Reaction to "The Process of Change" {3,199 words}

The author, Ms. Peggy Papp, has a very wide background in marital and family counseling and is very well qualified to write this book. During the course of her career, she has been closely involved with Nathan Ackerman, the teachings of Murray Bowen, Salvadore Minuchin, and Jay Haley. She has served on the faculties of the Ackerman Institute for Family Therapy, the Philadelphia Child Guidance Clinic, and the Center for Family Learning. Throughout this book, she has provided numerous real life examples of paradoxical and strategic interventions that were used on couples and families from a systems perspective.

Based on her experience in the field, she points out that no one approach to marriage and family therapy is correct in all instances. In her opinion, the therapist must integrate the techniques of many theories and be flexible enough and observant enough to work with a variety of ideas and interventions. In the opening chapter, Introduction, she said that when theory is presented without practice, then the theory tends to lose its meaning. Because of that, she has combined theory and examples over and over in this book to make her points.

In chapter two, The Dilemma of Change, Ms. Papp defined "system" and wrote that the key concepts of system involve "wholeness, organization, and patterning." Being a cognitive behaviorist, her approach to family therapy is to fix symptoms rather than focus on structure and boundaries. She talks about positive feedback loops and explains how information passes through the system. My initial opinion is that structural family therapy is better than the theory being described in this book because Ms. Papp seems to ignore or at least focus less on the effects of subsystems and boundaries. Toward the end of the chapter, she talked about the family's belief system and the therapist's need to understand hidden alliances and coalitions in order to develop some ideas for intervention. Her consideration of alliances and coalitions showed some structural therapy tendancies.

In chapter three, Forming a Hypothesis, the author started to get into family counseling theory by identifying some necessary early steps. The first step is for the therapist to form a hypothesis as a starting point for the investigation. Just like in the other family therapy approaches, it is important for the counselor to get off to a quick start. Ms. Papp said that the counselor should begin developing his or her hypothesis in the very first session, even if that means that the hypothesis is somewhat speculative. She maintained that position because once some initial thoughts for the hypothesis have been established, they can easily be modified as the sessions continue.

In her discussion on the gathering of information, I found the five questions about the symptom to be very helpful. I also liked her use of those questions in chapter five with the anorectic daughter. In the first session of structural family therapy, the therapist tries to gather information about the family structure, their subsystems, and their boundaries. But in cognitive behavioral family counseling, the therapist's interest is in understanding the dynamics of the symptom and the possible causes for the symptom. On page 20, Ms. Papp suggested that the therapist have a slow motion picture of the events that lead up to the symptom. But in lieu of that, I thought that the counselor could more easily have the family enact their conflict. I was glad to see that she saw value in the family's history, even though she had had to learn that the hard way with the Brief Therapy Project.

In chapter four, Setting the Terms for Therapy, the author made it clear that the family and the therapist are competing for control. She writes, "If the family is allowed to set the terms through their definition to the problem, the therapist will be lost because the family's definition is maintaining the problem." She indicated that the therapist must be aware of hidden agendas and contradictions so that he or she can define the problem and find quick solutions. I understand that the symptom helps maintain the family's equilibrium and that not all symptoms have equal importance. I thought that the example of the trainee on page 28 showed the importance of developing a quick hypothesis, and I appreciated her explanation on page 39 that extreme action is usually required to overcome the family's equilibrium.

On a more troubling note, though, I am finding Ms. Papp's cognitive behavioral approach to family therapy to be a little overwhelming. She seems to focus exclusively on the symptom and on the types of intervention that can be used to deal with it. She talks about direct intervention and paradoxical intervention and goes through the steps for setting up a paradox and a reversal. But I am not sure how a therapist can know for certain which technique would work best. I also am not sure how a structural family therapist, for example, would deal with some of these same situations. The problem for me with books like this one is that the examples all make the theories seem obvious until one tries to apply them in slightly different situations.

I did not feel comfortable with the therapeutic triangle discussed in chapter five, Negotiating Change. Through much of the chapter, I felt like the therapists were playing games with the family, and I can see how such tactics might backfire. If I were a family member undergoing this kind of counseling, I do not think that I would appreciate this technique. I would not like a therapist who staged a failure such as the one discussed in the book because, to me, the happy ending that resulted might have been more coincidental than predictable. The author indicated that the couple wanted to negotiate a different marital relationship, but I can see where they could have easily chosen a less favorable path.

