REPRINTED WITH PERMISSION from ©Kluwer Academic/Plenum Publishers, 1998 for The Journal of Psychology and Judaism,1998, vol. 22, pp. 115-128

This paper is based on a presentation given on December 22, 1996, at the Second Annual Nefesh Conference, held in Miami, Florida. The author wishes to express appreciation to conference organizers Dr. Norman Goldwasser and Dr. Norman Bloom; the panel, Phyllis Mayer, Chana Kahn, Dr. Shlomo Schuck, and Shimon Russel; and to Dr. Anne Rambo of Nova Southeastern University.

 

Abstract

There are a number of differences between normative and non-normative systemic therapy. It is useful to understand normative thinking because that is a traditional orientation. Non-normative clinical work also has much to offer both philosophically and practically: It is characterized by the premise that people’s behavior makes sense given their histories and current context. Therefore, when understood from the perspective of the individual, even his or her “psychopathology” would make sense. Using a composite case analyzed in normative terms and treated non-normatively, the author illustrates how to bridge these two approaches. Solution-focused methods constitute the interventions of choice.

The Orthodox psychotherapy community is familiar with systemic thinking (Wieselberg, 1992), but may not be aware of a distinction in outlook between normative (Kerr & Bowen, 1988; Minuchin, 1993) and non-normative clinical work (Andersen, 1991; Anderson & Goolishian, 1988; Boscolo, Cecchin, Hoffman, & Penn, 1987; McNamee & Gergen, 1992). Within the latter are a number of schools whose ideas have pierced mainstream therapy. Solution-focused work, pioneered by Steve de Shazer (1985, 1988a; de Shazer, Berg, Lipchik, Nunnally, Molnar, Gingerich, & Weiner-Davis, 1986; de Shazer & Molnar, 1984; de Shazer, Gingerich, & Weiner-Davis, 1987; Kral & Kowalski, 1989; Lipchik, 1988; O’Hanlon & Weiner-Davis, 1989; O’Hanlon & Wilk, 1987), and the Mental Research Institute, with tools such as reframing (Fisch, Weakland, & Segal, 1982; Watzlawick, Weakland, & Fisch, 1974), are but two examples.

Both normative and non-normative systemic thinking place symptoms outside of the person. Symptoms exist, instead, within “a relationship process that . . . . is anchored in the family system” (Kerr & Bowen, 1988, p. 237). They constitute evidence of interpersonal, rather than intrapersonal troubles. The congruence between normative and non-normative thinking ends here. A normative orientation assumes that the presence of problems indicates something wrong with a family’s structure (Minuchin, 1993), level of differentiation of members from their families of origin (Kerr & Bowen), or other aspects of family functioning.

Non-Normative Systemic Thinking

In contradistinction to the foregoing, non-normative thinking recognizes that what constitutes normality is elusive, perhaps impossible to pin down (Anderson, 1990; Gergen, 1991; O’Hara & Anderson, 1991). Rather than search for a single definition for normality, non-normative clinicians concede that there are multiple ways of viewing the world (Epstein & Loos, 1989; McNamee & Gergen, 1992)–and both the therapist and client may have valid perspectives on the problem. This removes the therapist from a hierarchical position as expert in relationship to the family (Griffith et al., 1990; Hoffman, 1988). A non-normative position assumes that, given his or her circumstances and history, the client’s choices make sense. Psychopathology is not part of this framework (Epstein & Loos; O’Hanlon & Wilk, 1987). The therapist would view the family “as a healthy unit struggling against a difficult outside problem rather than as an inherently flawed and disabled group of people” (Doherty, 1991, p. 38). Because the therapist does not define normality for the client, the therapist-client relationship is cooperative, based on the absence of therapist attempts to educate, challenge, or compel the client to a “better” world view. Therefore, resistance does not exist (Amundson, Stewart, & Valentine, 1993; de Shazer, 1984, 1988b; O’Hanlon & Wilk; Weakland & Jordan, 1992).

