H. Peter Laqueur, MD
the Father of Multiple Family Therapy
the First Model

 

By Lewis N. Foster

"Are you willing to tell me your name?", Peter asks the lady who is attending the Multiple Family Therapy Group (MFGT) for the first time with her husband and four children. Attempts to get her to talk earlier were unsuccessful, so Peter asked the husband to trade seats with him. Gently and with care Peter sits on the edge of his seat and begins joining with the lady while bringing in other members of the group.

This is Peter's first contact with the suicidal patient referred by another physician. She and her husband have talked very little with each other for years. Her orientation to the group and assessment by Peter will last throughout the session. By the end of the meeting she will have moved to the chair next to another suicidal lady, stood in the middle of the group with her husband and experienced the "yes-no" and "back-to-back" exercises, listened to her children and husband tell what she is "good for," and joined with the lady in the chair next to her.

Interruptions by late families and children needing to use the bathroom are handled with care and in-stride by Peter. To one family arriving late Peter announces that "there are comfortable seats on the floor" while pointing to an area to his left. The family settles in quickly, whispering to the people around them, and Peter announces that "we are talking about not talking," redirecting attention to the activity before the interruption.

Peter's thinning short white hair is parted on the left and he is wearing a Philippines style shirt, loose and hanging over his belt. The date is April 5, 1977. (Two years before his untimely death.) His endearing accent sounds like Dr. Ruth's and he is very comfortable being on center stage. His level of comfort in groups and ability to organize presented itself in his family of origin.

It has been said that Peter used his talent for manipulating people and events to help hold his family of origin together. There were many stormy times and conflicts. When strong emotions were frequently and openly expressed Peter would assume the role of mediator. There remained, however, a sense of closeness and love. Peter and his father, a renowned endocrinology professor, took frequent long walks during which his father would discuss ideas that inspired Peter's development.

Peter's personality was greatly influenced by his medical training and projected itself in a strong identity as a physician. He spent about twelve years of his life working and growing as a endocrinologist. Today's group is the result of a suggestion of a family therapist friend over twenty five years ago.

It was recommended to Peter that he see smaller groups of families rather than have everyone meet in the auditorium of the hospital. Peter spoke about this during a lecture presented at Catholic University of Leuvern in 1977.

Peter speaking in Leuvern: "In 1951, when I was the director of a department for clinical treatment of schizophrenic patients between the ages of 12 and 52 in a large hospital in the New York area, every Sunday the parents, and sometimes the brothers and sisters, uncles, aunts, etc., of these patients visited the hospital and during visiting hours they saw me, each in his turn, for a few minutes so that I could reassure them, give them hope, and try to explain the techniques and medications used to change the psychotic state of the patients."

"When we discovered these feelings in the group, we decided to do something which was altogether taboo in the period: We had all the patients and all their visitors join us for two to two-and-a-half hours in an open discussion of all questions related to schizophrenia, to treatment methods, to problems during the patients' stay in the hospital and those of the future when the patients would go home again, their employment, their possibilities for marriage and for having children, etc."

"We perceived that sometimes the so-called "healthy" members of the families were almost as sick as the patients themselves, the main difference being that the patients had been the first ones to be sent to the hospital. To prevent the frequent return of our patients to the hospital after having gone home, it became necessary to treat their families as well as them."

"We formed groups of four of five hospitalized patients and their families and met with them weekly in therapeutic sessions through out the patients' stay in the hospital. During 17 years of this work with hospitalized patients and their families, we were able to reduce the number of readmissions to the hospital by 80%."

"Sometimes discharged patients and their families continue to participate in these multiple family therapy sessions and gradually, as our method became better known, multiple family therapy groups were formed in clinics and offices with ambulatory patients and their families."

Peter's use of the video camera provided training opportunities for he and his trainees. Participants in his multiple family therapy groups were keenly aware of the presence of the camera and two rather large microphones on stands, around which the group was circled. "Did you get that on camera?", was a frequent question of the camera operator(s), which was his wife Ria (Victoria Laqueur) much of the time. The session described earlier is no exception.

The above April 5, 1977 group consisted of over thirty people, including trainees, and what appears on the video to be eight to ten families. Like an orchestra conductor Peter generates a theme, joins and interacts family to family, assess situations, creates verbal and behavioral interventions, and therapeutically dances with the group.

Peter said there were several different styles of multiple family therapy group leaders. The Orchestra Conductor Style, the School Teacher Style, the Directive Style, and the Laissy-faire Style. Can you guess who you would and would not want as a co-leader?

Assessing the families generally took place in the MFGT session. Peter developed nine descriptions of the structures of disturbed families, a list of seven mechanisms of change within the MFTG, and six factors to assist in determining whether families can hold their own against environmental forces.

These were explained in depth during the lecture he gave at Catholic University of Leuvern in 1977. the lecture was printed in Group and Family Therapy 1980, published by Brunner/Mazel. A copy of the lecture follows with permission of the H. Peter Laqueur Foundation.

