OUTPATIENT MULTIPLE FAMILY GROUP
Norman L. Paul, MD
Joseph D. Bloom, MD
and Betty Byfield Paul, ACSW
Editors' summary. Outpatient multiple family group therapy has emerged within the past two decades from conjoint family therapy and group psychotherapy. Particular emphasis in this paper is on the description of the participating families and on the emphatic impact on others, of the review of hitherto hidden critical historical material. Verbatim excerpts from the multiple family group sessions are presented to give the reader a view of the wide interactions between members of different families around affective historical material. The verbatim accounts are used to discuss different aspects of the primary value of the multiple family group setting.
The task of each family is ... to cherish the living, remember those who have gone before, and prepare for those who are not yet born.
---Mead and Heyman (14)
Mead and Heyman, in their pictorial essay, focus on the sweep of life experiences and the influence of the family on both the individual and society. The importance of transactional experiences between family members demands an understanding of the ways these experiences are perceived. Each transaction has its own history; each mode of perception is dictated by one's total personality and prior experience. The historical perspective is vitally important for all individuals in expanding their awareness of themselves in time and space and developing their sensitivity to both how they perceive others, and how others perceive them.
This paper will describe how multiple family group therapy is related to conjoint family therapy in terms of theory and technique. In each setting, the focus is on the review and understanding of the historical reality of the family, with specific emphasis on the current relevance for each family member of the affective material generated by events in the family's life history. Highlights of the pertinent literature on both conjoint and multiple family therapy will be reviewed. Material from a multiple family group, employed on an outpatient basis, will be presented to illustrate the impact of reviewing the historical reality for one family's experience with other families present.
REVIEW OF THE HISTORY OF CONJOINT FAMILY THERAPY
Freud, in many of his papers, focused on parental influences in the development of the child; however, at no time did he underscore the need for either assessment or intervention with the family as a unit. Interested in family therapy was stimulated by observations that schizophrenic patients, like children in treatment, are very dependent on family members. Rudin (18) reviewed a series of interviews of families of schizophrenic patients as part of his study of genetic factors in schizophrenia. He, as others since, was curious about the phenomenon of anteposition, wherein the mental disorder of the descendant tended to be manifest at an earlier age than that of the antecedents. This, plus the presence of similarities between the family's difficulties and those of the patient, coupled with the absence of specific Mendelian findings, implied the influence of social forces.
More recently, Nathan Ackerman (1) initiated a chain reaction of interest in the family with his paper, "The Unity of the Family." In developing such concepts as "family homeostasis" and "family equilibrium," Ackerman proposed that the family should be viewed as a critical reference point when dealing with individual disturbances. Ackerman and Sobel (2) underscored the need to understand family processes as a means of understanding the young child.
Jackson (9) focused sharply on some of the psychological upsets occurring in family members as a consequence of improvement in the identified patient. He tentatively related parental interaction patterns to specific symptoms and signs in the patient. He emphasized the importance of disabusing professionals of the concept of the "schizophrenic mother," which he held to be misleading and inappropriate in the light of his investigations. Lidz and his co-workers (13) stressed the importance of dissonant patterns of interaction, gleaned from studies of schizophrenic families. It is to be noted that Lidz's findings were based upon extensive investigations of schizophrenic families whose members were seen individually. Bowen and colleagues (6) described the fluctuation of symptoms from one family members to another as changes in family interaction and structure were taking place. Bowen later (5) elaborated on this thesis, pointing out the generational influences in the genesis of psychoses. He indicated, as an illustration, that a feeling in the mother can become a reality of her child without either one being aware that the transaction was occurring. The projection of unrecognized helpless feelings by mothers onto their children seemed to be one element contributing to a system of reverberating disturbances leading to a fixed family equilibrium. He called into question many concepts such as "rejecting mothers" and pointed to the need to become more concerned with the totality of family interaction and family process.
The dilemma in comprehending family therapy was reinforced by the formulation of the "double-bind" hypothesis of schizophrenia, elaborated by Bateson, Jackson, Haley and Weakland (3). Here emphasis was on the communicative strain within the fabric of the family, which suggested the importance of unraveling confusing patterns of communication. Wynne and his associates (22) described pseudomutuality in the family relations of schizophrenics. This thesis emphasized the discrepancy between what appears as a facade of family relatedness and the underlying, less readily recognized need to deny individuation for fear of disrupting the relationships. Paul and Grosser (17) and Scott and Ashworth (19) converged on the importance of family history and the history of mental illness in the parental backgrounds. These investigations suggest that any given family is a dialogue between history and resent interaction. The salient feature, which emerges from family studies to date, is the difficulty in translating via language the complexity of innumerable variables simultaneously operating in the genesis of a fixed family system.
Grosser and Paul (8) reviewed some of the pertinent ethical considerations dictating both the rationale and the resistance to conjoint family therapy. They formulated a series of goals. The following aims for conjoint family therapy, derived from Grosser and Paul, are also regarded as applicable to the multiple family therapy setting:
1) To develop an appreciation of both ego-alien and ego-syntonic affects among family members through shared emotional release and exposure.
2) To broaden the capacity for reality testing and consensual validation as a check on projections and distortions by having different family members review the same event from their respective pints of view. This serves to increase the individual's ability: (a) to tolerate differences in perception, and (b) to tolerate ambiguities and uncertainties.
3) To review historical material this may have relevance to present day intrafamilial problems.
