Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=wjfp20

Download by: [92.221.193.152] Date: 18 February 2017, At: 06:37

Journal of Family Psychotherapy

ISSN: 0897-5353 (Print) 1540-4080 (Online) Journal homepage: http://www.tandfonline.com/loi/wjfp20

Researching Systemic Therapy History: In Searchof a Definition

Lennart Lorås, Paolo Bertrando & Ottar Ness

To cite this article: Lennart Lorås, Paolo Bertrando & Ottar Ness (2017): ResearchingSystemic Therapy History: In Search of a Definition, Journal of Family Psychotherapy, DOI:10.1080/08975353.2017.1285656

To link to this article: http://dx.doi.org/10.1080/08975353.2017.1285656

Published online: 17 Feb 2017.

Submit your article to this journal

View related articles

View Crossmark data

Researching Systemic Therapy History: In Search of aDefinitionLennart Loråsa, Paolo Bertrandob, and Ottar Nessc,d

aWestern Norway University of Applied Sciences, Bergen, Norway; bSystemic-Dialogical School, Milano,Italy; cFaculty of Health and Social Sciences, University College of Southeast Norway, Centre for MentalHealth and Substance Abuse, Drammen, Norway; dNorwegian University of Technology and Science,Trondheim, Norway

ABSTRACTThis article reviews literature describing systemic therapy and it’sbasic elements. Today, many different models appear under thesame umbrella term, “systemic therapy,” sharing little more thana few features. However, a comprehensive definition is needed tomeet political and ethical demands, especially within the field ofmental health. Our proposed definition draws on elements fromthe Batesonian and Milan tradition, as well as the narrative, post-modern, and dialogical developments. Our aim is to help practi-tioners outside the systemic field to understand what systemictherapy is, and to support “insiders” in better describing thefoundations and practices systemic therapy.

KEYWORDSDefinition; family therapy;social constructionist theory;systemic theory; systemictherapy

Introduction

“While family therapists acknowledge the need for clinical practice to beevidence-based, the difficulty is identifying any one methodology that doesjustice to the work.” (Larner, 2004, p. 20)

The previous statement from Larner speaks to the heart of the concerns we wantto address in this article. Evidence based medicine (EBM) has become a domi-nant discourse in healthcare systems (Sackett, Rosenberg, Muir Gray, Haynes, &Richardson, 1996). Following the demands of EBM, the evidence base in sys-temic therapy has grown significantly (e.g., Carr, 2014; Retzlaff, Sydow, Beher,Haun, & Schweitzer, 2013; Stratton, 2010; Von Sydow et al., 2010, 2013).Systemic therapies, such as solution-focused brief therapy (SFBT) (de Shazer,1994) and strategic structural therapy (Haley, 1963; Minuchin, 1974), which aredirectly related to the Bateson research team and Mental Research Institute(MRI), has been accepted in the United States as evidence-based practices.Several projects conducting outcome research are also in progress. Two exam-ples are the work of LACT in Paris involving 65 therapists in seven countriesusing MRI brief therapy (http://lact.fr) and Giorgio Nardone and his colleagues

CONTACT Lennart Lorås Lennart.Loras@hib.no Western Norway University of Applied Sciences, P.O.Box 7030, Bergen 5020, Norway.

JOURNAL OF FAMILY PSYCHOTHERAPYhttp://dx.doi.org/10.1080/08975353.2017.1285656

© 2017 Taylor & Francis Group, LLC

work in Italy, represented by documenting and publishing outcome research inmultiple countries and languages (http://www.giorgionardone.it/pubblicazioni.php).

However, systemic therapists have been tending to drift away from the field ofpsychiatry for several years (Bertrando, 2009). We see many possible reasons forthis; one reason seems to be a lack of precise specifications and clinical guidelinesfor the systemic approach (Pote, Stratton, Cottrell, Shapiro, & Boston, 2003). Atthe same time, the demands made within the neo-liberal discourse and theimplementation of new public management (NPM) in the healthcare servicesfocus on effectiveness and documentation (Kirchhoff, 2010).

A historical review of the literature shows a plethora of different descriptions ofsystemic therapy’s elements. Currently, several models coexist within the umbrellaterm “systemic family therapy” (Boston, 2000). Some unifying feature of systemictherapy can be found, such as the importance given to understanding psycholo-gical difficulties in the context of social relationships and culture; or the signifi-cance of drawing distinctions andmarking “difference” as an aspect of the creationof change (Boston, 2000). The purpose of this article is to enhance the descriptionof systemic therapy to meet political and ethical demands by developing a usefuldefinition. The proposed definition is based on presented phases of the history ofsystemic family therapy. The definition is mostly for use within the field of mentalhealthcare, but can also be a useful pedagogic tool in order to “guide” systemictherapists in training, supervision, therapy, and research. Ultimately, we hope thatthis definition will help therapists, trainers, and researchers to be more specificwhen referring to systemic therapy in their work. This is important so that it ismore transparent what systemic therapy entails in practice. However, the defini-tion thatwe propose, does not aim todescribe specific elements in systemic therapy(i.e., the use of reflecting team, working with individual, etc.). Instead, it is anoverall definition of the basic features we believe characterize the systemicapproach as such.

First of all, we will present the process of our re-discovering the originaldefinitions and descriptions of systemic therapy interventions from the devel-opment of Milan systemic family therapy. We will then move on to postmoderndefinitions and descriptions of it. This will give us a foundation upon which wecan propose a definition of systemic therapy practice that can both do justice tohistory of systemic theory and practice, and, at the same time, respond to therequirements of present-day mental health occupational standards.