A typical MFTG led by Peter began with each family introducing its members and stating the reason's for attending. The next step would be to call on family members with similar roles and have them tell what hats they wear in the family and talk about their relationships with the family. This was followed by behavioral exercises developed by Peter and his trainees, or borrowed from others, such as the "Yes-No," "Back-To-Back," "Join Hands," and "Family Sculpture" exercises.

Peter recognized three phases of treatment:

Phase I - in which the family experiences feelings of relief.
Phase II - resistance to treatment as they come to understand their role in the dysfunction.
Phase III - slowly the family changes and works to support each other and other families.

END

 

 

 

Structures of Disturbed Families

By H. Peter Laqueur, MD

1. The Most Pathological Family. "Everyone is turned off on everyone else. They cannot talk to each other about anything, except perhaps the weather."

2. Mother or Father "in the Control Tower." "Communication by any member of the family is directed to the one in the control tower, who relays it to the other members. Direct communications between family members are avoided. All communications must go exclusively through the control tower, just as airplane pilots may not talk with each other over the radio when they are near an airport but communicate only through the controller."

3. Sex Gap. "Father and sons go fishing or hunting, while mother and daughters either stay home with the "serving" occupations less pleasant than the sports of men or do "feminine" things together like shopping, etc. There is little communication between the two subsystems."

4. Generation Gap. "There is no contact between parents and children. The parents' occupations do not interest the children and the plays and interests of the children are ignored or put down by the parents. The parents communicate with each other, but there is little communication between the generations."

5. Scapegoating. "One or two members of the family are accused of producing all the difficulties in the family and are being expelled (sent to the hospital or clinic or to the psychiatrist)."

6. Pathological Symbiosis. "Mother and son, or father and a daughter, are locked in a pathological symbiosis, producing much jealousy and finally alienation of the other family members."

7. Problems of In-Laws. "Father or mother has too intense a relationship with his or her own parent, so that the partner lives under the impression of always playing an inferior role in the interest of his/her spouse."

8. Mother Preoccupied With Outside Interest. "An uncle, or cousin, or perhaps a lover occupy too much of mother's time and energy, while the father is busy with work for the sake of financial security for the family and the children's education."

9. Different Value Systems." Important economic, racial, religious, philosophical differences and different cultural and social customs between father and mother can cause great difficulties, especially if the therapist identifies with one or the other because of his own value system."

END

 

 

 

Multiple Family Therapy
Mechanisms of Change

By H. Peter Laqueur, MD

(With notes added by Lewis N. Foster)

1. Learning by Analogy. The families in the Multiple Family Therapy Group (MFTG) have occasion to observe analogous conflict situations and learn from these examples.  A father can learn about paternal behavior by seeing other fathers in action, a mother from other mothers, a youngster from youngsters in another family. Within the same family there are no useful analogies. Jimmy, a youngster in family "A" and Tommy, of family "B", can discuss how Tommy's parents affect Tommy's behavior and from this discussion Jimmy's parents can quietly learn without being directly confronted.

Note: A.H. Strelnick, MD says the following about this Mechanism of Change. "Learning by analogy is Laqueur's terminology for the method of insight through observation. The potent impact of these observations often is the concrete alternative to family conflict that successful models provide. Families (who have been there) provide important incentive for others to learn and decrease the stigma and isolation created by any problem necessitating therapy. an extension of this concept is learning by identification, whereby individual members of the group find strong similarities in their mutual situations. although Laqueur implies that this is applicable only to parallel family positions (e.g., fathers identifying with fathers, etc.), <patients> so identify with <patients> independent of family position; adolescents dealing with individuation identify with married woman struggling with the same issues, and so on. When this concept is expanded to include the family as a whole, Laqueur labels it an identification constellation, and when applied to situations rather than people, he calls it tuning in to the discovery of parallels and simile in mutual situations. These similarities and differences--significant and trivial, large and small--provide a rich source of reality-testing." (Multiple Family Group Therapy: A Review of the Literature, Family Process)

2. Learning By Indirect Interpretation. Direct interpretation by the therapist, such as, "You behave this way because you hate your father," will most likely mobilize the patient's inner defenses against this unacceptable idea, although outwardly he may eagerly agree. The same observation couched in more general, indirect terminology, such as, "It is possible that a person's inner growth is hampered by his hidden hate of a parent," allows the patient to draw his own conclusions and learn by self-examination without being forced into the defensive by an open confrontation.

3. Use of Modeling. The therapist may use the healthier aspects of one family as a model and challenge to another family to change its behavior. Or the therapist, co-therapist and some observers may themselves model for the group different ways of solving a given conflict. The members of the group will at first imitate the desirable model, but eventually they will integrate it on a deeper level in their own behavior.

4. Learning Through Identification and Identification Constellations. The MFTG through its diversity provides many opportunities for identification. Identical family configurations produce something that could be called identification constellation. In a group containing four young female patients and their mothers (three of the mothers widowed, one divorced) very soon a strong identification of the four young women and the four mothers was observed.

5. Learning Through Trial and Error. The members of an MFTG have a unique opportunity to try out new behavior and either have it reinforced by the approval of the group or reject it if it does not achieve the desired result.