The whole idea of a group or team seems silly to me, but the examples used in the book obviously testify to the success of such techniques. I felt more comfortable with the cotherapy approach than with the consultation team. However, when I had read "The Family Crucible", I was surprised and concerned at that time to see cotherapists. Perhaps, in like manner, I will be less apprehensive about groups the next time I encounter a consultation team. One thing that I like about this book, though, are all the examples. As I use this book in the future, I believe that some of my negative concerns from this first reading will disappear. In fact, my only real question at this point is whether the client is required to pay everyone in the consultation group individually or whether they just pay a single sum for the entire team.

In chapter six, Case Presentation: The Daughter Who Said No, I thought about Whittaker and Napier when Don did not show up for the first session. As was the case in this chapter, both sessions proceeded in somewhat normal fashion, even though there was some expressed concern by both sets of therapists over an absent family member. Another similarity between this chapter and "The Family Crucible" was the incredible amount of detail that both sets of therapists provided about the physical details of their clients.

I initially questioned the therapist's hypothesis that the anorectic daughter was starving herself in order to remain a boy for her father. When Salvador Minuchin dealt with an anorectic girl, he solved that problem by calling the girl stubborn and making her condition a family problem rather than an individual problem. I can see from these two different cases that there are not any automatic answers for people's problems. A therapist must look at all the available data before being able to see the root cause of the pathology. Also, I think the therapists in this example made a wise decision by not trying to identify the problem in the first session. They were not confident to do so, so they did not try. With a paying client standing in front of you, a counselor could easily be tempted to make wild guesses just to keep the customer happy, but doing so in this case would have been a mistake.

Chapter six was an important chapter in this book to me. By discussing a full case and showing how some of the principles of the preceding chapters are used, the whole book, up to this point, has become easier to understand. I liked how the family's four problems were summarized on page 77, and I thought that the therapist did a good job of handling the father. However, I did not understand how Sandy could have automatically taken on the burden of her parents' unhappiness just because the therapist wanted her to, so I was glad that she refused the role.

I noticed the use of operational mourning when the therapists asked the parents to let Rachel mourn her leaving home, and I thought that the strategy was strange and clever. Rachel was upset and depressed, so the therapists were basically giving her permission to feel that way. In a few cases in this book, including chapter six, I have noticed that the author has freely indicated the mistakes and lessons learned by the various counselors, and I am pleased by her honesty. Too many times in the professional world, people are taught to hide their mistakes in order to appease those in control, but Ms. Papp seems to have the true nature of a scientist. Despite this, however, I still found the use of the group somewhat silly.

In chapter seven, Variations on the Style and Form of Interventions, the author spoke about the differences of each family's problem, indicated that the therapist must match an intervention method to the symptom, and then, provided three examples to convey her point. In the first example about the fairy tale and about happiness being earned through suffering, I could see the use of a paradoxical intervention, and that answered some of my earlier questions about this book. In the second example, about the ghost of Leopold, I saw the importance of mourning the first husband's death and getting on with life. But with the suggestion of a special Norway day, I did not agree that the mom's homesickness was a second ghost.

In the third example, the therapist concluded the case by saying that the combined messages of support and undermining the father were the keys to change. She said that merely coaching the father probably would not have worked, but I do not necessarily agree. I also thought that the therapist's and group's differing messages to change or not change, respectively, created a double bind for the father and added stress to the situation. In my opinion, merely coaching the father might not have made for such a dramatic a case, but it still may have solved the family's problems without creating the double bind.

In chapter eight, The Use of Paradox in a Medical Setting, the case study about the asthma patient, Raymond, provided an interesting situation. Because of the mom's reluctance to give Raymond some freedom, the therapists were trying to combine structural family therapy techniques with paradoxical interventions. While I still was not comfortable with the author's use of a group, I did like the way that she summarized the family's situation on page 126. In a very short time, she had been able to articulate the symptom plus the function that the symptom was serving. Also, in this case study, I was able to understand the significance of her paradoxical prescription, and it looked to me like the counselors were actually trying to outsmart their clients. In this particular instance, Ms. Papp got Raymond to break away from his mother as an act of defiance against her prescription rather than as an act of individual growth for him. The author's conclusion was that paradoxical interventions can be used when direct interventions do not work.

In chapter nine, Treating Couples, the author talked about the reciprocity that seems to exist in all couple relationships and about the use of metaphors to treat those relationships that are out of balance. I thought that the couples choreography sounded more like enactment than sculpting because Ms. Papp spoke about physical movement rather than nonverbal, frozen image. The four questions, on pages 142 and 143, asked by the therapist in couples counseling were similar to the ones asked on page 18 in family counseling. Also, the therapists in this form of treatment seemed to be very careful about how they selected couples for group therapy. Obviously, they were not just throwing a bunch of couples into a room together.