The concepts of non-normative thinking have important implications for the orthodox therapist: Therapists, too, have opinions, biases, values (Goolishian & Anderson, 1992; Hoffman, 1988)–and religious beliefs. These values creep into the therapy room to influence the client; therefore, we must know what they are and utilize them ethically (Abroms, 1978; Aponte, 1985; Epstein & Loos, 1989). Thus, the orthodox therapist need go to no lengths to “wear two hats” (or sheitels). As a non-normative systemic therapist, she or he may express personal values as part of therapy whether working in a religious environment (Friedman, 1985; Hirschhorn, 1996, in press) or not (Abroms; Aponte; Atkinson & Heath, 1990; O’Hanlon & Wilk, 1987). Because the therapist’s orientation is toward understanding and respecting client values, a statement of the therapist’s religious position does not detract from the importance conferred on the client’s own worldview. Given the non-hierarchical relationship of the therapist with the client, the therapist’s beliefs might open opportunities for creating new meaning (Epstein & Loos).

That therapists have their own positions not only has implications regarding religious beliefs but also concerning reverence for the Diagnostic and Statistical Manual (1994). If there can be many views of what is right or normal (Anderson, 1990; Gergen, 1991; O’Hara & Anderson, 1991), then this tome becomes merely an interesting political compendium rather than the source of an objective view of normality. Some have shown that receipt of a psychiatric label can work against the goals of therapy (Rosenhan, 1973) or even create the pathology it is meant to cure (Hofffman, 1988). The definition of the problem, then, comes, not from the therapist or the manual, but from the client. The therapist works within that construction to help the client find either meaning in the situation (Andersen, 1991; Boscolo et al., 1987; Anderson & Goolishian, 1988; Hirschhorn, in press; Hoffman, 1988; Watzlawick et al., 1974) or new ways of handling it (de Shazer, 1985, 1988a; de Shazer, Berg et al., 1986; de Shazer & Molnar, 1984; de Shazer, Gingerich et al., 1987; Fisch et al., 1982; Kral & Kowalski, 1989; Lipchik, 1988; O’Hanlon & Weiner-Davis, 1989; O’Hanlon & Wilk, 1987). Thus, non-normative thinking assumes that the client’s worldview is as valid as the therapist’s. Client choices make sense given context and history. The Orthodox therapist is not expected to be neutral. The therapeutic community does not hold an expert position regarding normality. Finally, the goal of therapy is to find meaning in, or new responses to, the situation.

What happens when normative professionals refer a case to a non-normative therapist? In describing their referral, they most likely have made a diagnosis and wish to confer with the therapist in the normative terms that they understand. For example, they may see the problem as one of intergenerational enmeshment. The act of labeling implies a normative stance. Bowen’s term, intergenerational (Kerr & Bowen, 1988), and Minuchin’s (1993) concepts of enmeshment and emotional cutoff indicate normative thinking because they reflect pre-determined ideas of what the normal family should look like and what is wrong with it when there are problems. One of the benefits of working from a non-normative position is that therapists respect all views–including those of the normative referring practitioner. It is therefore possible to wed some of the language of the traditional world with the philosophy and interventions of non-normative thinking. The following case, which might have originated with a referring psychiatrist familiar with normative family systems thinking, is drawn from several such families seen by the author. The names and details have been changed to insure confidentiality.

Case Presentation

Steve and Marlene bring their 16 year old daughter, Stephanie, to a therapist because her diabetes periodically goes out of control; their doctor suspects a psychological reason. Intergenerational family therapists want to get a picture of the historical patterns in the family because they perceive family process as transmitted multigenerationally (Kerr & Bowen, 1988). As the interview progresses, the therapist constructs a genogram. (McGoldrick & Gersen’s 1985 guide is considered authoritative on conducting the interview and drawing the genogram.) Figure 1 illustrates patterns of enmeshment, cutoff, conflict, and distance. Marlene’s great grandparents, Sora and Chaim, had a distant relationship. When their only child, Shirley, died in childbirth, Shirley’s husband, Henry, panicked and abandoned his two children. Sora and Chaim invested the tenderness they should have had for each other in their grandchildren, Marion and Yvonne. Their enmeshment meant that Yvonne never had to make a single decision. Marion saved herself somewhat from too much love by rebelling against her grandparents, in particular, Sora.