The development of (Milan) systemic therapy

Family therapy traces its origins from the 1950s, through the confluence ofdifferent kinds of theories and practices (Broderick & Schrader, 1991). The term“systemic therapy” was not used at the time, though, whereas the term “familysystems therapy” was preferred, as synonymous of family therapy (Bertrando &

2 L. LORÅS ET AL.

Toffanetti, 2000). All family therapy, at the time, was influenced by the systemiccybernetic thinking originated in the Macy Conferences on Cybernetics (Heims,1991), imported in psychiatry and psychotherapy by Gregory Bateson and hisgroup (Bateson, Jackson, Haley, & Weakland, 1956). However, some of thevarious family therapy models were closer to systemic ideas, especially conjointfamily therapy, developed byDon Jackson and JohnH.Weakland (1961) who hadbeen members of the original Bateson group. In 1961, Don Jackson and VirginiaSatir defined systemic therapy as:

(…) predicated on the necessity for viewing the symptoms of the identified patient orpatients within the total family interaction, with the explicit theoretical belief that thereis a relationship between the symptom of the identified patient and the total familyinteraction. The extent to which the therapist “believes” in family therapy will deter-mine his emphasis on techniques that convey this orientation to the patient. (p. 30)

Later, Brad Keeney and Jeffrey Ross (1985) echo this definition positing:“systemic family therapy is a perspective that emphasizes treating the patternsthat connect the problem behavior of one person with the behavior of otherpeople” (p. 3).

Powerful techniques: Strategic–systemic therapy

The Milan systemic family therapy approach was first presented by a group offamily therapists from Milan in Italy, led by Mara Selvini Palazzoli (SelviniPalazzoli, Boscolo Cecchin & Prata, 1978). Late in the 1960s, the group wascomposed of eight psychiatrists and psychoanalysts, practicing psychoanalyticfamily therapy. Subsequently, Selvini Palazzoli shifted to theMRI model, followedby three of them, Luigi Boscolo, Gianfranco Cecchin, and Giuliana Prata. TheMilan team used the cybernetic definition of a system as any unit structured byfeedback (Guttman, 1991). On this basis they saw pathological behavior as a resultof individuals being isolated or vilified in their struggles to maintain particularfamily relationships. For example, a person’s symptomatic behavior was seen as areaction to such isolation, or as a result of the person’s attempt to “strike back”against hurtful family relationships (Campbell, 1999). Therefore, the main goal ofMilan systemic therapy is to prompt change in patterns of interaction betweenmembers of the system, often achieved by a combination of positive connotationbased reframes, use of circular questions, and the therapist embracing what theteam called neutrality. The effort was not to prompt change through insight.

Palazolli, Boscolo, Cecchin, and Prata (1980) defined Systemic Theory (thentermed by Milan and others as communication/cybernetic theory) as:

(…) the family is a self-regulating system which controls itself according to rulesformed over a period of time through a process of trial and error. The centralidea of this hypothesis is that every natural-group-with-history, of which thefamily is a fundamental example, comes to exist through a period of time

JOURNAL OF FAMILY PSYCHOTHERAPY 3

through a series of transactions and corrective feedbacks. These assay what ispermitted and what is not permitted in the relationship, until the natural groupbecomes a systemic unit held together by rules peculiar to it alone. These rulesare related to the transactions, which occur in the natural group, transactionswhich have the quality of communication, whether on the verbal or nonverballevel. According to the axioms of Pragmatics of Human Communication(Watzlawick, Beavin, & Jackson, 1967) every behavior is a communicationwhich, in turn, automatically provokes a feedback consisting of another beha-vior-communication. (p. 3)

The Milan team continued:

Following this hypothesis, one arrives at still another hypothesis, families in whichone or more members present behaviors traditionally diagnosed as “pathological,”are held together by transactions and, therefore, by rules peculiar to the pathology.Hence the behavior-communication and the behavior-responses will have suchcharacteristics which maintain the rules and, thereby, the pathological transactions.Since the symptomatic behavior is part of the transactional pattern peculiar to thesystem in which it occurs, the way to eliminate the symptoms is to change therules. (Palazzoli et. al, 1978, pp. 3–4)

Here, and inmany other places in the Palo Alto Group andMilan literature, theemphasis is to evoke change in behavior in contrast to promoting change throughunderstanding. Reframes are used to use the logic and language of the client toevoke change in behavior. Insight and understanding, if it comes about, is after thefact by-product. One of the most explicit statements of this counter-intuitivereversal of logic is Heinz von Foerster’s (quoted in Poerksen, 2004, p. 23) famousquote: “In order to see act. Always act in ways to increase choice. In order to staythe same, change.”

Among the systemic techniques they used to counter the family’s resistance tochange were systemic focus, positive connotation, final reframings, familyrituals, homework, and paradoxical (“counterparadoxical”) interventions (seefor more details Campbell, 1999; Cecchin, Lane, & Ray, 2010; Goldenberg &Goldenberg, 2008; Selvini Palazzoli et al., 1978).

The early work of the Milan team (Selvini Palazzoli et al., 1978) was laterdescribed as first order cybernetics, characterized by dispassionate therapistsobserving the family system from the outside. Their therapeutic practice wascharacterized by a systematic search for differences in people’s behavior in relation-ships, how different family members perceived and construed an event, and byefforts to uncover the connections that link familymembers and keep the family inhomeostatic balance (Goldenberg & Goldenberg, 2008; Jones, 1993).

From another viewpoint on this practice, influenced both by the MRI’s(Watzlawick, Beavin-Bavelas, & Jackson, 1967), Jay Haley’s (1963) andSalvador Minuchin’s (1974) ideas, could be described as strategic–systemic(Boscolo & Bertrando, 1996). On one hand, the therapists had definite ideas ofwhere to lead their clients and what kind of change to pursue. On the other, they

4 L. LORÅS ET AL.

were no longer concerned with symptoms or presenting problems, instead theywere interested in the whole systemic family configuration. One example is thepositive connotation, a prescription to the family tomaintain their overall familyinteraction, rather than maintaining the individual’s symptom as inWatzlawick,Weakland, and Fisch (1974) symptom prescription.

