etiology


I’m taking a couples assessment class this summer, and right now I’m reading about a tension between family therapy models that Sciarra and Simon (in Handbook of Multicultural Assessment) call either idiographic or nomothetic.

Nomothetic models say that families have problems because they get out of whack in ways that families do. That is, each nomothetic model has its own list of ways that families can get out of whack and a therapist using that model is to keep a sharp lookout for those things. Structural therapists look for dysfunctional boundaries, for example. Strategic therapists look for incongruous hierarchies. Bowenians look for emotional reactivity. Emotionally-focused therapists look for maladaptive attachment styles. Each nomothetic model says that the therapist needs to assess for these underlying problems, treat them, and therapy should be successful.

Idiographic models call nomothetic models “cultural imperialism.” That means nomothetic therapists are just teaching (or tricking) their clients into thinking, feeling, and acting like them. Nomothetic therapists are forcing their culture on their clients. Calling someone a cultural imperialist is about as close to an accusation of pure evil as a post-modernist will make. Further, idiographic models say that culture (any culture) is oppressive of individuals, and that this oppression is the only reason families seek therapy. The ideographic therapist’s job (Sciarra & Simon list language-systems, solution-focused, and narrative therapies as idiographic) is to have a conversation with families about the ways they are being oppressed by their culture.

There are a couple of funny things going on here, but to understand it, first you need to know that nomothetic models are mostly “old-school” models that emerged in the 1950s and 60s, while ideographic models are newer, postmodern, all the rage, and emerged as a consequence of this nomothetic/ideographic conversation. In the 1980s, postmodern family therapists started saying that family therapy was arrogant and hierarchical and created the idiographic schools.

The first funny thing is that the old-school, nomothetic family therapy models emerged in much the same way, as a reaction to the arrogant and hierarchical field of psychiatry. The founders of family therapy said to psychiatry, “Human problems exist in the context of families. Your pathologizing medical model is not appropriate here.” Now the ideographic models are saying to the nomothetic founders, “Human problems exist in the context of cultures. Your pathologizing medical model is not appropriate here.”

Who is right? Well, that depends on your epistemology. So far, the nomothetic models have more experimental evidence to support them, and they are undeniably effective. To be fair, they have had more time to collect evidence, so in time things may go either way. And to be extra-fair, real post-modern idiographs can reject experimental evidence on philosophical grounds; experiments are so modern, so medical-model. What value system produced your research questions, anyway? That’s funny thing number two.

Funny thing number three is that, as Ken Wilber says, everyone may be right. Perhaps problems happen at every level of complexity, from our bodies to our minds to our families to our larger social systems, and nomothetic models just specialize in the family level, while idiographic models specialize in cultures. It’s a neat idea, possibly too neat, and difficult to tease out. I’ve written a little about it here.

The fourth funny thing is that the idiographic models, while broadening the scope of consideration in some ways, put the focus back on the individual in therapy. They say that culture is intrinsically dehumanizing, and that dehumanization is what an idiographic therapist talks about, but the other parties in the process are not part of the conversation. If I’m a narrative therapist and you send your depressed son to me, we will talk a lot about that depression. We will externalize it, maybe give it a name like “Mr. Funky,” talk about how Mr. Funky speaks with the voice of oppressive culture, talk about times when your son was able to overcome Mr. Funky’s influence and work on ways of increasing that ability. In the end, if I’m a good therapist, we have probably helped your son, but we’ve also focused on how your son thinks, feels, and behaves, where a nomothetic therapist would have been focusing on the whole family–how do they interact? Do the parents get along? How might this symptom of depression make sense in your son’s immediate system of relationships? Who all has a stake in this behavior and can we get them in the room too? And so on. There is a way that by ostensibly moving the location of pathology out of the family to the larger culture, ideographic models have brought the clinical focus back to individuals, which may seem like regression to the founders of family therapy.

Schizophrenia is a fascinating set of phenomena, the study of which has launched a thousand ships including, arguably, my field, family therapy; many of the original family therapists left psychiatry to study schizophrenia (or, as the DSM would have me write it, Schizophrenia–capitalizing words gives them more authority, don’t you think?) as an interactive process. That is, if all behaviors make sense in their context, what context might make schizophrenic behavior necessary?

There was an almost violent backlash against this line of thinking, as it seemed to (and did, in many cases) blame mothers for their schizophrenic children–as in the unfortunate phrase “schizophrenogenic mother.” The conventional wisdom about schizophrenia these days reads like a pharmaceutical company press release, something like, “Schizophrenia is a biological disease of the brain which is at present incurable, but there are drugs which can help manage the symptoms, and if taken regularly can provide a decent quality of life.”