Yvonne was the good girl who sometimes felt the desire to break free of her gilded cage. When she met Moshe, it was love at first sight. A sweet, quiet man who seemed pleased to let her make her own decisions, he gave her a breath of fresh air. But shortly after the birth of Jack, their first child, Yvonne, at age 22, had the first of many schizophrenic episodes.

Moshe came from a very different kind of home than Yvonne’s. His father, Harold, was a drinker, and he and his wife, Claudia, had a conflictual relationship. Domineering and difficult, Claudia focused on her children to escape Harold. Sydney became an alcoholic, Arnold involved himself in a series of poor relationships, never marrying, and Max left behind a trail of broken marriages. Moshe, perhaps as youngest, couldn’t escape and so avoided the pain as best he could through shy compliance. When he met Yvonne, he was delighted to find someone who seemed so the opposite of his mother. Yvonne was gentle and flattered him because she wanted his opinion so much. But he was not always capable of offering one–especially as regards baby-care–and his insecurity precipitated Yvonne’s break.

Not able to nurture a baby, Moshe certainly could not oversee Yvonne, leaving Jack, Aaron, Syliva, and Marlene to tend to their mother until she died. Their relationship, infused with a realistic understanding that their mother was “sick,” was tempered with bitterness because their lives had been sacrificed to her needs. This was especially true of Sylvia, the most independent of the siblings. Jack and Aaron had a very close relationship with each other, never dating, and even sharing an apartment for many years. As the oldest two, they felt the brunt of their mother’s incapacities and their father’s helplessness. Sylvia, frustrated, fought with Aaron often.

Marlene, the youngest, was most removed from the caretaking responsibilities and least called upon to think independently. She had the fewest life skills and remained enmeshed. She was ecstatic to marry a seemingly strong man who could make up for her weakness. Steve’s solitude gave Marlene the feeling that she had at last gotten the freedom she needed. Steve had good reason to be emotionally distant. He had an abusive father and a frightened mother who neglected her children and did not notice their abuse. His home life resembled that of his father-in-law, Moshe. Steve both worried about his mother and resented her–much as Marlene and her siblings both worried about and resented their mother. Steve was used to emotional removal: His father’s first marriage resulted in a half-sister who lived elsewhere with her mother; he never met her. His own sister ran away at 16. He did not hear from her for 15 years, only to learn that she had lived with a Lubavitch family, changed her name from Charlene to Chanie, became a ba’alas teshuva, and married a man who had taken a similar path. Steve had little contact with his estranged sister.

Marlene, a peaceful, caring woman, seemed a perfect match in Steve’s mind. He also liked his gentle father-in-law and felt that this family was a significant improvement upon his own. However, when Marlene’s attachment appeared to become cloying, Steve withdrew. Without realizing it, Steve became remote like his mother. The space Steve gave to Marlene could be frightening to her at times. But her grandparents were long deceased, she had never been close to her siblings, and the more she fretted at him, the more aloof her husband would become. Afraid of repeating bad family history, Marlene covered her fears with overcompetency regarding their only child, Stephanie. This was not hard to do because Stephanie was diabetic.

Intergenerational Case Analysis

The present analysis is only one of many possible constructions. There is no reason to privilege Bowen’s (Kerr & Bowen, 1988) or Minuchin’s (1993) theory over others. However, the referring physician would most likely understand the case normatively; therefore, it is helpful to explore it from this perspective. Central to Bowen’s examination of intergenerational family process is the concept of differentiation, defined as “the proportion of life energy prone to be invested and bound in relationships” (Kerr & Bowen, 1988, p. 68). High levels of differentiation imply a life that is not excessively invested in family. Bowen’s theory sees low levels of differentiation as losing the tug of war between togetherness and independence needs. Furthermore, it asserts that people marry others with approximately the same level of differentiation as they have. People with low levels of differentiation may tend to cling to one another. However, needs for individuality imply that a point comes when the person wants some independence. The independence may be scarry for someone not used to it–causing a rush back to the safety of the enmeshed relationship.