Systemic epistemology: Batesonian therapy

Amomentous shift in theMilan team’s theory and practice happened when theyfirst encountered Gregory Bateson’s original theories, which they up to thatmoment had merely second-hand knowledge of. Readings of the newly pub-lished Steps to an Ecology of Mind (Bateson, 1972) paved the way for a newunderstanding of therapy, shifting the focus from the observation of interactivesequences and patterns toward questioning the family’s belief system(Goldenberg & Goldenberg, 2008). Prompted by Bateson’s paper “Form, sub-stance, and difference” (1970), they now conceived all the therapist’s knowledgeas inherently provisional, and always open to be questioned and revised.Consequently, the fitness of the therapist’s hypothesis about the system shouldalways be checked against the clients’ feedback, and the therapist’s stance towardthe client should always be tentative and uncertain. These “guidelines” were putforward, in the team’s final joint article, as hypothesizing, circularity, andneutrality (Selvini Palazzoli, Boscolo, Cecchin, & Prata, 1980).

It was at this point the term “systemic family therapy” began to be used, todistinguish the team’s model from others, such as strategic and structural familytherapy (Schjødt & Egeland, 1998). It was first proposed as a definition of theMilan approach by Lynn Hoffman (1981).

The original Milan group, though, had already split in 1980. Selvini Palazzoliand Prata continued their search for classification and predictable interventionson families with psychotic members, while Boscolo and Cecchin began organiz-ing a comprehensive training for therapists, further elaborating their systemicideas (Goldenberg & Goldenberg, 2008). It is Boscolo and Cecchin’s route wewill follow in the current article.

Boscolo and Cecchin initially worked on developing the new features of theirmethod (Boscolo, Cecchin & Hoffman, 1987). It was centered on the therapeuticinterviewing process itself, particularly the use of circular questioning (Jones,1993). Circular questioning stems from Bateson’s (1972) ideas about informationas news of difference, and focuses on interpersonal connections and relationships,rather than individual characteristics, to address differences in the family mem-bers’ perception of events and relationships (Tomm, 1988). During a meeting inCalgary in 1982, organized byKarl Tomm, Boscolo, andCecchin got in touchwithHumberto Maturana, Heinz Von Foerster, Vernon Cronen and Barnett Pearce,who were among the most relevant representatives of constructivism (Bertrando& Toffanetti, 2000). In seeking to advance a new systemic epistemology, Boscolo

JOURNAL OF FAMILY PSYCHOTHERAPY 5

and Cecchin found a consonance in these authors’work, thus becoming central inadvancing first constructivist, then social constructionist and narrative approachesto therapy (Goldenberg & Goldenberg, 2008). All these orientations deny that anyobjective reality is knowable as such to therapists, holding instead that thetherapist’s own personal and theoretical bias should be included as a part of theobservation (Boston, 2000).

Probably the most relevant acquisition of this period for systemic therapywas the awareness of the contextual nature of any problem and/or psycho-pathology, leading to the conclusion that any relevant human issue can bedealt with by considering the relationship in which it is embedded.

Self-reflexivity: The influence of constructivism

Boscolo and Cecchin’s ideas about circular interviewing were adapted andfurther developed by Karl Tomm (1987a, 1987b, 1988), who assumed a moredefinite constructivist position. Tomm (1987a) claimed that systemic therapistsknow that they do not know, and, therefore, must go on asking questions to gainnew information and new hypotheses for their interventions. Therefore, heimplied that questions are in themselves therapeutic interventions. The maingoal of circular interviewing is to provide a new base of information within thefamily, which enables possibilities for new understandings of their interactions(Tomm, 1987a, 1987b). The dialogic process can thus be seen as an interventionin itself (Tomm, 1988).

The Milan systemic approach arrived in Britain at the beginning of the 1980s.DavidCampbell first developed training in systemic therapy at theTavistockClinicin London, thus becoming, together with his group, one of themain proponents ofMilan approach in the United Kingdom (Burck, Barratt, & Kavner, 2012;Campbell, 1999). He described his version of systemic therapy as comprisingthree different ways of understanding what we see and hear: (1) It is based on anappreciation that what people observe around themselves can be understood inunique and different ways, because any event can be seen from different contexts,each one giving different meaning for different people; (2) systemic thinkingimplies an appreciation that there is a meaningful connection between a person’sbeliefs and their behavior; and (3) systemic therapy sees the observer as a part of thetherapeutic system.What she observes is her own construction, and it is affected bythe interaction between her as a therapist and themembers of the observed system.This has been called second-order cybernetics (Von Foerster, 1982).

Campbell (1999) claimed that “post-systemic” family therapists of the newmillennium should pay allegiance to the core concepts of context, difference,feedback, patterns of interactions and meaning in language and change, butshould also incorporate a broader range of techniques and settings. The dividebetween systemic therapy and other family therapy approaches appeared, there-fore, at the end of the 1990s to be growing. Although this might make it hard to

6 L. LORÅS ET AL.

“pin down,” and open to criticism, David Campbell hailed systemic therapy’sflexibility and described this to be one of its advantages, because it’s flexibilitymake systemic ideas fit every context (Burck et al., 2012).

We can see that systemic therapy in its constructivist period shifted awayfrom the implicit behaviorism of first-order cybernetics, toward a more thor-oughly cognitive stance. Increasing information became the basic therapeuticmeans, and changing clients’ premises—unconscious cognitive foundations ofour way of seeing the world, according to Bateson (1936)—the main goal. Thisalso led therapists to pay more attention to client’s experiences and narratives,paving the way for further developments.