4) To encourage each family member to develop an empathic capacity for observing ego functioning in bearing anxiety and its related affects and fantasies.
5) To facilitate object relationships outside the family unit by neutralizing symbiotic patterns within the family circle.
6) To tolerate, work through, and integrate the fantasies and reality of termination.
REVIEW OF THE LITERATURE ON MULTIPLE
FAMILY GROUP THERAPY (21)
The multiple family group therapy literature has come from inpatient hospital services that made the first attempts at use of this mode of therapy. Detre et al. (7) and Paul (16) approached the situation of a collection of families in a hospital setting as an opportunity to educate and acquaint each family with some of the realities of family life existing in the idealized other families. Laqueur et al. (12) formalized multiple family therapy in the hospital setting, believing that it combined opportunities for peer group relationships and communication with sanctions for individuation. They found that the schizophrenics in the family units with which they worked seemed to improve; however, the relatives, upon observing the improvement, began to emerge as patients. They noted a process of revolving disorganization and reorganization of family structure. Blinder et al. (4) described the stages of group process in dealing with hospitalized patients and their families. Their object was assisting family members to neutralize recurrent feelings of anxiety, guilt and helplessness about the patient. They describe the concurrent use of individual and conjoint family therapy and multiple family therapy, which they felt involved families in the experiential aspects of treatment. A primary goal and, consequently, the principal focus in their treatment program was to encourage family members to learn about others and the self and to be that there can be an emotional kinship among families.
Laqueur (10, 11) was a devoted exponent of multiple family therapy (MFT) and focused on the trial and error learning properties for family members of this modality. Families could see that other families were peers, struggling with similar problems, albeit in their own manner.
A key element inherent in MFT is that the family unit will process and review their experiences of prior sessions between sessions. Thus, a natural homework-like feature is introduced into each family, permitting a digestion of the derivatives of the universal themes of fusion ↔ individuation, and dependence ↔ independence ↔ interdependence.
Nevin (15) elaborated on the general absence of outcome studies, citing this as a key factor accounting for its being "the overlooked" treatment.
The primitive state of development of this modality is in sharp contrast to its clinical effectiveness. This discrepancy is principally related to the inability to translate the enormous experiential data into language. The bankruptcy of our linguistic tools in coping with such data is particularly apparent when one is confronted by the experience of a multiple family group (20)
DESCRIPTION OF A MULTIPLE FAMILY GROUP
The multiple family group consisted of five families. One family left after ten sessions and was replaced by another family, after which the group remained constant. The group was carried on in an outpatient setting on a private basis, meeting once weekly for a 90-minute period. The group therapist (Normal Paul) was also the conjoint family therapist for each of the families present at the meetings. This resulted in a high degree of correlation of individual sessions with group sessions. A free flow of information between settings was actively encouraged by the therapist. In four cases, families had regular contact with the therapist in conjoint family sessions between the multiple family group meetings. At times, the parents of a family unit (grandparents) were seen i conjoint marital therapy; any family member could be interviewed individually at the option of either the therapist or family member. The group composition was generally constant; the usual number of people attending each meeting was between 20 and 22. Every meeting was audio taped; there was one observer (Joseph Bloom) in the room whose function was to record nonverbal affective communication. Graduate students in behavioral sciences also observed the group through a one-way screen. As part of their graduate work, they attempted to formulate an effective technique to observe and record communication in a setting providing a tremendous variety and richness of data.
The individual families in the group were:
The Henry family, which included parents in their late fifties with three adult sons. The family was referred for a family systems approach because the youngest son, who had been in a day hospital for several months, was suffering from depression and active suicidal behavior. The main family problem revolved around the secret known to all family members, but kept from the father, that he had multiple myeloma. His illness was initially presented to him as a "slight anemia." This distortion, coupled with the increasing severity of the father's illness, precipitated frantic behavior in the family, culminating in the scape-goating of the youngest son. The family left therapy after the father's illness was brought out into the open, both within the conjoint family therapy sessions and the group. They left after 10 sessions, with much pressure taken off the labeled patient, the youngest son. Their leaving reflected the intense charge generated by the father's illness for both his family and the other group members. It was too painful for everyone to see a dying man each week.
The Zucker family replaced the Henry family. This family consisted of parents in their forties and their four sons, aged 18, 16, 13 and 12. The labeled patient was the 16-year-old, Chuck, who was referred by the school guidance counselor for treatment because of truancy, alcoholism, delinquency and depression with suicidal impulsivity. Though this son was named after his father, father and son were very distant and cold in
their relationship. Father, a highly successful business troubleshooter and an obsessive man, was a severe martinet with his sons. He had a tragic background. When he was four, his mother chloroformed to death his younger sister, attempted to murder him with an overdose of Veronal, and then killed herself with Veronal. He "found out" about this when he was 21 and happened to go through his father's safe deposit box for his birth certificate required for Marine Corps enlistment, and discovered the inquest findings. His father had remarried when he was six. He remembered being told that his mother had "gone to the country"; later he defended vigorously the appropriateness of this lie. Me. Zucker had coped with his overwhelming sense of grief and helplessness by adherence to rigid orderliness, against which his namesake globally rebelled.