The four cases discussed in this chapter nicely broke up the chapter and also provided some good examples of the couples counseling process. However, I was struck by the intellectual level of the couple in the David and Goliath case. The wife seemed very perceptive in her ability to see her husband's giantism as his being big rather than being strong. Her language was fairly sophistocated, and the therapist responded by using the term "existential fear". While reading through this case, though, I thought to myself that many people may not be able to communicate with the therapist on such a high intellectual level. Another concern was when the counselor told the husband to involve his wife with an inconsolable depression, as if he could turn his depression on and off like a spigot. I left this example wondering whether the couple's relationship had improved through therapy or through the publication of the wife's writing.

In the second case study in chapter nine about the Phantom and the rock, I thought the sessions were interesting because I think that this couple's problems might happen a lot. I thought that the recommendation of whispering secrets to each other at night in darkness and seclusion was a clever way for the couple to get to know each other. I was not even shocked when the two got drunk together. My wife and I are Christian and have been married for over thirty years. But we know that couples have to be themselves within their faith rather than trying to be something they are not because of their faith.

In the third case about the fox and the satyr, the prechange test of prescribing the symptom seemed very appropriate. In other words, let the husband decide if and when change was safe and acceptable.

In the fourth case that involved the family of origin, the dynamics of having more people involved made this case much more complicated. I was able to see how the group pushed the wife into being more assertive by insisting that she not be, but I wondered if either the therapist or the group would ever lose credibility when one of them turns out to be wrong. In this example, I thought that the wife would not want the group around, and at times, that clearly seemed to be the case. While I understood that the group's antagonism was intentional, I wondered if this kind of conflict ever becomes counterproductive.

In chapter ten, Case Presentation: Anatomy of Violence, I was immediately interested in this example because I know of a family with a physical abuse problem. I liked the author's introductory comments at the beginning of the chapter because they made me feel like a partner in the process rather than just a reader. In some places of this book, I have felt like I had to figure out what was happening as it was happening. But in this chapter, I feel like I am being allowed to be more involved, and I like that.

In this example, I agreed with the group's initial assessment of Seth, the identified patient. When I was reading the opening dialogue, I, too, had the feeling that he seemed to be an expert of his own condition, and to me, that sent the message that something else is probably going on. In the battle over control of the sessions, I thought it was clever for the therapists to meet even though the family had canceled the session. In reading through the case, I have been able to sense this family's past experiences with unsuccessful therapy.

The therapists had an interesting way to deal with the family's conflicts, that of working with the struggles from the outside to inward. I can appreciate their understanding of relationships and how they are able to get families to make changes that they do not really want to make. This family had a habit of canceling sessions at the last minute as their way of being in control, but I noticed that the therapists were able to counter those attempts to some extent by the fourth session.

The reality of deadly violence in a family like this one really brought home the importance of having qualified counselors. I was almost entertained by Seth's list of tricks, including the brain tumor and the fake lawyer. However, I felt bad for Annette because she was being held in a relationship that was causing her a lot of anxiety. In the way that this case ended, I realized that the therapist does not always know the outcome of a situation. Their sessions ended abruptly amid the appearances of failure, but the family seemed to do all right after they were on their own. I was glad to see that Annette had been able to get out and that Seth had not fallen apart over her leaving.

In chapter eleven, Failures and Pitfalls, I found the authors honesty to be reaffirming. I was glad to read that a therapist never really knows what works, why something does not work, or even if it did or did not work. I was equally glad to learn that there are no hard and fast rules, absolutes, or certainties. The failures and pitfalls that were mentioned in this chapter were not surprising. The presence of all family members at each session was an issue in "The Family Crucible", and it has been an issue in this book. Therefore, I already knew that full family participation is important. The other main issue, which centered on family members undergoing individual counseling at the same time as family counseling, was not surprising either. I can understand that two counselors would not want to risk conflicting or ambiguous solutions.

Ms. Papp has written a very interesting and highly educational book that I have thoroughly enjoyed. She has provided numerous short examples in this book, some longer examples, and a lot very helpful case studies. The opening chapters were difficult reading, but the case studies that started in chapter six began to clear up a lot of the confusion. In general, I liked the way this book was written better than "The Family Crucible," and I liked the conversational dialogue that frequently appeared within the text. Mostly, I liked this book because of the many examples and because of the fact that a lot of the examples went into a sufficient amount of detail.

				Tom of Bethany

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