“Post-systemic”: Postmodern and social constructionist therapies

Although already an explicit aspect of the communication based systemic theoryand therapy introduced by the Bateson Team in the 1950s (see for exampleJackson, 1960), the inclusion of constructivist ideas introduced systemic therapyto second-order cybernetics in the mid-1980s (2002; Hoffman, 1990). Thismeant that therapists were called upon to include their own personal andtheoretical bias as a part of the observational system (Boston, 2000) and thatthey had to hypothesize about their clients as clients being observed by atherapist (Campbell, 1999). Don Jackson (1960) argues that:

Over and over again it has been necessary to learn the lesson that the observerinfluences the observed. In the field of mental health, we have not only to reckonwith the natural effect of the observers’ own bias but we have to deal with a secondvariable: the effect of this bias on the patient. (p. 30)

This shift led systemic therapists to be more and more interested in under-standing how the therapist (and the clients themselves) could give shape to theirbeliefs. A possible answer was found in social constructionist theory (Gergen,1994; MacCormack & Tomm, 1988; McNamee & Gergen, 1992; Strong,Sutherland, Couture, Godard, & Hope, 2008). Social constructionism focuseson people’s use of language and meaning making in relationships and cultures(Gergen, 2009; Lock & Strong, 2010). Reality is not the product of an isolatedobserver; it is rather a creation of the “linguistic dances” we all dance together(Hoffmann, 1990; Tomm, St. George, Wulff & Strong, 2014). This is a radicalchange not just from the position that external reality is “knowable,” but alsofrom the idea that each observer constructs her own reality, instead focusing onhow humans collectively interpret and construct their own way of understand-ing reality (Gergen, 2009).

The alternative view offered by social constructionists led systemic therapyinto considering the social world as a result of our interactions, with theinterpreted knowledge being socially constructed in a shared language(Anderson & Goolishian, 1988; Gergen, 1982). Social constructionism

JOURNAL OF FAMILY PSYCHOTHERAPY 7

encouraged “post-systemic” (or “post-Milan”) therapists to see clinical realitiessuch as psychiatric diagnosis and family roles as a result of social interactionsacross many different levels: cultural, societal, familiar, and individual(Campbell, 1999). The family is no longer seen as the most relevant humansystem, opening the way to the possibility of individual systemic therapy(Boscolo & Bertrando, 1996). All in all, most normative therapeutic theorieswere abandoned or put in the background (Bertrando & Toffanetti, 2000).

Social constructionism also introduced systemic therapy into postmodernism(Boston, 2000), allowing the inclusion of narrative and solution focused ideas. Theinfluence of narrative ideas on systemic practice is clearly visible in two books,TheTimes of Time (Boscolo & Bertrando, 1993) and Systemic Therapy with Individuals(Boscolo & Bertrando, 1996). At that time, Michael White was just becomingfamous (see White & Epston, 1991), but he was already a relevant influence onsystemic therapy. The idea was that if, instead of considering a system in the hereand now, we consider its development in time, we get a story. When we thinkabout time, we think in narrative terms. It is, therefore, impossible to think aboutsystemic therapy without taking narratives into account (Lorås, 2016).

Solution focused therapy became one of the most important developments ofsystemic therapy (actually, it was mostly a postmodern derivation of strategic–systemic therapy; see deShazer, 1985), by granting an elegant approach, centeredon solutions outside the boundaries of problem solving. It did not influencetherapists who were developing Milan-style models, though: the very notion offinding simple solutions to intractable problems did not appeal to the Milangroup, nor to their followers (Lorås, 2016). Rather than “chasing” solutions, theyaimed at generating hypotheses (Selvini Palazzoli et al., 1980).

Both these new approaches emphasized more and more the necessity ofconsidering, on the one side, the clients’ stories in order to make sense out ofthem, on the other, the strengths and resources they may mobilize in order tofind alternatives to their problems. At the same time, all postmodern andconstructionist approaches bring to the limit theMilan idea of hypothesis, seeingall the therapist’s knowledge as inherently provisional and local, for example, notendowed with any kind of superior expertise compared to the clients’.

In the following text, we will consider systemic therapy according to apostmodern and social constructionist approach. We will, therefore, leave theterm Milan systemic therapy, and use the phrase “post-systemic therapy” todescribe its further developments.

Meta-dialogues: The influence of reflecting team processes

Norwegian psychiatrist Tom Andersen (1992), who originally aligned with theideas from the Milan team, eventually rejected them, objecting to their view ofthe therapist as expert. Instead he introduced his own “reflecting team” in1985. In this practice, both the active therapist and the members of the

8 L. LORÅS ET AL.

therapeutic team share all their observations with the client, avoiding anysecrecy. The idea that led to the development of the reflecting team was thedesire to shift professional language toward everyday language, as well as theidea of sharing the professional’s knowledge directly with clients (Andersen,1992). Andersen (1992) described this movement as a shift from an “either–or”to a “both–and” stance. This allowed family members to choose which of theteam’s reflections (if any) they wanted to explore closer in the continuingconversation (Andersen, 1992).

Although Andersen never (to the best of the authors’ knowledge) wouldcharacterize his theoretical orientation within one specific method or epistemol-ogy, his authorship shows close ties to collaborative language systems therapyand social constructionist theory and practice. Whatever his therapeutic orien-tation, Tom Anderson’s reflective team had great influence in systemic therapy(Campbell, Draper, & Huffington, 1991).

