Genograms are based upon the premise that

Gehart, D. R. (2014) Mastering Competencies in Family Therapy Chapter 7

Intergenerational and Psychoanalytic Family Therapies

Lay of the Land

Although distinct from each other, Bowenian intergenerational therapy and psychoanalytic family therapy share the common roots of (a) psychoanalytic theory and (b) systemic theory. A psychoanalytically trained psychiatrist, Bowen (1985) developed a highly influential and unique approach to therapy that is called Bowen intergenerational therapy. Drawing heavily from object relations theory, psychoanalytic or psychodynamic family therapies have developed several unique approaches, including object relations family therapy (Scharff & Scharff, 1987), family-of-origin therapy (Framo, 1992), and contextual therapy (Boszormenyi-Nagy & Krasner, 1986). These therapies share several key concepts and practices:

• Examining a client’s early relationships to understand present functioning

• Tracing transgenerational and extended family dynamics to understand a client’s complaints

• Promoting insight into extended family dynamics to facilitate change

• Identifying and altering destructive beliefs and patterns of behavior that were learned early in life in one’s family of origin

Bowen Intergenerational Therapy

In a Nutshell: The Least You Need to Know

Bowen intergenerational theory is more about the nature of being human than it is about families or family therapy (Friedman, 1991). 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 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.

The Juice: Significant Contributions to the Field

If you remember a couple of things from this chapter, they should be:

Differentiation

Differentiation is one of the most useful concepts for understanding interpersonal relationships, although it can be difficult to grasp at first (Friedman, 1991). An emotional or affective concept, differentiation refers to a person’s ability to separate intrapersonal and interpersonal distress:

• Intrapersonal: Separate thoughts from feelings in order to respond rather than react

• Interpersonal: Know where oneself ends and another begins without loss of self

Bowen (1985) also described differentiation as the ability to balance two life forces: the need for togetherness and the need for autonomy. Differentiation is conceptualized on a continuum (Bowen, 1985): a person is more or less differentiated rather than differentiated or not differentiated. Becoming more differentiated is a lifelong journey that is colloquially referred to as “maturity” in the broadest sense. A person who is more differentiated is better able to handle the ups and downs of life and, more importantly, the vicissitudes of intimate relationships. The ability to clearly separate thoughts from feelings and self from others allows one to more successfully negotiate the tension and challenges that come with increasing levels of intimacy.

For example, when one’s partner expresses disapproval or disinterest, this does not cause a differentiated person’s world to collapse or inspire hostility. Of course, feelings may be hurt, and the person experiences that pain. However, he/she doesn’t immediately act on or act out that pain. Differentiated people are able to reflect on the pain: clearly separate out what is their part and what is their partner’s part and identify a respectful way to move forward. In contrast, less differentiated people feel compelled to immediately react and express their feelings before thinking or reflecting on what belongs to whom in the situation. Partners with greater levels of differentiation are able to tolerate difference between themselves and others, allowing for greater freedom and acceptance in all relationships.

Because differentiated people do not immediately react in emotional situations, a common misunderstanding is that differentiation implies lack of emotion or emotional expression (Friedman, 1991). In reality, highly differentiated people are actually able to engage more difficult and intense emotions because they do not overreact and instead can thoughtfully reflect on and tolerate the ambiguity of their emotional lives.

It can be difficult to assess a client’s level of differentiation because it is expressed differently depending on the person’s culture, gender, age, and personality (Bowen, 1985). For example, to the untrained eye, emotionally expressive cultures and genders may look more undifferentiated, and emotionally restricted people and cultures may appear more differentiated. However, emotional coolness often is a result of emotional cutoff (see the later section on Emotional Cutoff), which is how a less differentiated person manages intense emotions. Therapists need to assess the actual functioning intrapersonally (ability to separate thought from feeling) and interpersonally (ability to separate self from other) to sift through the diverse expressions of differentiation.

