 128– 29, 138, 177

predisposition, 10, 147, 149, 150 prejudice, 111, 244 problem(s): behavioral, 40, 70; core or underlying, 48, 70, 87, 89, 93–95, 159; definition or redefinition of, 78, 86, 89, 92, 97; family, 13, 79, 85, 86, 163, 210; financial, 103, 212; focus, 32, 89–94, 96; and focused therapy, xiv, 32, 234, 235; formulation of, 103; marital, 71, 91, 127, 160, 209, 227, 238; medical, 37, 78, 88, 171; presenting, 78, 94, 110, 115, 145, 171; referral, 79, 238; school, 40 projection, 55, 156 propinquity effect, 53 proximity, 53, 54, 66 pseudo-mutuality, 20 psychodrama, 226 psychoanalysis, xi, xii, 4, 25, 29, 120, 121, 125, 154, 234, 256 race, 109–13, 122 radical acceptance, xxix rapport, 34, 82–86, 152, 153 reframing, 33, 71 regression, 22, 49, 199, 239 reinforcement, xxix, 241 relabeling, 71 relapse, 239 religiosity, 181 resistance, xii, xvi, 96, 98, 103, 104, 105, 109, 123, 125–29, 131, 137, 141, 142, 151, 191, 193, 213, 218, 236 responsibility, 4, 5, 11, 14, 18, 38, 40, 42, 43, 49, 50, 65, 71, 72, 87, 89, 96, 98, 107, 128, 132, 140, 148–50, 153, 154, 156, 160, 165, 170, 172, 186, 187, 189, 192–94, 221 resource: 9, 13, 17, 51, 66, 93, 148, 181, 182; dilution, 9 retirement, 52, 65–67

306 | SUBJECT INDEX

risk factors, 87, 89, 200 rituals, 110, 148, 177 role(s): xv, xxi, 10, 13, 14–18, 32, 38, 43, 47, 60, 63, 66, 67, 78, 80, 81, 86, 92, 94, 110, 132, 133, 137, 157, 159, 165, 169, 170, 172, 194, 202, 220, 226; change, 38, 65; conflict, 199; division, 59, 64, 88; model, 113; reversal, 59, 64, 88 romantic love, 110 rules: 8, 10, 19, 32, 60, 69, 70, 71, 79, 96, 110, 130, 186, 190, 194; of conduct, 98n safety, 46, 74, 110, 130, 151, 173, 177, 184, 202, 243, 257 scapegoat, 18, 37, 40, 165, 215 schemas, 61 schizophrenia, 21, 147, 150 suicide: 37, 69, 78, 90–92; attempt, 111; threat, 89, 135 sculpting:, 164, 226, 227, 229; family, 226 secrets, 20, 46, 57, 119, 137–41, 187 sexuality/sexual: 25, 53, 113, 122, 149, 164, 173, 179, 182, 184, 185, 188, 198, 249, 250; abuse, 12, 89, 136, 139, 140, 200; behavior, 8; fantasies, 178; orientation or preference, 110, 111, 172, 173, 247; relations, 35, 36, 66, 121, 158, 212 security, xv, xxii–xxv, 7, 14, 19, 20, 37, 42, 53, 57, 59, 61, 66, 69, 73, 83, 108, 130, 131, 138, 148, 149, 160, 164, 177, 217, 224 self: xiv, xxvii, xxviii, 4, 15, 61, 72, 105, 199, 217; actualization, 25; awareness, 86; control, 115, 138; defeating behavior, 148; definition, 72; destruction, 27, 198, 200; devaluation, 183; disclosure, xv, 46, 117, 126, 142, 256; employed, 84; empowerment, 134; esteem,