The Chubb family came to treatment because of concern about the older siblings of a third son who had been treated over the past six years for childhood schizophrenia. The child, age 11, was in a residential treatment center. The parents attended the group with their two adolescent sons, ages 15 and 14. The youngest of their four children, a girl, aged six, was apparently developing normally. This family had many difficult problems. The mother had had an intense parasitic relationship with her own parents. After considerable previous individual treatment, with infrequent family meetings, she had been able to individuate to some extent, without the dire consequence of her father's death from a heart attack, as he had often predicted. Mr. Chubb was a successful engineer who had extreme difficulty in the recognition and management of his rage. He described a lonely, angry childhood filled with suicidal ruminations and gestures. The happiest moments in his life occurred when, as a fighter pilot, he would have an enemy plane within his gun sight. The main reason for their participation in this group was their concern for their adolescent sons. Both, but especially the second eldest, were extremely inhibited and shy. The second boy was so withdrawn as to present a preschizophrenic picture.
The Redstone, Jr. family (see accompanying chart) consisted of parents and three children: Norman, 12, Joe, 9, and Janet, 6. Joe, the second of the three children, lived at home and began therapy in 1969; family therapy began in 1973. The parents, the older son, Norman, and the father's mother, Mrs. Redstone, Sr., attended the meetings. Mrs. Redstone, Jr. had had a very destructive relationship with her partially deaf, variably psychotic mother. Her childhood was usually filled with magic and evil spirits and she had been chosen as the representation and repository of evil in her nuclear family. His mother dominated Mr. Redstone, Jr., an extremely inhibited, rigidly obsessed man. Mrs. Redstone, Sr., had married his father after the suicide of his father's first wife (same first name as the second wife). Mr. Redstone, Jr. was the only product of this second marriage. He learned that this was his father's second marriage when he was nine by overhearing a conversation. No discussion of this or of other events in his nuclear family ever took place. The son, Norman, age 12, was an extremely bright, verbal youngster, who had been rebellious and frequently anxious. This family attended the group in part for the benefit of this boy. Mrs. Redstone, Sr. was 73 years old; she appeared depressed and solicited frequent barbs from her daughter-in-law.
The Smith family included parents in their sixties, and married daughter and her alcoholic husband, and a divorced older son with a history of 11 years of hospitalizations for schizomanic psychosis. The parents in this placid-appearing New England Yankee family had always felt they had a happy adjustment. The son, Peter, had been a brilliant Yale student who had his first psychotic break during the sophomore year; he never returned to his previous level of functioning. The daughter, Liz Smith Black, married a despairing, unemployed alcoholic young man who had impregnated her before marriage. Mrs. Smith's paradoxically sweet, yet angry manner generated the others oscillating feeling of loss of control and helplessness. Mr. Smith, a retired diplomat, was a confirmed advocate of peace at any price. His mother died when he was four. He grew up managing most of his emotions by denial and by busying himself.
The Holt family consisted of parents in their mid-forties, a son, aged 12, and a daughter, aged 12. They came for individual family therapy in 1974 because of a marital situation that was heading toward the divorce court. Their problems were less severe than any of the other families and had to do mainly with the management of abrupt anger and bitterness in the course of everyday life.
As can readily be seen the group was a heterogeneous assembly, ranging from children in pre-adolescence to grandparents, who brought a broad variety of experiences to the sessions; the potential for mutual help through sharing these experiences was great. On the problematic side of this group was the presence of the seriously psychotic and neurotic. Although the features emphasized in this brief sketch are the pathologies of these group members, it should be remembered that these people also brought many assets to the sessions. They were an affluent, motivated group of families, above average intelligence, who's decision to participate in multiple family therapy was their own.
As has been stated, the amount of material generated in this setting is large and varied. Any number of phenomena could be illustrated. One could demonstrate similarities and differences between multiple family group therapy and regular group therapy in terms of resistance, variable symbiotic patterns and transference. One could report examples of communication problems between the generations; one could focus on how the children in the group handle themselves and interact in a group of this nature. Excerpts from two meetings have been chosen for this paper to illustrate a central theme in our approach to treating the family unit. Both examples include a vivid recollection of the past. Group reaction is noted to demonstrate how the family groups reacted to a review of emotionally charged historical material.
The first illustration took place during the last half-hour of a session. The major theme of this meeting was the early death of a mother. One father, Mr. Zucker, defensively belabored the point that, after his mother committed suicide when he was four years old, it was the "right thing" to be told, "She went to the country." Each of the six adolescents present vigorously took issue with this assertion. Mrs. Zucker, resonating to her husband's denial, poignantly stated:
Mrs. Zucker (tearful): My mother died when I was about a year and a half, so I always knew she was dead.
Dr. Paul: What?
Mrs. Zucker (crying): I always knew she was dead.
(Silence. Mrs. Zucker cries softly.)
Mrs. Smith: You never really had her, did you?
Mrs. Zucker (muffled): I didn't know I was going to do that (crying) here.....
Mr. Redstone, Jr.: This is something that you spoke of before, too. You told us this before.
Mrs. Zucker: Well, I always knew she was dead, so I faced it.
Mrs. Redstone, Sr.: But the person who brings you up, biologically she is not your mother, but otherwise--she is your mother....I brought up two children and...
Mrs. Zucker: Well, you---you feel differently.
Mrs. Redstone, Sr.: Hm?
Mrs. Zucker: You feel differently.
Mrs. Redstone, Sr.: You feel differently if you know.
Mrs. Zucker: Well.....oh, I don't mean that. I mean, then my grandmother took care of me, my grandmother and my grandfather; and then they died. And then an aunt took care of me.....and uh.....(crying)....