Genograms

The genogram has become one of the most commonly used family assessment instruments (McGoldrick, Gerson, & Petry, 2008). At its most basic level, a genogram is a type of family tree or genealogy that specifically maps key multigenerational processes that illuminate for both therapist and client the emotional dynamics that contribute to the reported symptoms. New therapists are often reluctant to do genograms. When I ask students to do their own, most are enthusiastic. However, when I ask them to do one with a client, most are reluctant. They may say, “I don’t have time” or “I don’t think these clients are the type who would want to do a genogram.” Yet after completing their first genogram with a client, they almost always come out saying, “That was more helpful than I thought it was going to be.” Especially for newer therapists—and even for seasoned clinicians—genograms are always helpful in some way. Although originally developed for the intergenerational work in Bowen’s approach, the genogram is so universally helpful that many therapists from other schools adapt it for their approach, creating solution-focused genograms (Kuehl, 1995) or culturally focused genograms (Hardy & Laszloffy, 1995; Rubalcava & Waldman, 2004).

The genogram is simultaneously (a) an assessment instrument and (b) an intervention, especially in the hands of an intergenerational therapist. As an assessment instrument, the genogram helps the therapist identify intergenerational patterns that surround the problem, such as patterns of parenting, managing conflict, and balancing autonomy with togetherness. As an intervention, genograms can help clients see their patterns more clearly and how they may be living out family patterns, rules, and legacies without conscious awareness. As a trainee, I worked with one client who had never spoken to her parents about how her grandfather had sexually abused her and had no intention of doing so because she believed it would tear the family apart. This changed the day we constructed her genogram. I had her color in each person she knew he had also abused. When she was done, the three-generation genogram had over 12 victims colored in red; she went home and spoke to her mother that night and began a multigenerational process of healing for her family.

Rumor Has It: The People and Their Stories

Murray Bowen

A psychoanalytically trained psychiatrist, Bowen (1966, 1972, 1976, 1985) began working with people diagnosed with schizophrenia at the Menninger Clinic in the 1940s and continued his research in the 1950s at the National Institute for Mental Health (NIMH), where he hospitalized entire families with schizophrenic members to study their emotional processes. He then spent the next 30 years at Georgetown University developing one of the most influential theories of family and natural systems, which has influenced generations of family therapists.

Georgetown Family Center: Michael Kerr

A longtime student of Bowen, Michael Kerr has also been one of his most influential students and has served as director of the Georgetown Family Center, where Bowen refined his clinical approach.

The Center for Family Learning: Philip Guerin and Thomas Fogarty

Guerin and Fogarty co-founded the Center for Family Learning in New York, one of the premier training centers for family therapy. Both Guerin and Fogarty have written extensively on the clinical applications of Bowen’s model.

Monica McGoldrick and Betty Carter

Betty Carter and Monica McGoldrick (1999) used Bowen’s theory to develop their highly influential model of the family life cycle, which uses the Bowenian concept of balancing the need for togetherness and independence to understand how families develop. McGoldrick’s work with genograms is the definitive work on this tool subject (McGoldrick, Gerson, & Petry, 2008).

David Schnarch

Grounded in Bowen’s intergenerational approach, Schnarch developed a unique approach to working with couples, the sexual crucible model, which is designed to increase a couple’s capacity for intimacy by increasing their level of differentiation. One of the hallmarks of this approach is harnessing the intensity in the couple’s sexual relationship to promote the differentiation process.

The Big Picture: Overview of Treatment

Much like other approaches that have psychodynamic roots, intergenerational therapy is a process-oriented therapy that relies heavily on the self-of-the-therapist, most specifically the therapist’s level of differentiation, to promote client change (Kerr & Bowen, 1988). This therapy does not emphasize techniques and interventions. Instead, therapists use genograms and assessment to promote insight and then intervene as differentiated persons. For example, when one partner tries to get the therapist to take his/her side in an argument, the therapist responds by simultaneously modeling differentiation and gently promoting it in the couple. By refusing to take sides and also helping the couple tolerate their resulting anxiety (their problem is still not fixed, and neither partner has been “validated” by the therapist), the therapist creates a situation in which the couple can increase their level of differentiation: they can use self-validation to soothe their feelings and learn how to tolerate the tension of difference between them. Change is achieved through alternately using insight and the therapeutic relationship to increase clients’ levels of differentiation and tolerance for anxiety and ambiguity.