Opening the dialogue: The influence of dialogical therapy

Finnish therapist Jaakko Seikkula, initially influenced byMilan systemic therapy,later established his own “open dialogue approach” (Seikkula, 2002; Seikkula &Olson, 2003). In it, Batesonian references are substituted by Mikhail Bakhtin’s(1935) dialogical ideas. In open dialogue, all members of the relevant systemaround a problem have their own say both about the presenting issue and thetherapeutic process, without necessarily searching for a final agreement. Despiteits apparent anarchy, such a method has shown extremely relevant results(Seikkula & Olson, 2003). A similar dialogical emphasis, albeit centered on thetherapist’s inner conversation appears in the work of Peter Rober (2005).

Whereas, pure dialogical approaches seem to have severed all their connectionswith the systemic model, dialogical systemic therapy, as proposed by PaoloBertrando (2007), presents a new theoretical framework, based on Bertrandosoriginal work within the Milan model, with the intention to bridge the gapbetween systemic and a dialogical understanding. As a dialogical therapistBertrando claims that in order to entertain a relationship with the client onequal terms, therapists do not need to renounce their expertise/wisdom, but are“knowing not to know” about clients lives. Therapists maintain their opinions inthe same way as others in the dialogue do, without renouncing their ideas andfeelings. Therefore, he encourages an attitude of constant questioning and anability to face dilemmas and doubts, without entertaining too many certainties(Bertrando, 2009). Bertrando describes the “new” dialogical therapy as guided bythe use of systemic hypotheses within a collaborative frame.Hypotheses, therefore,are reintroduced in the therapeutic process and are considered as the product of ajoint creative effort by both therapist and clients (Bertrando, 2007).

All dialogical approaches, independently of their origin, put an emphasis ofthe shared creation of meaning, and link it to the clients’ emotional experience.

JOURNAL OF FAMILY PSYCHOTHERAPY 9

All in all, postmodern therapies seem to shift the focus of therapy from the realmof concepts, cognition, and epistemology, drawing it closer to experience. Thelived experience of clients, in narratives and dialogues now seem to be the maintarget of therapeutic interventions, thus reintroducing in therapy not only therelevance of viewpoints and beliefs, but also the clients’ bodies, sensibilities, andfeelings (Bertrando & Arcelloni, 2014).

Manualization: The quest for consistency

Throughout most of its history, systemic therapy showed many facets, withoutever attempting to find some unifying description. The need of such a unifyingdescription became especially apparent when attempting to create manuals forusing systemic therapy in specific situations, such as research (e.g., Asen & Jones,2000; Trowell et al., 2007) or training (Pote et al., 2003). The most importantsystemic manual is probably the Leeds manual, created within the context of theLeeds Family Therapy Research Center (LFTRC), directed by Peter Stratton. Poteand colleagues, through amulti-faceted and recursive research process, compiled asystemic family therapy manual and adherence protocol, which contains a synth-esis of techniques from theMilan, narrative and solution-focused schools (Allison,Perlesz, Pote, Stratton, & Cottrell, 2002). The 11 specific competences that theLFTRC team identifies for systemic therapy are:

(1) System focus: The central focus is on the system, rather than theindividual.

(2) Circularity: Behavioral patterns within systems are circular in natureand always evolving.

(3) Connections and patterns: The therapist should consider connectionsbetween circular patterns of behavior and connections betweenbeliefs and behavior within systems.

(4) Narratives and languages: Behavior and beliefs are the basis forstories or narratives, which are constructed in language by, aroundand between the individual and the family system.

(5) Constructivism: Each individual will interpret and make sense of herworld from her own frame of reference.

(6) Social constructionism: Meaning is constructed in social interactionsbetween people and is context-dependent and constantly changing.

(7) Cultural context: The therapist should consider the importance of contextin relation to cultural meanings and narratives within people lives.

(8) Power: The therapist should take a reflexive stance toward powerdifferentials within both the client system and the therapeuticrelationship.

(9) Second-order cybernetics/co-constructed practice: In therapy reality is co-constructed between the therapist (and team) and the people they meet.

10 L. LORÅS ET AL.

(10) Self-reflexivity: Therapists should be alert to their own constructions,functioning, and prejudices.

(11) Focus on strengths and solutions: Therapists should take a non-pathologizing, positive view of the family system and their currentdifficulties, emphasizing strengths and solutions in clients’ stories.

Although manuals represent a first step toward a definition of systemictherapy, the necessity to indicate in detail all aspects of it, even when simplylisting competences, makes them not concise enough to offer a simple andeconomic definition of the field. This is what we will try to rectify.

Toward a definition of systemic therapy

The systemic approach has been considerably developed throughout the years,incorporating elements from first- and second-order cybernetics, structural,strategic, narrative, solution focused therapy, constructivism, social construc-tionism, postmodernism, among others (Carr, 2012). In the current section, wewill present our proposal for a useful definition of systemic therapy, and we willdiscuss its elements and some of its implications to research and practice.

Although systemic family therapy, to a large extent, can be said to have evolvedin line with the rest of society, its proponents seem not to have sufficiently dealtwith offering specific definitions of their therapeutic interventions. Linguisticemphasis and language understanding has gained a growing relevance in “post-systemic therapy” (Pote et al., 2003). Problems may arise when the systemicapproach is used in the context of both public- and private-based healthcaresystems, which ask for standardized procedures and clear descriptions of theinterventions assessed (Marrell & Koser, 2015). In many cases, the vagueness ofdefinitions can lead healthcare managers and practitioners to prefer otherapproaches, such as cognitive–behavioral therapies. Therefore, the need for aprecise definition seems clear. Based on our immersion in both the history andliterature of the approach, we propose the following definition of systemic therapyto be used in the context of mental healthcare:

Systemic therapy is based on the assumption that people’s challenges and difficultiescan best be solved within the relational system and context in which they arose.Clients’ own experience and history are considered to be the best starting point forfinding new ways of dealing with their problems. The basic therapeutic goal is there-fore tomobilize the strengths of their relationships so as tomake disturbing symptomsunnecessary or less problematic for them. The understanding of meaning as created inlanguage also makes it a therapeutic goal to identify each client’s thoughts and beliefs,and link them to their emotions and feelings, in order to co-create new meaning andthe possibility of new alternative relationships. Throughout the therapeutic process,the therapists maintain an attitude of respect and uncertainty, knowing that clients’expertise and knowledge of their lives must be mobilized, and that the therapists’knowledge is always provisional.