So schizophrenia is assumed to be a biological disease of the brain though it, like every other Mental Disorder, has no laboratory test that can detect its presence. The best we can do is a set of behavioral diagnostic criteria which, frankly, are a bit of a mess. You may notice as you read that different flavors of schizophrenia may have nothing or little in common with each other. Are they really the same “disease”? We don’t know.

We do have good evidence that you can inherit, in some fashion, a tendency for one of these constellations of behaviors. There is good evidence that environmental factors are also important, though they are not a big part of the mainstream discussion. We also have evidence that therapy helps in a lot of cases. There is some (hotly contested, I’m sure) evidence from the World Health Organization that unmedicated schizophrenics can eventually recover while those on medication do not. Here is a trailer for a moving documentary about two recovered women and the public perception of schizophrenia, called Take These Broken Wings. Also, consider checking out the documentary A Brilliant Madness, about John Nash, in which puts the lie to A Brilliant Mind, which showed Nash recovering with the help of psychopharmaceuticals.

The DSM says that schizophrenia may be overdiagnosed (or at least is diagnosed more often) in African- and Asian-American men, that it affects men differently than women (men tend towards the negative symptoms were women tend towards delusions and hallucinations), and that incidence rates are something like .5-1.5% of adults.

Here are a few terms that you’ll need to know to get through the criteria:

affective flattening: does not show emotion. Also, “affect” means “emotion” to scientists and people who like to talk like scientists.

alogia: lack of speech.

avolition: lack of motivation.

prodromal: symptoms coming early on in the course of a disease.

echolalia: repetition of others’ speech sounds.

echopraxia: repetition of others’ movements

And here are the diagnostic criteria, word-for-word, from the DSM-IV-TR, pp. 312-319:

Diagnostic criteria for Schizophrenia

A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):

(1) delusions

(2) hallucinations

(3) disorganized speech (e.g. frequent derailment or incoherence)

(4) grossly disorganized or catatonic behavior

(5) negative symptoms, i.e., affective flattening, alogia, or avolition

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other.

B. Social/occupational dysfunction: For a significatn portion of the time since th onset of the distrubance, one or more major areas of functioning such as work, interpersonal relations, or self-care are mardekly below the level achieved prior to the onset (or when the onset is in childhood or adolewscence, faliure to achieve expected level of interpersonal, academic, or occupational achievement).

C. Duration: Continuou signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. Doring these prodromal or residual periods, the signs of the ditrubance may be manifested by only negative symptoms or two or more symptoms listen in Criterion A pressent in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition.

F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

Classification of longitudinal course (can be applied only after at least 1 year has elapsed since the initial onset of active-phase symptoms):

Episodic With Interepisode Residual Symptoms (episodes are difined by the reemergence of prominent psychotic symptoms); also specify if: With Prominent Negative Symptoms

Episodic With No Interepisode Residual Symptoms

Continuous (prominent psychotic symptoms are present throughout the period of observation); also specify if: With Prominent Negative Symptoms

Single Episode In Partial Remission; also specify if: With Prominent Negative Symptoms

Single Episode In Full Remission

Other or Unspecified Pattern

Diagnostic criteria for 295.30 Paranoid Type

A type of Schizophrenia in which the following criteria are met:

A. Preoccupation with one or more delusions or frequent auditory hallucinations.

B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Diagnostic criteria for 295.10 Disorganized Type

A type of Schizophrenia in which the following criteria are met:

A. All of the following are prominent:

(1) disorganized speech

(2) disorganized behavior

(3) flat or inappropriate affect

B. The criteria are not met for Catatonic Type.

Diagnostic criteria for 295.20 Catatonic Type

A type of Schizophrenia in which the clinical picture is dominated by at least two of the following:

(1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor

(2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli

(3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism

(4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumptions of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing

(5) echolalia or echopraxia

Diagnostic criteria for 295.90 Undifferentiated Type

A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type.

Diagnostic criteria for 295.60 Residual Type

A type of Schizophrenia in which the following criteria are met:

A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.

B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

I am going to start seeing clients in a few weeks in the clinic at the University of Oregon. Part of that process is beginning to “date a model.” That means I have to choose one of the many styles of family therapy and try it out to see if it’s really my thing. I’m a born generalist and integrator, so this is a difficult choice to make. Below, I typed up the “In a Nutshell: The Least You Need to Know” sections for each family therapy model in Diane Gehart’s excellent book, Mastering Competencies in Family Therapy. (Actually, I’ve left out one–collaborative therapy–because I know almost nothing about it, so it’s not one of my active choices.)

Those of you who know me (and I believe that’s pretty much all of you, readers) and have the stamina to read these eleven paragraphs, I would love to know which of these models you think sounds the most like me.