Making Connections: The Therapeutic Relationship

Differentiation and the Emotional Being of the Therapist

More than in any other family therapy approach, in intergenerational therapy the therapist’s level of differentiation (Bowen, 1985; Kerr & Bowen, 1988) and emotional being (Friedman, 1991) are central to the change process. Intergenerational therapists focus on developing a therapeutic relationship that encourages all parties to further their differentiation process: “the differentiation of the therapist is technique” (Friedman, 1991, p. 138; italics in original). Intergenerational therapists believe that clients can only differentiate as much as their therapists have differentiated (Bowen, 1985). For this reason, the therapist’s level of differentiation is often the focus of supervision early in training, and therapists are expected to continually monitor and develop themselves so that they can be of maximum assistance to their clients. Bowen therapists assert that the theory cannot be learned through books (such as this one) but can only be learned through a relationship with a supervisor or teacher who uses these ideas to interact with the student (Friedman, 1991).

A Nonanxious Presence

The greater a therapist’s level of differentiation, the more the therapist can maintain a nonanxious presence with clients (Kerr & Bowen, 1988). This is not a cold, detached stance but rather an emotionally engaged stance that is nonreactive, meaning that the therapist does not react to attacks, “bad” news, and so forth without careful reflection. The therapist does not rush in to rescue clients from anxiety every time they feel overwhelmed by anger, sadness, or another strong emotion; instead, the therapist calmly wades right into the muck the client is trying to avoid and guides the client through the process of separating self from other and thought from feelings (Friedman, 1991). The therapist’s calm center is used to help clients move through the differentiation process in a safe, contained environment in which differentiation is modeled. When clients are upset, the “easiest” thing to do is to soothe and calm their anxieties, fears, and strong emotions; this makes everyone calmer sooner, but nothing is learned. The intergenerational therapist instead shepherds clients through a more difficult process of slowly coaching them through that which they fear or detest in order to facilitate growth.

The Viewing: Case Conceptualization and Assessment

Viewing is the primary “intervention” in intergenerational therapy because the approach’s effectiveness relies on the therapist’s ability to accurately assess the family dynamics and thereby guide the healing process (Bowen, 1985). Although this is true with all therapies, it is truer with intergenerational therapies because the therapist’s level of differentiation is critical to the ability to accurately “see” what is going on.

Emotional Systems

Bowen viewed families, organizations, and clubs as emotional systems that have the same processes as those found in all natural systems: “Bowen has constantly emphasized over the years that we have more in common with other forms of protoplasm (i.e., life) than we differ from them” (Friedman, 1991, p. 135). He viewed humans as part of an evolutionary emotional process that goes back to the first cell that had a nucleus and was able to differentiate its functions from other cells (i.e., human life begins with one cell that divides to create new cells, which then differentiate to create the different systems and structures of the body: blood, muscle, neurons, etc.). This process of differentiating yet remaining part of a single living organism (system) is a primary organizing concept in Bowen’s work, and the family’s emotional processes are viewed as an extension (not just a metaphor) of the differentiation process of cells. Thus Bowen’s theory of natural systems focuses on the relationship between the human species and all life past and present.

Of particular interest in family therapy are natural systems that have developed emotional interdependence (e.g., flocks of birds, herds of cattle, and human families; Friedman, 1991). The resulting system or emotional field profoundly influences all of its members, defining what is valued and what is not. When a family lacks sufficient differentiation, it may become emotionally fused, an undifferentiated family “ego mass.” Intergenerational therapists focus squarely on a family’s unique emotional system rather than on environmental or general cultural factors, and they seek to identify the rules that structure the particular system.

This approach is similar to other systemic conceptualizations of the family as a single organism or system; however, Bowen emphasizes that it is fundamentally an emotional system. Because this system has significant impact on a person’s behavior, emotions, and symptoms, one must always assess this context to understand a person’s problems. For example, in the case study at the end of this chapter, the therapist explores how, Wei-Wei’s panic attacks fit within the broader fabric of the family system, her immigration history, and her professional life, rather than focusing solely on the medical and psychological aspects of the attacks.

Chronic Anxiety

Bowen viewed chronic anxiety as a biological phenomenon that is present in all natural systems. Chronic anxiety involves automatic physical and emotional reactions that are not mediated through conscious, logical processes (Friedman, 1991). Families exhibit chronic anxiety in their responses to crises, loss, conflict, and difficulties. The process of differentiation creates a clear headedness that allows individuals and families to reduce the reactivity and anxiety associated with survival in natural systems and instead make conscious choices about how to respond. For example, chronic anxiety in a family may result from a mother feeling guilty about a child’s lack of success, in which case it is the therapist’s job to help the mother increase her level of differentiation so that she can respond to the child’s situation from a clear, reasoned position rather than with a blind emotional reactivity that rarely helps the situation. In the case study at the end of the chapter, the therapist works with the mother to reduce her anxiety and panic as her son finishes medical school and begins his independent life as an adult.