Another solution to enmeshment may be an escape into mental illness. Schizophrenic breaks often happen for the first time after the young person leaves home because the desire to disentangle from enmeshment precipitates a realization that one cannot stand on one’s own (McGoldrick & Gersen, 1985). With no certain identity, the individual prefers an alternate reality over enmeshment (Kerr & Bowen, 1988). Similarly, members of a violent family may express the dance between individuality and togetherness by not leaving or making shalom. Bowen’s concept also explains why people who have suffered through one disasterous relationship may enter into another: Unless the level of differentiation increases, history repeats itself. Finally, someone afraid of enmeshment may live a life remote from the family, what Minuchin (1993) calls disengaged and Bowen (Bowen & Kerr, 1988) refers to as emotional cutoff. Such a person would be at a similarly low level of differentiation as one who is enmeshed.

From Figure 1, we learn that Stephanie’s maternal great-great grandparents had a distant relationship. They may have had a low level of differentiation. If Sora could not invest emotional energy in Chaim, it would be natural for her to invest it in the children. We can guess that their daughter, Shirley, repeated the pattern she observed at home in marrying an emotionally distant man, Henry. Unable to connect, he abandoned his children when his wife died during the childbirth of their second daughter. Sora’s estrangement from her husband led to enmeshment with her grandchildren. Marion, however, rebelled, creating much turmoil in the family. The turmoil was a good way to keep her hovering grandmother at arm’s length. Yvonne was delighted to marry in order to escape from the net cast about her but could not handle the requirement for decision-making entailed in having a baby. This explains her schizophrenic episodes. She chose a remote man as an antidote to her grandmother’s smothering only to discover that she had come to depend on all the answers her grandmother offered. Schizophrenia can be thought of as a way to not have a self (Kerr & Bowen, 1988): It avoids both getting entangled and making independent decisions.

Moshe was not the best person to have to deal with a schizophrenic wife and four children. He chose his wife because her gentle ways were a relief after the chaos of his parents’ violent relationship. But her breakdown left him unable to cope with his children. Yvonne, who was enmeshed with all the children to the degree her illness would allow, had a special, warm relationship with Marlene in her moments of ability to connect at all. There were also moments of freedom during which Marlene either came to depend on her older siblings or suffered acute anxiety. She both craved and feared that freedom. Marlene was attracted to what she thought was Steve’s strength. She was mistaken in thinking an inability to be close was strength. Steve came from much the same sort of home as his father-in-law, Moshe–one of abuse, tension, and pain. The difference was that Steve’s mother, Arlene, reacted to her situation by avoiding the children whereas Moshe’s mother, Claudia, reacted in opposite fashion. Both neglect and emotional reactivity represent poor levels of differentiation. When Steve and Marlene had a diabetic child, it was natural that their lack of differentiation and their inability to handle decision-making would adversely affect their child. A typical interaction pattern in this family is pictured in Figure 2.

With a detailed family history indicating patterns of enmeshment, cutoff, and low differentiation–all normative ways of looking at the family in historical context–the therapist now may raise some hypothetical questions in order to understand, from the family’s perspective, how they make sense of their situation: Does Stephanie get worse to bring her distant father closer to the family? Does she get worse to help her mother feel competent? Does she get worse to reverse the escalating path of maternal enmeshment? Does Marlene really want that enmeshment or is she secretly glad that her daughter’s symptom can involve Steve in the family? Does Steve really resent Stephanie’s sickness, or might he perhaps be glad of a way into the family warmth? Is his irritation with Marlene’s smotherliness really irritation or is it perhaps a grudging admiration for a closeness he has never experienced and is afraid of? These proposed explanations would make sense to the referring doctor who could be informed, “Indeed, after hearing your description, I would agree that the family is enmeshed. It would be most therapeutic if we could encourage the mother to give some space to her daughter. Do you feel the child would be capable of measuring her own insulin without the mother’s supervision?” If the doctor indicated that he or she thought the child would be better off if we could enable her to help herself, then upon this normative framework of history and hypothesis, non-normative interventions can be built.

