Georg Ivanovas From Autism to Humanism - systems theory in medicine
Issues of this chapter: hierarchical structure in the living; network pathologies; symptoms in the frame of an ecological context; reactions of a system after a therapeutic intervention, paradox interventions
Systemic psychotherapy does not belong to CAM or observational medicine, neither from its theoretical background, nor from its social context. It was introduced by respected people of the scientific world, it was practiced at known institutes and even at universities and it was, in opposite to most CAM methods, theory based from the very beginning. It is discussed here as it provides basic and necessary insights into the systemic approach.
After WW II, family therapy came into the focus of interest. Many psychotherapists found that the treatment of an individual was less effective than the therapy of families. It was observed that a patient might make good progress in an individual therapy, but behaved like before, being with her family (Satir 1964). Some saw here a causal link and blamed the family (Hayes 1991). But this was an unsatisfactory situation. It put the therapists in the role of a moral instance they could not fulfil. Even more, such a view aggravated the problem in the way of the self-fulfilling prophecy (chap. 4.2). Parents, in the knowledge of their unlimited responsibility, did not behave naturally anymore and the relation between children and parents became poisoned (Dörner et al 2001).
Systemic psychotherapy came to the opposite conclusion, condensed in statements like: “Families do not fail, therapists do” (Whitaker cited in Roberto: 455). Such statements represents a radical change of attitude of the therapist and created a real shift of paradigm. The family became “the natural context for both growth and healing” (Minuchin/Fishman 1981: 11).
All behaviour of families is polycontextural and organized in a recursive manner, embedded in positive and negative feedback mechanisms. Therefore, the search for causes is quite often futile and the fight against ‘causes’ not effective. The simple positive feedback mechanism of anger has been described earlier (chap. 4.2). The analytic approach investigates the precise conditions of this mechanism. The systemic approach looks at the context that enables this mechanism to develop or to stop at a certain point. If someone becomes sometimes angry this is not an important issue. But it might be, if someone is always or often angry or cannot control it anymore, that is, if there is no mechanism to control the positive feedback leading to an exponential runaway.
When a certain circuit gets out of control it has to be seen as a disturbance of the cybernetic interplay of the whole system (Bateson 1972: 430-431), as a network pathology (chap. 6.7).
Classical examples for circular relations creating problematic situations are the wife who nags because her husband drinks and the husband who drinks because his wife nags; or the child that does not want to go to school because his mother is so anxious and she is anxious because her husband is always angry and the husband is angry because the child does not want to go to school. In such cases quite often the attempt to control a situation (the uncontrolled anger of a patient, the husband drinking or the child not going to school) serve even as an amplifier, as a part of a schismogenetic pattern.
It is not up to the physician to decide, how a family should live, how it carries out its tasks. This would involve personal values. Every family has its own values, its own theories in how it should behave. This has been called the ‘myth’. Myths may govern the behaviour and communication of all family members, such that everybody tries to influence the other to obey a certain value, a set point. It is important for the therapist to be aware of this (Papp 1983: 154) and not to confuse it with his own values. The main question is therefore, how well a family is able to carry out its task (Minuchin/Fishman: 20). In the normal case, “the healthy family finds creative ways to reconcile present needs with the past traditions and values that cycle slowly through current living” (Roberto 1991: 448).
Emotions in such a network are an expression of the family structure and not an independent or individual issue. Minuchin and others could trace this down to the physiological parameters. Insulin and catecholamins in the blood of a child change when observing arguments between its parents. We all experience this in one way or another, feeling relaxed in one company and stressed in another. Often it is impossible to explain why we feel that way, but it has clear consequences for our metabolism. Minuchin and Fishman talked in such a case of a ‘conjoined physiology’ (Minuchin/Fishman: 12-13), others of family somatics (Kröger/Altmeyer 2000). This concept of a conjoined physiology resembles the neurophysiological mirroring (chap 4.2).