JOURNAL OF FAMILY PSYCHOTHERAPY 11

The definition implies a contextual and relational therapy, which takes intoaccount the different developments within the systemic therapy field, as well associal constructionist ideas. In short, the statement: “Systemic family therapy isbased on the assumption that people’s challenge and difficulties can best besolved within the relational system and context in which they arose” can betraced back to Bateson’s (1972) ideas about context, where he maintains thathuman behavior always needs to be contextualized.

“Clients’ own experience and history is considered to be the best startingpoint for finding new ways of dealing with their problems. A therapeutic goal istherefore to mobilize the strengths of their relationship so as to make disturbingsymptoms unnecessary or less problematic for them,” is linked with solution-focused ideas (de Shazer, 1994), which is also described as a central element insystemic family therapy (Pote et al., 2000) and system theory about homeostaticbalance (Jackson, 1957; Jones, 1993).

“The understanding of meaning as created in language also makes it atherapeutic goal to identify each client’s thoughts and beliefs, and link them totheir emotions and feelings, in order to co-create newmeaning and possibility ofnew alternative relationships” has its origin in social constructionist theory(Gergen, 1982; Lock & Strong, 2010; McNamee & Gergen, 1992), togetherwith Campbell’s (1999) three ways of understanding what we see and hear,complemented by the new emphasis on feelings (Bertrando & Arcelloni, 2014).This development, focusing of insight and emotions, is based in the morerecently emerging postmodern and language-oriented approaches.

“Throughout the therapeutic process, the therapists maintain an attitude ofrespect and uncertainty, knowing that clients’ expertise and knowledge of theirlives must be mobilized, and that the therapists’ knowledge is always provi-sional,” emphasizes the hypothetical dimension of the therapist’s understandingof clients first proposed by the Milan team (Selvini Palazzoli et al., 1980), as wellas the dialogical component described by Bertrando (2007).

A more precise definition, albeit still grounded in the theoretical and philo-sophical stance of systemic therapy, can help and support researchers andpractitioners in providing more legitimacy for systemic therapy practice withinmental healthcare systems. There is good evidence for the efficacy of familytherapy in different contexts (Asen, 2002; Carr, 2014; Stratton, 2010), as well asits cost effectiveness (Crane et al., 2013; Morgan, Crane, Moore, & Eggett, 2013).It is difficult, however, to discriminate which model of family therapy has beenused in different research studies. More recent meta-analyses on effectivenesshave been conducted only on studies claiming to use a specific systemic model(Retzlaff et al., 2013; Sydow et al., 2013); the specification of the nature of such asystemic model, though, is still unclear. Arguing for the legitimacy of systemictherapy, therefore, remains a difficult task. Having a clear definition that con-siders systemic theory, history and practice, will help to describe systemic clinicalpractice and research in a way that, in the end, can build more empirical

12 L. LORÅS ET AL.

evidence for (the use and effects of?) systemic therapy in the mental healthcarefield. Also, having a definition grounded in systemic and social constructionisttheory will allow a better linking of theory and practice in training for futuresystemic therapists.

Closing reflections

The Leeds Systemic Family Therapy Manual (2000) provides a thoroughaccount of systemic therapeutic interventions through practice-oriented exam-ples. It presents, however, no clear definition of the therapeutic approach itdescribes. Our proposal for a definition is intended as a contribution to a shortand transparent presentation of systemic therapy in non-systemic contexts,particularly in mental health, due to the requirement of clearly defined inter-ventions (The Norwegian Health Directorate, 2008). The definition we haveoffered contains elements from the original Milan systemic therapy, as well aspost-systemic and social constructionism. We believe such a definition can easethe understanding and discrimination of the basic values and features of thistherapeutic approach for both students and mental health professionals whohave not yet been exposed to systemic ideas.

References

Allison, S., Perlesz, A., Pote, H., Stratton, P., & Cottrell, D. (2002). Extended dialogue aboutsignificant developments: Manualising systemic family therapy: The leeds manual.Australian and New Zealand Journal of Family Therapy, 23(3), 153–158. doi:10.1002/anzf.2002.23.issue-3

Andersen, T. (1992). Reflections on reflecting with families. In S. McNamee & K. Gergen(Eds.), Therapy as a social construction (pp. 54–68). Newbury Park, CA: Sage Publications.

Anderson, H., & Goolishian, H. A. (1988). Human systems as linguistic systems: Preliminaryand evolving ideas about the implications for clinical theory. Family Process, 27, 371–393.doi:10.1111/famp.1988.27.issue-4

Asen, E. (2002). Outcome research in family therapy. Advances in Psychiatric Treatment, 8,230–238. doi:10.1192/apt.8.3.230

Asen, E., & Jones, E. (2000). Systemic Couple Therapy and Depression. London: Karnac Books.Bakhtin, M. M. (1935). Discourse in the novel. In M. Holquist (Eds.), The dialogic imagina-

tion (pp. 259–422). Austin, TX: Texas University Press. 1981.Bateson, G. (1936). Naven (2nd ed.). Stanford, CA: Stanford University Press.Bateson, G. (1970). Form, substance, and difference. In G. Bateson (Eds.), Steps to an ecology

of mind (pp. 448–465). New York, NY: Ballantine Books. 1972.Bateson, G. (1972). Steps to an ecology of mind. New York, NY: Ballantine Books.Bateson, G., Jackson, D., Haley, J., & Weakland, J. (1956, October). Toward a theory of

schizophrenia. Behavioral Science, 1(4), 251–264. doi:10.1002/bs.3830010402Bertrando, P. (2007). The dialogical therapist: Dialogue in systemic practice. London: Karnac