Non-Normative Conceptualization and Interventions

The first rule of non-normative systemic thinking is that behavior makes sense in context (Anderson & Goolishian, 1988; Boscolo et al., 1987; Doherty, 1988; Epstein & Loos, 1989; Fisch et al., 1982; Griffith et al., 1990). That is, given the history, skills, current conditions, and choices available to people, their behavior is reasonable. Any of the questions above, if answered in the affirmative, provide good reasons for Stephanie’s diabetic symptoms to worsen. It is a shame that less painful ways are not used, but this father has no role model in how to be close to his family. He has learned to put on an aura of expertise through which he can perform a useful function. This mother has been struggling to find a constructive way to relate to her child, but all she knows is tending to sickness–just as she tended to her mother’s. All the other hypothesized reasons, too, make sense in context.

Normalizing behavior that families and society may have pathologized enables them to view their actions with newfound self-respect. Such reframes (Fisch et al., 1982; O’Hanlon & Wilk, 1987; Watzlawick et al., 1974) might go something like, “Naturally, Steve, you would be so removed from the family! You’re a survivor. How would you have learned, given your parents and the terrible life you experienced, to be warm and close? You do a marvelous job of handling things when a crisis occurs. The fact that you care for your family shows how well you have risen above your origins.” In the same way, Marlene might be told, “You are an expert in tending to sickness–and in keeping away from it also in order to make time for yourself. You managed to stay sane. That is to your credit.” It appears that finding a meaningful way to understand these historical patterns reduces the family members’ self-blame and, perhaps for the first time, gives them a sense of hope. They see themselves in a different light, as people who survived under difficult odds. From this, they come to believe in their own resources. Whatever the intrapsychic explanation, recognizing the wisdom of peoples’ choices given their difficult contexts is a highly respectful initial intervention which, by itself, can produce significant change (Andersen, 1991; Anderson & Goolishian, 1988; Fisch et al; Hoffman, 1988; Watzlawick et al). This approach creates an atmosphere in which resistance (Amundson et al., 1993; de Shazer, 1984; Weakland & Jordan, 1992) and power plays (de Shazer, 1988b) are avoided.

A thorough understanding of the family’s plight–from their perspective–can be followed by a search for solutions (de Shazer, 1985, 1988a; de Shazer, Berg et al., 1986; de Shazer & Molnar, 1984; de Shazer, Gingerich et al., 1987; Kral & Kowalski, 1989; Lipchik, 1988; O’Hanlon & Weiner-Davis, 1989; O’Hanlon & Wilk, 1987). One way to introduce the concept of solutions to a family stuck in unhappy patterns would be to ask something like: “If crises were not occurring, what would be different?” (de Shazer et al., 1986). All the family members could be polled for this. This question must be asked and re-asked to pull out solutions. Stepanie might say that her dad would be more involved with the family. Marlene might say that she could go back to school. The therapist might then ask Stephanie in what way dad would be involved more and how would her mother manage to leave her so as to attend school.

Another solution-focused intervention is called the miracle question (de Shazer, 1988a). The original form of the question is: “Suppose that one night, while you were asleep, there was a miracle and this problem was solved. How would you know? What would be different? How will your [family] know without your saying a word to [them] about it” (p. 5)? For religious families, this question can easily be adapted by substituting the word nais for the word miracle. Steve might shyly come to admit that he wished he could be comfortable being closer to his family in quiet times. Always looking to elicit ideas from the family rather than to supply answers, the therapist might ask Marlene and Stephanie how this could be accomplished. Stephanie might suggest that dad take her fishing. Because the therapist mentioned being Orthodox, Marlene might feel comfortable indicating that she would like the whole family to begin having Shabbos dinners together with Steve making kiddush (Hirschhorn, 1996). An orientation toward solutions and an unconstrained look at all worldviews opens up possibilities.

Circular questions (Boscolo et al., 1987) provide a way of helping family members understand the world from one another’s perspective. For example, the therapist might ask Stephanie what she supposed Steve’s miracle might be. Then we could check out her answer with her dad. She might, for example, think his miracle was that she left him alone, or if she was a provocative teenager, she might say, “He probably wishes I’d drop dead.” If he believed she meant it, he might respond by protesting, or he might get angry at her. The answers will uncover relational patterns about which the family might not be aware.