Mr. Smith: Well, I remember preferring my stepmother, my new stepmother, to the housekeeper that took care of me in the interim between my mother's death and my father marrying again.
Mrs. Redstone, Sr.: I hate that word stepmother. I never liked it.
Mrs. Zucker: Well, if I were one, I wouldn't like it either, I guess.
Mr. Smith: You know the difference . . . it becomes necessary to make the distinction.
Mrs. Redstone, Sr.: Why?
Mr. Smith: Well, in my family it did because my sister never accepted the stepmother at all. She was just a person. So in talking with her (his sister), if you said "mother" she would immediately think you were talking about her own mother.
Mrs. Redstone, Sr.: (begins a story about her husband, his first wife, and herself, which she had never before told her only son, Mr. Redstone, Jr. One can observe the searching and often disjointed manner in which she organizes the details.) Well, the children were small . . . Mr. Redstone, Sr. had been living with his mother for four years after his wife assed away, and----I've never mentioned this----and I went to New Orleans to talk to my daughter and as her . . . we talked about it . . . and Dr. Paul thought I ought to speak about this. And Nathan [Mr. Redstone, Jr.] is quite disturbed and he's blown it up to a great big I-don't-know-what. But I did get some information on what happened. When the older boy was born, his mother [the first Mrs. Redstone, Sr.] was . . . she was quite ill; and every time there was a . . . and then she was quite sick after that; and the family took care of the boy until she got better, and she was away for a while. Then there was a legal abortion between Bob and Lisa [Mrs. Redstone, Sr.'s step-children]. And she was quite ill then. And then Lisa was born; i think when Lisa was either three weeks or three months old, Bob was taken by the family to visit for the day, and someone else was taking care of the baby, and the mother took her life . . . was gas. And they didn't know until Mr. Redstone, Sr. came home and fund the condition. She was alone at the time. She didn't die, but she was taken to the hospital, and Mr. Redstone, Sr. and somebody else sat with her for----sat right there----for 24 hours, and then she passed away. And (sighs) the baby was boarded out from one person to another until she finally got a couple who had no children who took care of her until . . . I got to know them. And Mr. Redstone, Sr. moved to his mother's with Bob and Bob was with all the time. I met Mr. Redstone, Sr. through an aunt of his, whose husband was my mother's cousin, so I didn't know that side of the family, but I did know the aunt and her family. And . . . Bob, Mr. Redstone, Sr.'s mother wanted Bob to live with her, and he wanted to come and live with us and the aunt, and that's the arrangement; that's what Mr. Redstone, Sr. wanted, to have his children with him. I didn't know at the time that there was any talk about separating---the mother wanted, I mean, the grandmother wanted the little boy with her, I think the . . . I found out that the (turns to Mr. Redstone, Jr.) you wouldn't want me to call her the . . . by her maiden name, or when I say "the children's mother" you don't like that . . .
Mr. Redstone Jr.: (in an irritated tone): You can call her whatever you want to.
Mrs. Redstone, Sr.: Well, the children's first mother, when they were two [this is about the first Mrs. Redstone Sr.'s childhood], there were four children, two girls and two boys, and they had a business in Portland, Maine, and the grandparents lived in Providence. The came to visit the grandparents at one time and the father and son went back to Portland, because he had to go to his business, and you remember, there was a boat that got lost in the storm? But the mother, they never did know what happened to the other son, but the mother became demented, and was placed in a sanatorium, and the two children were placed in an orphanage. This was all in Providence. And when they were 16, this orphanage would have the child go out and either be placed somewhere, or to earn a living, and they were placed, this 16-year-old was placed in a home near where the Redstones lived. And she was a very nice girl, musical . . . pretty . . . and thee people she lived with asked the Redstones, there were five children in the Redstone family, and they asked the one that was nearest her age if she would meet her and sort of be a friend to her; and this is what happened. My husband's sister, when this girl would come to the house, Mr. Redstone, Sr. would take her home to where she would live; and this formed a friendship. But he was an introvert, and very much by himself most of the time, was very musical; he'd go into the living room and sit down, and sit at that piano for hours and just . . . and books. And when he graduated from M.I.T. he went away, but the mother didn't want him away from home, so he came back, and then, as I say, this friendship, and he was he was 32, 32 years old when he married. And then all this trouble started. (Silence.)
Mrs. Redstone, Sr.: Two months before we were to be married, someone came to me, someone in the family came to me and told me what had happened with the mother [the first Mrs. Redstone, Sr.}. I had met Lisa, I had met Bob,, and I didn't know what to do. I had made all the arrangements, and this was the person I wanted to marry. I didn't, I guess it didn't make any difference. But the children grew up, nothing was said to me by anybody in the family and when we, after we were married, I asked Mr. Redstone, Sr. if there was anything he wanted to tell me about his past life, or how we were to live, and what he said----"No." And I did know, and I didn't say anything because evidently he wanted to start a new life without any memories and without me having any memories, I guess; or thoughts of what had happened . . . and when Lisa, I don't know how old she was, but I said, and I see now that it must have been wrong. I would tell people that the mother died in childbirth. And Lisa, for a long time after she was grown up and old enough to know, felt badly that she was the cause of her mother's death. And, of course, I didn't know that she felt this way or that anything was said, and Nathan didn't know until he was 12 years old---and we were just one nice family. And it didn't matter about whether there was, I wasn't taking, I told the children I wasn't talking taking the mother's place, that they had a mother and she was a lovely mother, and how musical, and all this, that she was, but . . . we had a very nice life. Now Nathan thinks he should have been told. And the children had three families. There was my family; there was the mother's family; and the father's family, so they really were beautifully taken care of.