Systemic and Strategic Therapies: Using what most therapists consider the classic family therapy method, systemic family therapists conceptualize the symptoms of individuals within the larger network of their family and social systems while maintaining a nonblaming, nonpathologizing stance toward all members of the family. Systemic therapies are based on general systems and cybernetics systems theories,¬† which propose that families are living systems characterized by certain principles, including homeostasis, the tendency to maintain a particular range of behaviors and norms, and self-correction, the ability to identify when the system has gone too far from its homeostatic norm and then to self-correct to maintain balance. Systemic therapists rarely attempt linear, logical solutions to “educate” a family on better ways to communicate–this is almost never successful–but instead tap into the systemic dynamics to effect change. They introduce small, innocuous, yet highly meaningful alterations to the family’s interactions, allowing the family to naturally reorganize in response to the new information. Because this method effects change quickly, systemic therapies were the original brief therapies.

Structural Therapy: As the name implies, structural therapists map family structure–boundaries, hierarchies, and subsystems–to help clients resolve individual mental health symptoms and relational problems. After assessing family functioning, therapists aim to restructure the family, realigning boundaries and hierarchies to promote growth and resolve problems. They are active in sessions, staging enactments, realigning chairs, and questioning family assumptions. Structural family therapy focuses on strengths, never seeing families as dysfunctional but rather as people who need assistance in expanding their repertoire of interaction patterns to adjust to their ever-changing developmental and contextual demands.

The Satir Growth Model: One of the first prominent women in the field, Virginia Satir began her career in family therapy at the Mental Research Institute working alongside Jay Haley, Paul Watzlawick, Richard Fisch, and the other leading family therpists in Palo Alto. [These were the folks who came up with the “systemic and strategic therapies,” above.] She eventually left the MRI to develop her own ideas, which can broadly be described as infusing humanistic values into a system approach. She brought a warmth and enthusiasm for human potential that is unparalleled in the field of family therapy. Her therapy focused on fostering individual growth as well as improving family interactions. She used experiential exercises (e.g., family sculpting), metaphors, coaching, and the self of the therapist to facilitate change. Her work is practiced extensively internationally, with Satir practitioners connecting through the Satir Global Network.

Symbolic-Experiential Therapy: Symbolic-experiential therapy is an experiential therapy model developed by Carl Whitaker. Whitaker referred to his work as “therapy of the absurd,” highlighting the unconventional and playful wisdom he used to help transorm family. Relying almost entirely on emotinal logic rahter than cognitive logic, his work is often misunderstood as nonsense, but it is more accurate to say that he worked with “heart sense.” Rather than intervene on behavrioral sequences like strtegic-systemic therapists, Whitaker focused on teh emotional process and family structure. He intervened directly at the emotional level of the system, relying heavily on “symbolism” and real life experiences as well as humor, play, and affective controntation.

For the astute observer, Whitaker’s work embodied a deep and profound understanding of families’ emotional lives; to the casual observer, he often seemed rude or inappropriate. When he was “inappropriate,” it was always for the purpose of confronting or otherwise intervening on emotional dynamics that he wanted to expose, challenge, and transform. He was adamant about balancing strong emotional confrontation with warmth and support from the therapist. In many ways, he encouraged therapists to move beyond the rules of polite society and invite them selves and clients to be genuine and real enough to speak the whole truth.

Bowen Intergenerational Therapy: Bowen intergenerational theory is more about the nature of being human than it is about families or family therapy. The Bowen approach requires therapists to work from a broad perspective that considers the evolution of the human species and the characteristics of all living systems. Therapists use this broad perspective to conceptualize client problems and then rely primarily on the therapist’s use of self to effect change. As a part of this broad perspective, therapists routinely consider the three-generational emotional process to better understand the current presenting symptoms. The process of therapy involves increasing clients’ awareness of how their current behavior is connected to multigenerational processes and the resulting family dynamics. The therapist’s primary tool for promoting client change is the therapist’s personal level of differentiation, the ability to distinguish self from other and manage interpersonal anxiety.

Psychoanalytic Family Therapies: These therapies use traditional psychoanalytic and psychodynamic principles that describe inner conflicts and extend these¬† principles to external relationships. In contrast to individual psychoanalysts, psychoanalytic family therapists focus on the family as a nexus of relationships that either support or impede the development and functioning of it’s members. As in traditional psychoanalytic approaches, the process of therapy involves analyzing intrapsychic and interpersonal dynamics, promoting client insight, and working through these insights to develop new ways of relating to self and others. Some of the more influential approaches are contextual therapy, family -of-origin therapy, and object relations family therapy.

Behavioral and Cognitive-Behavioral Family Therapies: In the general mental health field, cognitive-behavioral therapies (CBTs) are some of the most commonly used therapeutic approaches. They have their roots in behaviorism–Pavlov’s research on stimulus-response pairings with dogs and Skinner’s research on rewards and punishments with cats–the premises of which are still widely used with phobias, anxiety, and parenting. Until the 1980s, most of the cognitive-behavioral family therapies were primarily behavioral: behavioral family therapy and behavioral couples therapy. In recent years, approaches that more directly incorporate cognitive components have developed: cognitive-behavioral family therapy and Gottman method couples therapy approach.