Once many of the bits and pieces of members’ miracles are out for discussion, another solution-focused intervention could be a homework assignment called the noticing task (de Shazer, 1985). Suppose, for example, that in our discussion, the therapist asked Marlene what she thought Stephanie’s miracle was and Marlene thought that Stephanie would like more independence from her mother. Specifics count, so the therapist would ask, “What would she do differently? How would you be different?” Marlene might list the fact that Stephanie would take her own medicine, measure her sugar, monitor her diet. Stephanie probably would chime in that mom is correct, but has left out allowing her to go out with friends. Now we are ripe for the noticing task. We ask mom to notice how Stephanie is getting better in each of the items on the list. Such a task, of course, primes everyone for more desirable behavior.

One way of attempting to help families see improvement is to quantify the results of the difference question or the miracle question using a rating scale (de Shazer, 1985). This procedure is subjective–that is its strong point. Stephanie might be asked to quantify the amount of time dad spends with her on a scale from zero to ten. If, this week she says, “It would be a two, and only when I have a crisis,” then the homework that follows could be to notice improvements in her father’s spending time with her. At the following session, Stephanie might be asked to again place her father’s attentiveness on a scale. If the number goes up–and it usually does–it appears that therapy is working. If the number has not gone up, the subject becomes a potential topic for discussion.

It is also possible that the family is too burdened to think of solutions. They can still change. Given the positive understanding of their behavior (Boscolo et al. 1987), they need no longer berate themselves for it. It is possible that just presenting explanations to them which show how their behavior makes sense will free them to evolve less painful ways of handling their lives (Andersen, 1991; Boscolo et al.). It may be, however, that this family has good reasons not to change: Perhaps if Stephanie becomes too independent, Steve will not stick around at all. If change is not observed after various interventions, the therapist can explore all the excellent reasons the family may have for staying the same (Fisch et al., 1982; Watzlawick, et al., 1974). The therapist can let the family know that these are good rationales and perhaps they need to keep handling things the same way in the future. Even if they actually do not change, the anxiety associated with self-blame may be reduced, and their attitude towards their choices may improve.

Conclusion

Non-normative therapy credits clients with making reasonable choices given their history and context. Therefore, if Bowen’s understanding of schizophrenia is correct (Kerr & Bowen, 1988), then even Yvonne’s “choice” makes sense: With no skills at independent living and faced with the horror of suffocating love, she escaped into an alternate reality, perhaps one in which she could fantasize some degree of control over her world. Deep understanding of the client’s behavior can, by itself, effect positive changes (Andersen, 1991; Anderson & Goolishian, 1988; Hoffman, 1988).

A selection of solution-focused interventions provides further alternatives from which clients can choose new behaviors and attitudes (de Shazer & Molnar, 1984). The need for new options does not imply pathology; it simply expands the number of ways of handling problems (O’Hanlon & Wilk, 1987). These interventions provide concrete modes of turning nebulous miracles (de Shazer, 1985) into reasonable goals. Of most importance to therapists is that these are client miracles, client goals–not ours (Amundson et al., 1993; de Shazer, 1984, 1988b). Even when clients are not ready to change, these interventions could help improve family harmony by illuminating the patterns that have arisen and how they make sense. The family might come to evolve more amenable ways of coping over time (Boscolo et al., 1987).

Non-normative interventions take a burden off therapists who do not have to supply the answers and do not have to be right. They can be themselves. This enables practitioners to be open about their values in a manner that enhances therapy (Abroms, 1978; Aponte, 1985; Epstein & Loos, 1989). This is of particular relevance to Orthodox professionals (Hirschhorn, 1996). The same flexibility allows the non-normative clinician to utilize the conceptual framework offered by a referring–normative–professional in handling a new case. Although the referring doctor may have seen Marlene as enmeshed and incompetent, Steve as inadequate, and Stephanie as manipulative, this pathologizing view need not interfere with either the therapist’s relationship to the referring physician or cooperative work with the family. Marlene’s behavior may be considered enmeshed while noting the constraints her history provided for behaving differently. Her incompetency at parenting can be compared to a competency at handling illness, and the therapist can build upon these latter skills. Steve’s and Stephanie’s behavior can be similarly reframed (Fisch et al., 1982; Watzlawick et al., 1974). The preceding case illustrates the power, flexibility, and respect of a non-normative orientation for an orthodox therapist.

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