Norman Redstone: Three grandmothers!
Mrs. Redstone, Sr.: No, dear, there were two grandmothers, because the other grandmother had passed away.
Dr. Paul: But in terms of the enduring effects of some of these early tragic experiences, here, I mean, just to add a little to what you said, here Lisa did not know her mother, because her mother had died.
Mrs. Redstone, Sr.: Well, what difference did it make?
Dr. Paul: Okay, but when Lisa comes to the age at which her mother died, she told me that she spent a whole year, that year, concerned that she was going to take her own life.
Mrs. Redstone Sr.: but she told me . . . I didn't know that.
Dr. Paul: No, but I mean, this is in terms of the enduring effects of some of these experiences, which one may not even recall anything about. Or know even less about.
Mrs. Redstone, Sr.: Well, I don't know, there were aunts who would say one thing and when they met someone else, they would say something else, you know. My husband, now Bob does not want any part of this. He doesn't believe in it, he wants to live his life, now; he doesn't want anything of the past. He not interested in anything of the past, because---he's happy now. He's, he's satisfied. What is he going to, what is he going to stir up. And think of what has happened before. It's gone. I mean this.
Dr. Paul: If it were only gone, that would be wonderful. I wanted to ask Mrs. Zucker, when you were talking about your mother, how did you feel there before? I mean, you seemed to become tearful. Were you thinking about her, or yourself, or what?
Mrs. Zucker: No, It was . . . mainly feeling . . . unwanted.
Dr. Paul: What?
Mrs. Zucker (in tears): Unwanted.
Dr Paul: You were unwanted. And you felt this periodically during your life? Thinking about her?
Mrs. Zucker: No, it's just what . . . because you know, you're sort of referred to as "the child." You know . . . to these other people, you're just "the child." (voice breaks) Sort of like---excess baggage.
Dr. Paul: Chuck, is this the way you felt? In relation to your father? Excess baggage?
Chuck Zucker (low): Sometimes. Not all the time. I didn't feel really like excess baggage; I felt that I was the problem more.
Mrs. Holt: That's the sad part of it.
Dr. Paul: What?
Mrs. Holt: I said this is the sad part of it. Kids get the impression that they are the problem when it's your own problems that you're just . . . you're just taking your feelings out on the kids because they're handy and I suppose they're not supposed to fight back or anything, but this is far off the point. But Joe and I have decided that we need a little guidance and we'd like to ask for it. And from the kids, too. You spoke of your father, and his demanding excellence and things. Well, to use a recent example . . .
* * *
The second illustration is taken from a meeting held four weeks later. The theme of this session was the withholding of information, both factual and emotional, from family members. Just before the following excerpt, occurring during the last half hour of this meeting, Mr. Redstone, Jr. described that he had knowledge that his son Norman had almost been run into by a car while on his bicycle. However, he refused to tell Norman of his informant.
Dr. Paul: The whole question of withholding information is a very important one. Mrs. Smith reviewed her diary and she came up with something that she read from August and September of '62. And she taped it. She felt totally unable to read it aloud to her family; she felt her voice was wretched. And it tends to shed some light on feelings that she had inside that the rest of the family really didn't know too much about. I have it here now. And I thought it would be quite useful to play it and see what everybody thinks about while hearing it. Now this was recorded last month.
On Tape, the voice of Mrs. Smith: The summer races away. Mais oui is in Eastport tonight with Sara Cabot. As guest of Mrs. Carr, Alan Carr's mother. Pop [Mr. Smith] is reading Win Brook's The Shining Tides, downstairs, expecting to finish it and then come to bed. Peter [her son] has turned out his light and radio and appears to have gone to sleep. Bob and Hal [friends of her son] are playing records in the studio---not much longer, I hope.
Liz [her daughter] and I got to the beach on sunny days last week to improve our color and succeeded quite well. Went to Peg-gotty as it's the nearest.
Today I increased the number of sandwiches in the boys' lunch. From three to four. I want to fatten Bob up these last two weeks before he goes to Marine Camp. We are all going to the Music Service, Thursday P.M. Bob and Pete went to Vermont as guests of the Scotts---Jacky. Pete came home Tuesday morning . . . and Bob frightened us by not appearing till Wednesday P.M. He had hitchhiked and ridden to Canada for a meal with a good-natured drunk---graduate of Stanford.
Sunday, August seventeen: Bob left for Marine Camp yesterday. I got his breakfast and saw him to the train at six-thirty, everybody else sleeping soundly. The day never cleared. Pop took pictures of three portraits, Binky, Dee, and Kay [Mrs. Smith is a painter].
Today we stirred about quarter to nine. Now, at eleven, all are fed except Liz, and I am boiling a ham. Still cloudy. Peter saw Mr. Daniels, expert archer, in the movies last night and nothing will do this morning but to get out his bow and bits of leftover arrows and practice. And Pop is heartily with him. So I think I'll was my hair, which is groaning for attention.
The past bits were to sort of lay background for what's coming now.
