How many therapists does it take?

Anybody who has ever been in a family knows the lonely feeling of not being understood, as though nobody else sees the big picture…

Anybody who has ever been in a family knows the lonely feeling of not being understood, as though nobody else sees the big picture the way you do. At the same time, to be in a family is to be part of a fiercely insular system that protects its own. This ambivalent combination of being possessed and protected, while possibly also feeling isolated and hurt, is at the basis of much psychological distress.

"People give you confusing messages that seem to say `I love you, but I don't love you'; `I leave you because I love you too much'. Or `I beat you up because I love you too much'," says Dr Gianfranco Cecchin, an Italian psychiatrist and one of the founding fathers of Milan Systemic Family Therapy, who was in Dublin last week to give a seminar.

While one person in a family may suffer a physical or psychological illness that becomes identified as the family's "problem", the "problem is really only a message that something is wrong in the family system", he believes. Dr Cecchin's seminal work has been profoundly influential in the Republic over the past 20 years, inspiring a quiet revolution in the way professionals view families with "problems".

A growing and accomplished group of Irish psychologists and other professionals are practising "systemic family therapy", in which three or four therapists at a time deal with one family. This intense but gentle process can do in a few sessions what other talking therapies may take a year to accomplish. One neutral therapist sits with the family, while the other therapists sit behind a screen, observing, commenting on and videotaping the process.

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Today, a new three-year master's degree programme in systemic family therapy will be announced in Limerick. It is a joint initiative by the University of Limerick's Department of Educational and Professional Studies, the Mid-Western Health Board and St Vincent's Psychiatric Hospital in Fairview, Dublin.

St Vincent's secretary/manager Edward Byrne points out: "collaboration is the key to good mental health service delivery". Tom Houlihan, chief nursing officer, also believes that "we help families most when we share our expertise". The University of Limerick course, which begins in September, has already been flooded with queries and is open to GPs, psychologists, psychiatrists, social workers and nurses, all of whom are embracing the need for intense, multi-disciplinary, supportive work with families.

Sister Geraldine Collins, the co-ordinator of the Limerick Family Therapy and Consultation Service, explains: "As families move through different life-cycle stages, difficulties may occur at times of transition - such as pressures associated with adolescence or adjusting to retirement. At these times of change, family members adopt new roles and positions. They often find it useful to explore and talk together in a therapeutic context about their difficulties."

Family therapy and training have been provided in several Dublin centres - such as St Vincent's, the Mater Hospital and the Clanwilliam Institute - but this is the first time that a health board, a university and a psychiatric institution have joined together to develop a master's degree programme outside Dublin. In traditional one-to-one therapy, the therapist talks with a single client, bringing all his or her own prejudices and judgments to the case. In family therapy, no moral judgments are made, which is why it is important to have several therapists offering different perceptions.

Occasionally, a therapist behind the screen may telephone a question to a family member, if they feel that family member's true feelings are not being heard. For example, a therapist may offer: "Jenny looks very sad while her mother talks about her illness. Does Jenny feel sad?" Meanwhile, the therapist who sits with the family remains completely neutral so that when the family leave the room, no member can say that the therapist sided with one or another.

"We all said what needed to be said without worrying about hurting one another's feelings because we felt safe," was how one Irish family member described her experience of family therapy.

Another stated afterwards: "It made me aware that the problem could be viewed from many angles."

Family members also talk about experiencing "a sense of relief at having someone else listening to us talking, with less potential for conflict". This kind of open communication is sorely needed in today's mutable society where families in crisis are on the increase. The family therapy master's degree programme is "an important and timely response to the current crisis in the definition, structure and conduct of family life," believes Marie Murray, director of psychology in St Vincent's and director of the new master's degree programme.

"Increasingly, we hear reports of adolescents abusing alcohol and drugs; domestic violence is on the increase and marital breakdown is causing great concern because of all the pain involved. There are fewer supports from previous traditional sources of help."

A strength of Irish families is their "great sense of unity", says Dr Cecchin, who believes that Italian and Irish families are more alike than any other two nationalities in Europe. The foundation of systemic family therapy is that "everything that happens, happens in connection with someone else. Nothing happens to an individual in isolation. If there's a problem, you have to see how many people participate in that problem. That does not mean that they are the cause of the problem," Dr Cecchin says. "Families create terrible stories for one another and can be very cruel, yet at the same time their mutual need for survival brings out the positive," he adds.

The key to healing both individuals and families is to mine the family for the "positive" things that they do for one another, he believes.

"Instead of telling a family what they are doing wrong, we help them find out what they are doing right. If they are still alive, they are doing something right," says Dr Cecchin.

Therapists must maintain a total lack of moral judgment to each family situation, he believes: "There is no one way that any family should be. The therapist must keep away from the position of knowing what is good for them. To be moralistic and to criticise is very easy, but if you are moralistic, then first you have to know what is the right kind of family and nobody knows that because the family is a social construction that keeps changing through the years."

This moral neutrality is what makes therapy so effective in an environment of rapid social change, when what constitutes "family" is a state of mind, rather than a permanent institution. In this context, moral neutrality means being respectful of adults' and children's points of view, while protecting them from harm.

Dr James O'Boyle, consultant psychiatrist and medical director, Area 7 of the Eastern Regional Health Board, and at St Vincent's Fairview, states: "In the current uncertain situation for so many families, there is a need for psychiatry to respond to a wide diversity of new family forms and, indeed, to the different cultural background of many clients."

Details of the programme from Admissions Office, University of Limerick (061- 202015). The Family Therapy Association of Ireland (FTAI) is a member of the Irish Council for Psychotherapy (ICP). For further information contact 01-2722105