Books.Bertrando, P. (2009). Surviving in psychiatry as a systemic therapist. Australian and New

Zealand Journal of Family Therapy (ANZJFT), 30(3), 160–172. doi:10.1375/anft.30.3.160

JOURNAL OF FAMILY PSYCHOTHERAPY 13

Bertrando, P., & Arcelloni, T. (2014). Emotions in the practice of systemic therapy. Australianand New Zealand Journal of Family Therapy, 35, 123–135. doi:10.1002/anzf.1051

Bertrando, P., & Toffanetti, D. (2000). Storia della terapia familiare. Milano, Italy: Cortina.Boscolo, L., & Bertrando, P. (1993). The times of time. London: Karnac Books.Boscolo, L., & Bertrando, P. (1996). Systemic therapy with individuals. London: Karnac Books.Boscolo, L., Cecchin, G., Hoffman, L., & Penn, P. (1987). Milan systemic family therapy:

Conversations in theory and practice. New York, NY: Basic Books.Boston, P. (2000). Systemic family therapy and the influence of post-modernism. Advances in

Psychiatric Treatment, 6, 450–457. doi:10.1192/apt.6.6.450Broderick, C. B., & Schrader, S. S. (1991). A history of family and marital therapy. In A. S.

Gurman & D. P. Kniskern (Eds.), Handbook of family therapy (Vol. II). New York, NY:Brunner/Mazel.

Burck, C., Barratt, S., & Kavner, E. (2012). Positions and polarities in contemporary systemicpractice: The legacy of David Campbell. London: Karnac Books.

Campbell, D. (1999). Family therapy and beyond: Where is the milan systemic approachtoday? Child Psychology & Psychiatry Review, 4(2), 76–84. doi:10.1017/S1360641799001896

Campbell, D., Draper, R., & Huffington, C. (1991). Second thoughts on the theory and practiceof the Milan approach to family therapy. London: Karnac Books.

Carr, A. (2012). Family therapy: Concepts, process and practice. London: Wiley-Blackwell.Carr, A. (2014). The evidence base for family therapy and systemic interventions for

child-focused problems. Journal of Family Therapy, 36, 107–157. doi:10.1111/joft.2014.36.issue-2

Cecchin, G., Lane, G., & Ray, W. (2010). Eccentricity and intolerance: A Systemic Critique.Human Systems, 21(1), 7–26.

Crane, D. R., Christenson, J. D., Dobbs, S. M., Schaalje, G. B., Moore, A. M., Pedal, F. F., …Marshall, E. S. (2013). Costs of treating depression with individual versus family therapy.Journal of Marital and Family Therapy, 39(4), 457–469. doi:10.1111/j.1752-0606.2012.00326.x

de Shazer, S. (1985). Keys to solution in brief therapy. New York, NY: Norton.de Shazer, S. (1994). When words were originally magic. New York, NY: Norton.Gergen, K. J. (1982). Toward a transformation in social knowledge. New York, NY: Springer

Verlag.Gergen, K. J. (1994). Realities and relationships: Soundings in social construction. Cambridge,

MA: Harvard University Press.Gergen, K. J. (2009). An invitation to social construction (2nd ed.). London: Sage.Goldenberg, H., & Goldenberg, I. (2008). Family therapy an overview. Pacific Grove, CA:

Brooks/Cole.Guttman, H. (1991). Systems theory, cybernetics, and epistemology. In A. S. Gurman & D. P.

Kniskern (Eds.), Handbook of family therapy (Vol. II). New York, NY: Brunner/Mazel.Haley, J. (1963). Strategies of psychotherapy. New York, NY: Grune and Stratton.Heims, S. J. (1991). The cybernetics group. Cambridge, MA: The MIT Press.Hoffman, L. (1981). Foundations of family therapy. New York, NY: Basic Books.Hoffman, L. (2002). Family therapy: An intimate history. New York, NY: Norton.Hoffmann, L. (1990). Constructing realities: An art of lenses. Family Process, 29(1), 1–12.

doi:10.1111/j.1545-5300.1990.00001.xJackson, D. D. (1957). The question of family homeostasis. The Psychiatric Quarterly

Supplement, 31(part 1), 79–90.Jackson, D. D. (1960). The etiology of schizophrenia. New York, NY: Basic Books.Jackson, D. D., & Satir, V. (1961). A review of psychiatric developments in family diagnosis

and family therapy. In N. Ackerman, F. Beatman, & S. Sherman (Eds.), Exploring the base

14 L. LORÅS ET AL.

for family therapy: Papers from the M. Robert Gomberg memorial conference (pp. 2–51).New York, NY: Family Service Association of America.

Jackson, D. D., & Weakland, J. H. (1961). Conjoint family therapy: Some considerations ontheory, technique, and results. Psychiatry, 24, 30–45. doi:10.1080/00332747.1961.11023261

Jones, E. (1993). Family systems therapy: Developments in the Milan-systemic threapies.New York, NY: John Wiley & Sons.

Keeney, B., & Ross, J. (1985). Mind in therapy – Constructing systemic family therapies.New York, NY: Basic Books.

Kirchhoff, L. W. (2010). De skjulte tjenestene – om uønsket atferd i offentlige organisasjoner[The hidden services – about unwanted behaviours in public organisations] (PhD-dissertation). Karlstad University, Sweden. LACT http://lact.frRead12.07.16.