Monday, August 18, now wait a minute . . . August 27, Wednesday: I should not write it; my life has everything I want, but I am sad today, awfully sad because of the transiency of it all. This morning I argued with Pete. I can always seem to argue, but alas! I find it utterly impossible to express how I love all the family. Pete spoke about something---we were up in his room---some asset that he must remember to have in, quote, his house, unquote. [Pet's "house" is the parents' summerhouse in which they are all residing at the time this was taped, and which the parents plan to leave to Pete after their death.] And I thought how we had heard often and joked about that house that will be Peter's someday; and I wondered will he ever have it" (Mrs. Smith breaks into sobs as she listens to her voice on the tape.) And will it ever fulfill itself as he dreams it? Because we, who have scoffed at him or been entertained by his dreamings, may never see him grow up; or he may grow up and we not be here. And I do love him so and do so want him to find this fulfillment.
And so, alone this afternoon---because he's gone off to get parts for his beloved bicycle---I want to stand up and say "Oh, Pete, you mean and always will mean so very much that is most dear to me, from the time you were a sound-asleep little hard-to-raise baby boy, straight through till now, when you are an almost-man and still hard-to-raise---so it seems. You have an unworldly blindness that affords you a protection and at the same time makes you vulnerable. All of your charms rise out of your youthful unawareness of them. Oh, I know you want to be strong and dashing and accomplished, and you look in the mirror imagining about it. But you shall have all those assets without effort, just by being clean and neat and polite. For in the little efforts you make lie implicit the large graces, the color and shine of personality. You needn't worry."
But how Pete, and Pop and Liz, how are we to find for ourselves, for each other, the great lasting wonder and fulfillment that should unite us always---though death seems to bring silences and absolute parting? All going our separate ways, as we must. In what essence of striving or belief or true emotion can we finally meet? That was what I wanted to say to each of them because I at least have such a need of meeting those I love, beyond the plane of trivial work, which I do and do now.
To get the work done; to keep the house running; I've gotten to bellowing around so much I'm utterly tired of it. What can they remember of me but a tiresome voice? Not the work, though it fills a function. It can never capture the imagination; and, unlike my mother, I can make no lovely music. I've lost my zest for partnership with the children at games and athletics, the things I liked once, so what can I be to any of them? I wish I knew. I would try to be it. And oh, anyway, I will try it, to cherish them as I do underneath all the time. Somehow, we must build the tie, the bridge across the unknown.
(End of tape playback).
Dr. Paul: I wonder how you people felt when you heard this. What you've thought about, because in many ways, Mrs. Smith speaks for everybody.
Norman Redstone---age 12 (forlorn): I identified with her feeling useless. There are many times I feel useless.
* * *
Norman Redstone: It's nice to have a diary to communicate to. Especially things you wouldn't want to communicate to anybody else.
Mrs. Smith: Well that was the trouble you see. I had to write it; I couldn't say it.
Mr. Zucker: That's what I was going to say. If you can talk like that . . . sound like a voice from another generation or a poetry that you study in college . it was elegantly put, and hit a lot of, hit home in our family. It just seemed like the prototype of our situation. In terms of . . .
* * *
Norman Redstone: Was that recorded with you and Dr. Paul or was there somebody . . .
Mr. Smith (speaking for his wife): She did it at home; she simply read from a journal of that year. To the tape. All by herself.
Norman Redstone: Oh.
Mr. Redstone, Jr.: I thought it was very well written. I thought it was, it was actually beautiful. And I sat here feeling very envious of you to . . . actually . . . to know how you feel. Because sometimes Dr. Paul will ask me, how I feel and sometimes, at times when, for example at home or in the car Nan (his wife) asks me how I feel---and as far as I'm aware, I don't know.
Mrs. Smith: You don't always know.
Mr. Smith: But there's a big gap between how she felt at the time and how the children, how her feelings got through to them at the time.
Mr. Redstone, Jr.: Yes, but I don't understand the point that you're trying to make.
Mr. Smith: They got through in quite the reverse.
Mr. Chubb: At first I wondered why Mrs. Smith didn't read her diary here and then later on . . . it was probably too upsetting . . . it was very moving and very sad. In fact, Jane looked like she was . . . were you upset about that?
Mrs. Chubb: Yes, I was very moved.
* * *
Mr. Zucker: One of the interesting things is that I think that by the time you get to recognize feeling like that, to either say it or to write it, you almost have to write it because the people aren't there to say it to; and you have this business you know, of how the trivial day-to-day mechanical things take all your time. And it seems as though the reason this applies to everybody has to do as much with the nature of the times as the nature of the individuals involved. I mean, perhaps, maybe in Victorian times, if you had a houseful of servants taking care of these types of things, then you had the opportunity to communicate feelings like this, maybe in a more elemental way, earlier in your family history.
Peter Smith: Well, apparently in Victorian times, with all the servants, in spite of all the servants, these feelings didn't get expressed either.
Liz Smith Black: No, even less.
Mr. Chubb: I got the impression from what you said that Pete was upset at that time or you knew some---No?
Mrs. Smith: No, no, I didn't think he was upset at all. I was just arguing with him about trivial things too much.
Mr. Chubb: I mean, uh . . .
Mrs. Smith: I thought it was my fault that . . .
Mr. Chubb: I mean you talked about he'd never, never have the home and the . . .
Mrs. Smith: Well, that was just looking ahead for a moment. I was regretting that we hadn't been more communicative with him about his home, really; I mean we'd sort of been amused by it, but we hadn't really taken him seriously.