40, 112, 114, 119, 126, 130, 131, 147, 159, 183, 185, 192, 193; evaluation, 140; fulfilling ideas, 217; fulfilling prophecy, 55, 217; harm, xxvi, xxix, 199; knowledge, 244; management, xxx; mutilation, 198; preservation, 7, 217; reliance, 166; sufficiency, 66, 166 separation: xvi, 13, 39, 44, 46, 51, 52, 58, 61, 62, 66, 67, 127, 128, 134, 146, 173, 200, 202, 229, 233, 234, 236; and individuation, 61, 64; and unification, 52, 58, 61, 64, 65, 123, 199 short-term therapy, xii, 161, 173, 181, 239 siblings, 9, 17, 18, 49, 80, 157, 205, 211, 227 similarity, 9, 15, 17, 53, 54, 56, 110 social class, 28, 113 stability, xxii, 7, 15, 17, 22, 27, 29, 39, 64, 69, 70, 129–31, 135, 138, 149, 160, 164, 177, 178, 184, 193, 194, 201, 202, 240 stereotype, 111, 217 strategy, 53, 187 stress, xxx, 22, 30, 40, 44, 84, 85, 115, 135, 136, 156, 184–87, 196, 199, 200 structure, xiv, xv, xxii, xxxi, 3, 4, 12, 13, 19, 26, 28, 32, 51, 54, 60, 69, 104, 120, 147, 177, 186, 199, 203, 255, 256 stuck–unstuck therapy, xvi, xxv, 31, 32, 84, 97, 122, 125, 136–42 substance abuse, 78, 89, 198, 200 suicide, xvi, 69, 78, 90, 91, 92, 135, 198–215; attempt, 111, 197, 202, 203, 205, 211–14; threat, 37, 89 symptom: xv, xvi, xxvi, 31, 32, 37, 41, 43, 47–50, 51, 69, 70, 71, 73, 84–87, 93, 105, 110, 118, 145–51, 153, 154, 157, 159, 160–67, 170,

SUBJECT INDEX | 307

173, 199, 214, 239, 244, 256, 257; first-order, 70, 71; focus, 94 synthesis. See thesis, antithesis, and synthesis syntonic. See ego system(s): 3–24; and the individual, 8–11; belief, xxiii, 7; closed, 12; and dialectics, xxvi, xxxi, 32, 52, 78; dynamics, xxiv, xxv; and focus of therapy, 94; goal of the, 7–8; open, 12; social, 12, 244; structure, xxii; and subsystems, 3; theory, xiii, xv, 201; and therapy, xiii, 73 termination of therapy: xi, xvi, 41, 67, 98, 107, 134, 137, 140, 165, 169, 234–40, 242; forced, 235; circumstantial, 236; enforced, 236 therapy, types: behavior, xii, xxvi, xxviii, 47; cognitive behavior, 199; dialectic behavior, xxvin; marital, 155, 164, 228, 258; psychodynamic, xii, xiii, xxi, 47, 82, 95, 96, 199, 234; short-term or time-limited, 234, 235; strategic family, xiii; structural family, 71 therapeutic process, xv, 74, 103, 105, 120, 123, 125, 141, 142, 151, 236 thesis, antithesis, and synthesis, xxvi, xxix, 28, 29, 51 transference, xii, 122, 156 transition, 51, 52, 59–61, 64, 66, 71, 133, 151, 173, 184, 224

transparency, 121, 187, 191 trauma, xiv, xxx, 55, 64, 65, 123, 125, 138, 170, 180 treatment plan, 78, 85, 89, 90, 92, 93–99, 103 triangles, 37, 39–40, 137 triangulation, 39, 48, 64, 146 triggering event, 77, 78, 87, 199, 202 truancy, 47, 228 trust: xxv, 20, 21, 46, 54, 57, 73, 78, 82, 98, 105, 107, 109, 114, 117–19, 122, 132, 137–39, 141, 168, 172, 173, 17, 178, 180, 181, 186–88, 190, 194, 247, 257; building, 34, 191–92 unconscious, 121, 125, 199 validity: 54, 55, 93; external, 54; internal, 54 violence, 133–33, 182, 188, 202 wedding ceremony, 57–58, 177 wife, xii, xxv, 6, 15, 16, 33, 35, 41, 42, 44, 70, 72, 80, 132, 138–40, 152– 57, 165, 166, 181, 182, 189 working alliance, xv, 74, 77, 78, 121, 135, 145, 236 working through, xi, xii, 99, 107, 165, 234 Zen Buddhism, xxvi, xxviii, xxix, xxx, 255

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Moshe Almagor received his PhD in clinical psychology from

the University of Minnesota in 1983 and has been with the University of Haifa Clinical Program since that time. He served as director of the program and is head of the Laboratory for Personality Assessment, being recognized as an authority on Minnesota Multiphasic Personality Inventory instruments. He has been engaged in couple and family therapy since 1982 and is a senior clinical psychologist and codirector of the Mifne Center for individual, couple, and family therapy, where he supervises therapists and trains supervisors in family therapy. He is also a member of the Israeli Council for Psychology. Professor Almagor lives in Haifa, Israel. He is married and has eight children and nine grandchildren.