The Multigenerational Transmission Process

The multigenerational transmission process is based on the premise that emotional processes from prior generations are present and “alive” in the current family emotional system (Friedman, 1991). In this process, children may emerge with higher, equal, or lower levels of differentiation than their parents (Bowen, 1985). Families with severe emotional problems result from a multigenerational process in which the level of differentiation has become lower and lower with each generation. Bowen’s approach is designed to help an individual create enough distance from these processes to comprehend the more universal processes that shape human relationships and individual identities (Friedman, 1991). Thus, in the case study at the end of this chapter, the therapist will assess the emotional content of the parents’ prior life in China, which is viewed as an ongoing aspect of the family’s current reality.

Multigenerational Patterns

Intergenerational therapists assess multigenerational patterns, specifically those related to the presenting problem. Using a genogram or oral interview, the therapist identifies patterns of depression, substance use, anger, conflict, the parent–child relationship, the couple’s relationship, or whatever issues are most salient for the client. The therapist then identifies how the current situation fits with these patterns. Is the client replicating or rebelling against the pattern? How has the pattern evolved with this generation? The therapist thereby gains greater clarity into the dynamics that are feeding the problem. In cases of immigration, such as that at the end of this chapter, the historic family patterns may change because of different cultural contexts (e.g., the family attempts or is forced to blend and adapt), may be rigidly the same (e.g., the family wants to adhere to traditions), or may be radically different (e.g., the family wants to “break” from the past).

Level of Differentiation (see Juice)

When differentiation is used as part of case conceptualization, the therapist assesses the client’s level of differentiation along a continuum, which Bowen developed into a differentiation scale that ranges from 1 to 100, with lower levels of differentiation represented by lower numbers (Bowen, 1985). Bowen maintained that people rarely reach higher than 70 on this scale.

Although there are pen-and-paper measures such as the Chabot Emotional Differentiation Scale (Licht & Chabot, 2006), most therapists simply note patterns of where and how a person is able or unable to separate self from other and thought from emotion.

What is most useful for treatment is not some overall score or general assessment of differentiation, but the specific places where clients need to increase their level of differentiation to resolve the presenting problem. For example, a couple may need to increase their ability to differentiate self from other in the area of sex so that they can create a better sexual relationship that allows each person to have preferences, discuss them, and find ways to honor these preferences without becoming emotionally overwhelmed.

Emotional Triangles

Bowen identified triangles as one of the most important dynamics to assess because they are the basic building block of families (Bowen, 1985; Friedman, 1991; Kerr & Bowen, 1988). A triangle is a process in which a dyad draws in a third person (or something, topic, or activity) to stabilize the primary dyad, especially when there is tension in the dyad. Because triangles use a third person or topic to alleviate tension, the more you try to change the relationship with the third entity, the more you ironically reinforce the aspects you want to change. Thus, therapists assess triangles to identify the primary relationship that needs to be targeted for change.

Bowen maintained that triangulation is a fundamental process in natural systems (Bowen, 1985). Everyone triangulates to some degree: going down the hall to complain about your boss or coworker is triangulation. However, when this becomes the primary means for dealing with dyadic tension and the members of the dyad never actually resolve the tension themselves, then pathological patterns emerge. The more rigid the triangle, the greater the problems.

The classic family example of a triangle is a mother who becomes overinvolved with her children to reduce unresolved tension in the marriage. This over involvement can take the form of positive interactions (over involvement in school and social activities, emotional intimacy, constant errands or time devoted to the child) or negative interactions (nagging and worrying about the child; the therapist suspects that this is what is going on in the case study at the end of the chapter). Another common form of triangulation is seen in divorced families, in which both parents often triangulate the child, trying to convince the child to take their side against the other parent. Triangulation can also involve using alcohol or drugs to create dyadic stability, complaining or siding with friends or family of origin against one’s spouse, or two siblings siding against a third.