Liz Smith black: I remember those conversations, we used to talk about, about Peter, and I used to describe the kind of person we were going to marry and then we'd go into great elaborate detail about what he house was going to be like---but it was more of a joking kind of . . .
Mrs. Zucker: Do you think feelings . . . do you still have the same feelings of concern? Do you think they affected . . .
Mrs. Smith: Not the way I did, no.
Neutralization of myths that other families have it either "much better than our family" or "much worse than we do" can lead to an active recognition that there is a potential for emotional kinship existing within the family and between families. The difficulties endured by different families have common denominators insofar as mothers, fathers, sibling, and children share common problems. Providing the environment for forthright discussion of these various problems, with the focus on their relevance to each family's history, encourages the development of empathic resonance within the family unit. If people can understand and feel the problems that others have, they are in a better position to accept, support and even encourage their own family members.
The illustrations underscore a critical aspect of the multiple family group process. They highlight the impact and empathic response to secrets previously hidden by one member from the other members in a family or the other families present. In both instances, the therapist had encouraged the sharing of such secrets with the families. In the first instance, Mrs. Redstone, Sr. was prompted to expose information about her son's father that he had never known. In doing so, both she and her son's father, now deceased one year, became more real and human for the son. It seemed that the specific timing of her disclosure during the meeting was prompted by a unanimity of opinion on the part of the adolescents that it was important to know about the realities of what had transpired rather than to be told distortions or lies. She made it clear that she disliked intensely her own view of herself as a stepmother, which contributed to the need to distort her role vis-à-vis her two stepchildren, as well as her son. An additional factor that seems to have contributed to the keeping of the secret was the manner in which her predecessor had died, her husband's denial of this to her, plus the fact that she shared her predecessor's first name.
Mrs. Smith, an attractive, intelligent woman in her early sixties, had an extraordinary need to deny the existence of her unpredictable anger and its impact upon her children. The feelings that she could not share directly with her family, either at the time she experienced them in 1962 or during the meeting, exposed a completely different side of her inner emotional life. It revealed an unshared, deep-seated tenderness for her family, which was mingled with intense regret. At the same time, she expressed an anticipatory sadness about the possibility of her son's emotional separation from her; this ushered in the ominous foreboding that he would never really make the grade. This material points out the hidden wish that her son be dependent on her in perpetuity, co-existent with the expressed wish that he achieve a sense of personal fulfillment. it is of interest that this excerpt was written two years before her son dropped out of college with his first full-blown psychotic episode. Mrs. Smith's revelation to the group exerted a profound effect on the group members. Some experienced great difficulty sleeping that night, and all were deeply moved by her expression of sadness, helplessness and regret. Her son, though he had heard this tape in a prior individual family session seemed to be started to hear again a different side of his mother, a side that had never been made observable to him.
These two examples demonstrate different aspects of the primary value of the multiple family group setting. In the first case, the disclosure of the withheld material was very much in keeping with the expressed theme of loss of a mother. It was the group setting and the fact that Mrs. Redstone, Sr. resonated to the group theme that made it possible for her to review in a rich, detailed manner, a crucial story that up until that time had only been known in a fragmentary way by members of her family. In the second case, the material introduced to the group via the tape provided a stimulus for reflection and introspection that went beyond the immediate meeting. The theme of withholding crucial historical information with associated feelings was underscored repeatedly in the group sessions. Mrs. Smith's diary entry represents one kind of communication that was pathological, insofar as it kept her verbally and emotionally remote from her family. The taped review of this excerpt provided an empathic entree to discussing similar difficulties in other families. The multiple family therapy groups thus become a place where each family can review its own historical reality in the light of, and in comparison with, the realities that exist in other families.
The individual entering therapy approaches it with built-in ambivalences, expressed in part by resistances and defenses that perpetuate the status quo. The family as a unit manifests similar patterns when beginning therapy. It approaches the treatment setting with its own notions as to who is causing the problem; sometimes-different members take turns in being so labeled. This scapegoating of a person as the source of the family's pain serves to maintain a fixed family equilibrium. At the same time, other members can nurture the fantasy that they have no role in the genesis of the labeling process. This type of family homeodynamics represents a maladaptive compromise that the family has made with the unpleasant realities of its past, present, and anticipated future. This is expressed in the avoidance of both painful past experiences and the recognition that through aging, separations and finally death, the family unit itself must break up.
The multiple family groups provide a comfortable setting where different family styles can intermingle. The regressive undertow, expressed in part by each family's tendency to avoid change, becomes transparent as family styles clash. By focusing on the historical affective sources of the maladaptive family equilibrium, neutralization of the family's need for maintaining the labeled member in the scapegoated position can begin.
In summary, the use of focus on the historical affective reality, relating to present, is to free us from the tyranny of a false or fixed past. This can give family members new options to make their individual futures less sinister. One of the more dramatic features of multiple family group therapy is that children become aware that their parents have had problems and lived through anguish that renders the parents more human and more real to them.
What we have described are a few elements of the authors' approach to multiple family group therapy that represent a departure from others who have conducted similar ventures in this area. The authors take issue with Blinder and his associates' (4) belief that the goals of this therapeutic modality are limited and circumscribed insofar as they do not use any of the techniques associated with "depth" psychotherapy. In this paper, the historical perspective represents "depth" psychotherapy. At this point, it is not possible to make a judgment about the limitations of this therapeutic approach in terms of the amount of personality reconstruction possible or the degree of neutralization of the maladaptive family equilibrium.