Problems might arises, when the family becomes stuck at a transition point in its life cycle (Hayes 1991), when children go to school or finish it, when parents get a new job or lose it, when new persons become attached to the family, at certain round birthday numbers or when members of the family become ill or die, that is, when the situation is ‘heated up’, such that special patterns and states develop, just as seen with silicone oil. (chap. 4.11)
In such cases the symptom of a family member might have a stabilizing effect. The typical example is the child becoming asthmatic when the parents have a tendency to separate. A physiological explanation would be that the family tension increases the stress hormones in the child facilitating asthmatic attacks. The concern of the parents makes them more cooperative and brings them closer together. As the situation relaxes, the asthmatic symptoms decline. This, the child becomes an indicator of the stress level of the family. Simultaneously the child also gets some power over the family communication. For example, parents often report that the child becomes symptomatic, as well, when the relation between the parents is very good. This can be explained with a felt set point of the child concerning the distance between the parents which has to be maintained. Any divergence from this inner picture produces stress and symptoms.
In such a situation the whole family seems to be governed by one member, or better by the symptoms of one member. May be a certain disease or symptom is accidental at first. But with the time it develops an own meaning, a signification. Often the metaphoric interpretation is heard that an asthmatic crisis is an expression for a ‘suffocating situation’. Such metaphors play an important role in the development of an homeostatic process (Papp: 141-142). But the crisis might produce the suffocating situation it is the consequence of.
Stability or homeostasis is not maintained by the symptomatic member, the so-called identified patient. This would be a misunderstanding of networks. Such a symptom “represents a convergence of prescribed family roles and legacies, biological predisposition in the symptomatic member, previous attempts by the family to solve the problem, and perhaps random misfortune, as well” (Roberto: 451-452).
A symptom might be somehow accidental at first, but through a long-standing, repetitive pattern of interaction (Papp: 140) the situation becomes rigidified (Roberto: 451), developing a homeostatic regulation. In the terms of synergetics it could be said that the problem arises when there is only one possible state for the family, whereas according to the internal and external conditions a different state or different states would be more probable and better adjusted.
This process does not only involve the family members. The physician becomes part of it, as well. His intervention contributes to the outcome, whether he wants it or not, especially as the family has the possibility to chose a physician who matches best its pattern. He might contribute to the problem by deepening the valley of the state. For example, he might treat the insomnia with drugs making patients dependent, or by inducing other self-fulfilling prophecies.
If there is a homeostasis including the identified patient being ill, the system ‘family’ will protect itself against disturbances from outside. Outer influences in order to change the internal pattern might provoke a reaction of the system against this intervention. Or, if something is changed in the identified patient another member of the family might counter-balanced this by becoming symptomatic (Hayes 1991), as shown in the case of the hyperkinetic girl (chap. 2.2) and the autistic boy (chap. 6.8).
In a case where the family pattern is rigid it becomes difficult to influence it from outside, because the family will try to continue the same pattern all over. The attempt to change such a pattern is as futile as stirring in heated silicone oil (chap. 4.11). At best, the direction of the pattern changes, but not the pattern itself. In heated silicone oil the pattern resumes after any disturbance because it is the optimal form to transport heat to the surface. The same is true with ‘heated’ families.
Treating a symptomatic child leaves the family pattern unchanged. Drug therapy in such a case often solidifies only the rigidity of the family structure, not only the rigidity of the individual metabolism.
But psychotherapy is often not better off. The more open and direct the therapist tries to re-educate a disturbed family the more probable it is that he induces processes that lead to a stronger rigidity (Haley 1963: 225)
It does not really help to understand the situation. First, understanding depends more on our values. Second, knowledge is no therapeutic means. It is as often in medicine: we might “learn a lot but not change much” (Keith and Whitaker cited in Roberto: 466).
The essential contribution of systemic psychotherapy is its different stance towards therapy. It is a shift in attitude. Instead of searching and altering self defined causes, it tries to find solutions. In this regard, but only in this, it resembles behaviouristic methods. However, it differs from them as these follow a reductionist paradigm.
In systemic psychotherapy there are several schools with different techniques and theories how new solutions can be obtained. However, every school uses also the techniques of the other schools. “The truth is that different systems of family therapy are more alike in practice than their theories suggest” (Nichols cited in Hayes 1991).
These different schools can be divided into two major classes, the ‘structural’ and the ‘strategic’ approach. It might also serve as a blueprint for judging different methods of empirical medicine and those parts of orthodox medicine which exceed the strict reductionist model.