Note: A.H. Strelnick, MD says, "Learning through trial and error becomes another mechanism of change in MFT, because the group gives the family members a uniquely protected, surrogate rich environment in which to experiment with new modes of behavior. Not only the family but the group is present to reinforce more adaptive or discourage maladaptive changes. This is possible, in part, because of the decreased authoritarianism of the group; neither therapist nor parents have the authority they possess in smaller groups. This is well documented in the comparative psychotherapy work of Harrow, Astrachan, Becker et al."

6. Learning To Understand Intrafamilial Codes. Every family seems to develop its own code for internal verbal and nonverbal communication among its members. Not only must the therapist learn to understand this "internal language" of the family in order to reach them, but often the family members themselves are not aware of using a code and another family may have to point out to them what they are doing. a mother may have a specific signal for shutting off further discussion of a painful subject--like stroking her forehead or touching her hair--to which all members of the family react to instantly but without being aware that they react to this signal until somebody points it out to them.

7. Amplification and Modulation of Signals. A sensitive patient can pick up a signal from the therapist and amplify and modulate it. For example, an overanxious father and his rebellious daughter get into frequent violent quarrels in the MFTG. The therapist says, with a twinkle in his eye and a smile to another patient, "Isn't that the very thing we had between you and your mother a few weeks ago?" Patient "B" says, "Sure," and forthwith attacks father "A", "you don't think that your scolding will endear you to your daughter or make her behave better, do you?" The parents of "B" confirm that scolding and fighting did not get them anywhere with their daughter but that a reasonable, open-minded approach worked. Families "C" and "D" pitch in and now the signal from the therapist to "B" has been amplified and modulated in a way that makes it much more effective than if the therapist had just "preached" to father "A."

Note: A.H. Strelnick, MD says, "He uses this as a model for therapist-patient relations, but it also seems appropriate for explaining how any statement is universalized and translated for all to respond to and to understand. Much of this process is concrete translation of one family's situation to another's. Families may gain confidence from another just by properly understanding how the family has been able to cope with a comparable problem." This is "the method by which patients or families may pick up interpretations by the therapist and sensitize others."

8. Delineation of the Field of Interaction. The manner in which MFT helps a family understand a problem within a system of interactions. The family sees how the environment (not just the family) affects an individual and how he affects the behavior of those around him. The family then learns to share joint responsibility for what happens to the "parent" and their home situation. Thus, MFT helps a family make the transition from viewing the "patient-as-the-problem" to the "family-system-as-the-problem." (Strelnick)

9. Those Events That Have the Least Probability of Occurring Have the Most Significant Information Value. (Strelnick) "Any new, more realistic, or appropriate behavior in the family group setting can become the {focus of excitation} for the group as it attempts to emphasize the significance of and reinforce the observed change. These are often insightful, profound, or perturbing statements or behavior from the quietest or most disturbed members of the group. an example I observed was the questioning of a disturbed patient by the eight-year old son of an older patient. The patient, who was deliberately holding back expression of his true feelings, was disarmed by the innocence and sincerity of the small boy asking a question the staff knew they could not ask without the patient withdrawing still further. The patient expressed his deep, negative feelings and for the first time accepted the support of the group."

End

 

 

 

 

Factors That Determine Whether An Individual Or A Family Can Hold Their Own Against Environmental Forces

By H. Peter Laqueur, MD

1. The system can react with enough adaptability and elasticity
. *(The organization influence #4, there needs to be a clear distinction, for example, between the parenting and marital relationships. Both relationships must be nurtured regularly.)

2. The system must be sensitive to variations in the external milieu and to changes in its internal milieu. *(The tenderness influence #2, the family must be sensitive to and value the diversity of each member and express feelings, thinking and behavior openly. Change in the neighborhood, community and society need to be dealt with flexibly, while maintaining the character and personality of the family.)

3. If there is an overload of events and information, the system can process all this efficiently. *(The operation influence #5, the family exists essentially for the members, not the members existing for the family.)

4. The system can make a realistic selection (with good judgment) between correct and incorrect impressions and information. *(The choice influence #3, it's not what we don't know that causes problems, it is what we know that isn't true.)

5. For survival, the system can focus on those phenomena which are most important and to concentrate its attention on high priority activities. It can postpone occupation with dreams and fantasies until later, when there is time for it; so, it must not indulge in the game of "procrastination." This, of course, does not apply to thoughts and creative images, which precede new ideas and inventions. *(The attention influence #1, for subsistence, the family must be able to focus on those events which are most important to survival of self and the family. It must not indulge in the game of "putting off" until later what needs attention now.)

6. The system can perceive of making logical plans and of executing them, while continuously seeing the mediator and final results (feedback). *(The wisdom influence #6, the family must be able to collectively sense and recognize the situation's); consider the options; inspect the feedback of the middlemen (MFTG & therapists); look at the consequences of each option; come up with the right solution's for them; make plans; and follow through with them.)

*Note: Lewis N. Foster found the above factors useful in deciding need and appropriateness for multiple family group therapy and readiness for leaving the group. He reordered the factors, added a little and renamed them.

End

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