The Family Projection Process

The family projection process describes how parents “project” their immaturity onto one or more children (Bowen, 1985), causing decreased differentiation in subsequent generations. The most common pattern is for a mother to project her anxiety onto one child, focusing all her attention on this child to soothe her anxiety, perhaps becoming overly invested in the child’s academic or sporting activities. The child or children who are the focus of the parent’s anxiety will be less differentiated than the siblings who are not involved in this projection process.

Emotional Cutoff

A particularly important process to assess is emotional cutoff, which refers to situations in which a person no longer emotionally engages with another in order to manage anxiety; this usually occurs between children and parents. Emotional cutoff can take the form of no longer seeing or speaking to the other or, alternatively, being willing to be at the same family event with virtually no interaction. Often people who display cutoff from their family believe that doing so is a sign of mental health (e.g., “I have set good boundaries”) or even a sign of superiority (e.g., “It makes no sense for me to spend time with that type of person”). They may even report that this solution helps them manage their emotional reactivity. However, cutoff is almost always a sign of lower levels of differentiation (Bowen, 1985). Essentially, the person is so emotionally fused with the other that he/she must physically separate to be comfortable. The higher a person’s level of differentiation, the less need there is for emotional cutoff. This does not mean that a highly differentiated person does not establish boundaries. However, when differentiated people set boundaries and limit contact with family, they do so in a way that is respectful and preserves emotional connection, and not out of emotional reactivity (e.g., after an argument). Emotional cutoff requires a little more attention in assessment because it can “throw off” an overall assessment of differentiation and family dynamics. People who emotionally cut themselves off as a means of coping often appear more differentiated than they are; it may also be harder to detect certain family patterns because in some cases the client “forgets” or honestly does not know the family history. However, at some times and in certain families, more cutoff is necessary because of extreme patterns of verbal, emotional, or childhood abuse. In such cases, where contact is not appropriate or possible, the therapist still needs to assess the emotional part of the cutoff. The more people can stay emotionally engaged (e.g., have empathy and cognitive understanding of the relational dynamics) without harboring anger, resentment, or fear, the healthier they will be, and this should be a therapeutic goal.

Sibling Position

Intergenerational therapists also look at sibling position as an indicator of the family’s level of differentiation; all things being equal, the more the family members exhibit the expected characteristics of their sibling position, the higher the level of differentiation (Bowen, 1985; Kerr & Bowen, 1988). The more intense the family projection process is on a child, the more that child will exhibit characteristics of an infantile younger child. The roles associated with sibling positions are informed by a person’s cultural background, with immigrants generally adhering to more traditional standards than later generations. Most often, older children identify with responsibility and authority, and later-born children respond to this domination by identifying with underdogs and questioning the status quo. The youngest child is generally the most likely to avoid responsibility in favor of freedom.

Societal Regression

When a society experiences sustained chronic anxiety because of war, natural disaster, economic pressures, and other traumas, it responds with emotionally based reactive decisions rather than rational decisions (Bowen, 1985) and regresses to lower levels of functioning, just like families. These Band-Aid solutions to social problems generate a vicious cycle of increased problems and symptoms. Societies can go through cycles in which their level of differentiation rises and falls.

Targeting Change: Goal Setting

Two Basic Goals

Like any theory with a definition of health, intergenerational therapy has clearly defined long-term therapeutic goals that can be used with all clients:

1. To increase each person’s level of differentiation (in specific contexts)

2. To decrease emotional reactivity to chronic anxiety in the system

Increasing Differentiation

Increasing differentiation is a general goal that should be operationally defined for each client. For example, “increase AF’s and AM’s level of differentiation in the marital relationship by increasing the tolerance of difference while increasing intimacy” is a better goal than “increase differentiation.”

Decreasing Emotional Reactivity to Chronic Anxiety

Decreasing anxiety and emotional reactivity is closely correlated with the increasing differentiation. As differentiation increases, anxiety decreases. Nonetheless, it can be helpful to include these as separate goals to break the process down into smaller steps. Decreasing anxiety generally precedes increasing differentiation and therefore may be included in the working rather than the termination phase of therapy. As with the general goal of increasing differentiation, it is clinically helpful to tailor this to an individual client. Rather than stating the general goal of “decrease anxiety,” which can easily be confused with treating an anxiety disorder (as may or may not be the case), a more useful clinical