The specific problem for all of us in how to promote individual growth in our patients, at the same time balancing this with a recognized sense of indentify with their families and with society at large. In any family, we believe that one of the critical tasks is for parents to be able to present and describe to their children, serially, the realities of their own life experiences, with the associated emotional overtones. The developing children then can learn that hate, love, jealousy, anxiety, sadness and other feelings are natural; such feelings, having been accepted and managed by their parents, can then be mastered by themselves. In this manner, children can acquire a sense of continuity of emotions from generation to generation by empathic responsiveness to their parents, thereby creating a sense of enduring closeness between the generations.
This paper illustrates work in progress in the area of multiple family group therapy, which has emerged from conjoint family therapy and group psychotherapy. Particular emphasis here has been on the description of the participating families and the empathic impact on others of the review of hitherto hidden critical historical material. The plethora of phenomena dictated focus in this paper on one aspect, namely, material generated by the group. Other features of this experience are mentioned. The implications for the development of a historically oriented approach to multiple family therapy are considerable.
1. Ackerman, N.W.: The unity of the family. Arch. of Peadiatrics, 55: 51-62, 1938.
2. Ackerman, N.W., & Sobel, R.: Family diagnosis: An approach to the pre-school child. Amer. J.
Orthopsychiatry, 20: 744-753. 1950.
3. Bateson, G,. Jackson, D., Haley, J., & Weakland, J.: Toward a theory of schizophrenia. Behav.
Sci., 1: 251-264. 1956.
4. Blinder, M.G., Coleman, D., curry, A.E., & Kessler, D.R.: MCFT: Simultaneous treatment of several
families. Am. J. Psychotherapy. 19: 559-569. 1965.
5. Bowen, M.: A family concept of schizophrenia. In: Jackson, D. (Ed.), The Etiology of Schizophrenia.
New York. Basic books. 1960.
6. Bowen, M., Dysinger, R.H., Brodey, W.M., & Basamania, B.: Study and treatment of five hospitalized
family groups each with a psychotic member. Paper read at the Annual Meeting of the American
Orthopsychiatric Association. Chicago, Illinois. 1957.
7. Detre, T., Kessler, D.R., & Sayers, J.: A socio-adaptive approach to treatment of acutely disturbed
psychiatric inpatients. Proceedings of the Third World Congress of Psychiatry, 501-506. 1961.
8. Grosser, G.H., & Paul, N.L.: Ethical issues in family group therapy. Am. J. Orthopsychiatry, 34:
9. Jackson, D.D.: The question of family homeostasis. Psychiatr. Q. Suppl., 31: 79-90. 1957.
10.Laqueur, H.P.: Multiple-family therapy and general systems theory. Int. Psychiat. Clinics. 7: 99-124.
11.Laqueur. H.P.: Mechanisms of change in multiple family therapy. In: Sager, C.J., & Kaplan, H.S.,
(Eds.), Progress in Group and Family Therapy. New York, Brunner/Mazel, 1972.
12.Laqueur, H.P., La Burt, H.A., & Morong, E.: Multiiple family therapy: Further developments.
Int. J. Soc. Psychiatry. Special Congress Ed., 2: 70-80. 1964.
13.Lidz, T., Fleck, S., Cornelison, A., & Terry, d.: The intrafamilial environment of schizophrenic
patients: Marital schism and marital skew. Ame. J. Psychiatry. 114: 241-248. 1957.
14.Mead. M., & Heyman, K.: Family. New York. Macmillan. 1965
15.Nevin, D.: Multiple family therapy, the overlooked treatment approach: it's alive and ready for use.
Am. J. Orthopsychiat., 44: 223. 1974.
16.Paul, N.L.: Unpublished data. 1963.
17 Paul, N.L., & Grosser, G.H.: Operational mourning and its role in conjoint family therapy.
Community Mental Health J., 1: 339-345. 1965.
18.Rudin, E.: Vererbung und Enstehung Geistiger Storungen, 1 Zur Vererbung und Neuenstehung
der Dementia Praecox. Monographien aus dem Gesamtgebiete der Neurologie und Psychiatrie,
19.Scott, R.D., & P.L.: The "axis value" and the transfer of psychosis: A scored analysis of the
interaction in the families of schizophrenic patients. Br. J. Med. Psychol., 38: 97-116. 1965.
20.Selvini Palazzoli, M., Cecchin, G., Prata, G. & Boscolo, L.: The tyranny of linguistic conditioning. In:
Paradox and Conterparadox. New York, Aronson, 1978, pp. 51-53.
21.Strelnick, A.H., Multiple family group therapy: A review of the literature. Family Process. 16,
(3): 307-323. 1977.
22.Wynne, L.C., Ryckoff, I.M., Day, J., & Hirsch, S.I.: Pseudo-mutuality in the family relations of
schizophrenics. Psychiatry. 21: 205-220. 1958.
Note: Norman and Betty Paul and Joseph Bloom distributed booklets of this article and Betty sent a copy to the MFGT Resource Center. The booklet is reprinted from GROUP AND FAMILY THERAPY 1981, edited by Lewis Wolberg and Marvin Aronson, Brunner/Mazel, Inc., New York, 1981.
All identifying data in this paper have been altered to preserve the anonymity of each person in the group.
Request: If you have pictures of the authors (or more articles by them) and are willing to share them with the MFGT Resource Center so they can be added, please email them to email@example.com
Return To Homepage