Cognitive-behavioral family therapies integrate systemic concepts into standard cognitive-behavioral techniques by examining how family members–or any two people in a relationship–reinforce one another’s behaviors to maintain symptoms and relational pattern. Therapists generally assume a directive, “teaching,” or “coaching” relationship with clients, which is quite different from other approaches of “joining” or “empathizing” with clients to form a relationship. Because this approach is rooted in experimental psychology, research is central to its practice and evolution, resulting in a substantial evidence base.

Solution-Based Therapies: Solution-based therapies are brief therapy approaches that grew out of the work of the Mental Research Institute in Palo Alto (MRI) and Milton Erickson’s brief therapy and trance work. The first and leading “strength-based” therapies, solution-based therapies are increasingly popular with clients, insurance companies, and county mental health agencies because they are efficient and respectful of clients. AS the name suggests, solution-based therapists work with the client to envision potential solutions based on the client’s experience and values. Once the client has selected a desirable outcome, the therapist assists the client in identifying small, incremental steps toward realizing this goal. The therapist does not solve problems or offer solutions but instead collaborates with clients to develop aspirations and plans that they then translate into real-world action.

Narrative Therapy: Developed by Michael White and David Epston in Australia and New Zealand, narrative therapy is based on the premise that we “story” and create the meaning of life events using available dominant discourses–broad societal stories, sociocultural practices, assumptions, and expectations about how we should live. People experience “problems” when their personal life does not fit with these dominant societal discourses and expectations. The process of narrative therapy involves separating the person from the problem, critically examining the assumptions that inform how the person evaluates himself/herself and his/her life. Through this process, clients identify alternative ways to view, act, and interact in daily life. Narrative therapists assume that all people are resourceful and have strengths, and they do not see “people” as having problems but rather see problems as being imposed upon people by unhelpful or harmful societal cultural practices.

Albert Ellis was one of the guys who invented cognitive therapy, which began as a kind of wacky-fringe psychotherapy in the 1950s and has grown to be one of the dominant and most-researched forms of therapy today. It’s effective and simple–easy to teach. Ellis’s version of cognitive therapy, Rational Emotive Behavior Therapy, is alive and well too.

Ellis’s basic tenets were that thoughts or beliefs, not events, cause emotions and that irrational thoughts or beliefs cause our emotional problems. Most people think it’s their situations that are causing their problems, but Ellis said that we feel bad when our situation is in conflict with an irrational belief, and that it is the belief that makes us feel bad. So his style of therapy basically consisted of deconstructing people’s irrational thoughts and beliefs.

I think that he was right in a lot, though not all, cases. There are many other effective forms of therapy that, instead of cognitions, target behavior, emotions, social systems, or some combination of the four. There are also, of course, non-therapy interventions that aim to improve people’s psychological experience by targeting biological systems, like drugs or the prefrontal lobotomy, and interventions that target political systems–various kinds of activism.

But irrational beliefs are as good a place to start as any. Here is Ellis’s list of our major irrational ideas, quoted from Jacobs, Masson, & Harvill’s Group Counseling: Strategies and Skills (pp. 285-6). Keep in mind that these don’t usually exist as overt beliefs–you might have to dig to find them in yourself, running you.

Which few are your main irrational ideas?

1) It is a dire necessity for an adult human being to be loved or approved by virtually every other person in one’s life.

2) One should be thoroughly competent, adequate, and achieving in all possible respects if one is to consider oneself worthwhile.

3) Certain people are bad, wicked, and villainous and they should be severely blamed or punished for their villainy.

4) It is awful and catastrophic when things are not the way one would very much like them to be.

5) Human unhappiness is externally caused and people have little or no ability to control their sorrows and disturbances.

6) If something is or may be dangerous or fearsome, one should be terribly concerned about it and should keep dwelling on the possibility of its occurring.

7) It is easier to avoid than face certain life difficulties and self-responsibilities.

8) One should be dependent on others and needs someone stronger than oneself on whom to rely.

9) One’s past history is an all-important determiner of one’s present behavior and because something once strongly affected one’s life, it should indefinitely have an effect.

10) There is invariably a right, precise, and perfect solution to human problems and it is catastrophic if this perfect solution is not found.

11) One should become quite upset over other people’s problems and disturbances.

12) The world should be fair and just and if it is not, it is awful and I can’t stand it.

13) One should be comfortable and without pain at all times.

14) One may be going crazy because one is experiencing some anxious feelings.

15) One can achieve maximum human happiness by inertia and inaction or by passively and uncommittedly enjoying oneself.