Larner, G. (2004). Family Therapy and the politics of evidence. The Association forFamilytherapy, 26, 17–39.

Lock, A., & Strong, T. (2010). Social constructionism: Sources and stirrings in theory andpractice. New York, NY: Cambridge University Press.

Lorås, L. (2016). Paolo Bertrando: To some extent. An interview with the Italian systemictherapist and psychiatrist, Paolo Bertrando. Fokus På Familien, 1, 1–26.

MacCormack, T., & Tomm, K. (1988). Social constructionist/narrative therapy. In F. M.Dattillio (Ed.), Case studies in couple and family therapy: Systemic and cognitive perspec-tives. New York, NY: Guilford Press.

Marell, F., & Koser, L. (2015). Familytherapy and New Public Management. Fokus PåFamilien, 1, 42–59.

McNamee, S., & Gergen, K. J. (Eds.). (1992). Therapy as social construction. London: Sage.Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.Morgan, T. B., Crane, D. R., Moore, A. M., & Eggett, D. L. (2013). The cost of treating

substance use disorders: Individual versus family therapy. Journal of Family Therapy, 35,2–23. doi:10.1111/j.1467-6427.2012.00589.x

Palazolli, M. S., Boscolo, L., Cecchin, G., & Prata, G. (1980). Hypothesizing- circularity-neutrality. Family Process, 31, 217–230.

Poerksen, B. (2004). At each and every moment, I can decide who I am. Cybernetics andHuman Knowing, 10(3–4), 9–26.

Pote, H., Stratton, P., Cottrell, D., Boston, P., Shapiro, D., & Hanks, H. (2000). The leedssystemic family therapy manual. Leeds, UK: Leeds Family Therapy Research Center.

Pote, H., Stratton, P., Cottrell, D., Shapiro, D., & Boston, P. (2003). Systemic family therapycan be manualized: Research process and findings. The Association for Family Therapy andSystemic Practice, 25, 236–262.

Retzlaff, R., Sydow, K. V., Beher, S., Haun, M. W., & Schweitzer, J. (2013). The Efficacy ofSystemic Therapy for Internalizing and Other Disorders of Childhood and Adolescence: ASystematic Review of 38 Randomized Trials. Family Process, 52(4), 619–652. doi:10.1111/famp.12041

Rober, P. (2005). The therapist’s self in dialogical family therapy: Some ideas about not-knowing and the therapist’s inner conversation. Family Process, 44, 477–495. doi:10.1111/famp.2005.44.issue-4

Sackett, D. L., Rosenberg, W. M. C., Muir Gray, J. A., Haynes, R. B., & Richardson, S. W.(1996). Evidence based medicine: What it is and what it isn’t. British Medical Journal, 312,71–72. Retrieved from http://www.bmj.com/cgi/content/full/312/7023/71

Schjødt, B., & Egeland, T. H. (1998). Fra systemteori til familieterapi [From systemic theory tofamily therapy]. Oslo, Norway: Tano AS.

Seikkula, J. (2002). Monologue is the crisis: Dialogue becomes the aim of therapy. Journal ofMarital and Family Therapy, 28(3), 283–284. doi:10.1111/j.1752-0606.2002.tb01186.x

JOURNAL OF FAMILY PSYCHOTHERAPY 15

Seikkula, J., & Olson, M. (2003). The open dialogue approach to acute psychosis: Its poeticsand micropolitics. Family Process, 42, 403–418. doi:10.1111/famp.2003.42.issue-3

Selvini Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. (1978). Paradox and counter-paradox. New York, NY: Rowman & Littlefield Publishers.

Selvini Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. (1980). Hypothesizing-circularity-neutrality. Three guidelines for the conductor of the session. Family Process, 19, 73–85.

Stratton, P. (2010). The evidence base of systemic family and couples therapy. Association forFamily Therapy UK, Retreived from www.aft.org.uk

Strong, T., Sutherland, O., Couture, S., Godard, G., & Hope, T. (2008). Karl Tomm’scollaborative approaches to counseling. Canadian Journal of Counseling andPsychotherapy, 42(3), 174–191.

Sydow, K. V., Retzlaff, R., Beher, S., Haun, M. W., & Schweitzer, J. (2013). The Efficacy ofSystemic Therapy for Childhood and Adolescent Externalizing Disorders: A SystematicReview of 47 RCT. Family Process, 52(4), 576–618. doi:10.1111/famp.12047

The Norwegian Health Directorate. (2008). Psychological health care for children and adoles-cents – guide for outpatient clinics. Oslo, Norway: Author.

Tomm, K. (1987a). Interventive Interviewing: Part I. Strategizing as a fourth guideline for thetherapist. Family Process, 26, 3–13. doi:10.1111/famp.1987.26.issue-1

Tomm, K. (1987b). Interventive Interviewing: Part II. Reflexive questioning as a means toenable self-healing. Family Process, 26, 167–183. doi:10.1111/famp.1987.26.issue-2

Tomm, K. (1988). Interventive Interviewing: Part III. Intending to ask lineal, circual, reflexiveand strategic questions. Family Process, 26, 2–13.

Tomm, K., St George, S., Wulff, D., & Strong, T. (eds.). (2014). Patterns in interpersonalinteractions: Inviting relational understandings for therapeutic change. London: Routledge.

Trowell, J., Joffe, I., Campbell, J., Clemente, C., Almqvist, F., Soininen, M., … Tsiantis, J.(2007). Childhood depression: A place for psychotherapy. An outcome study comparingindividual psychodynamic psychotherapy and family therapy. European Child &Adolescent Psychiatry, 16(3), 157–167. doi:10.1007/s00787-006-0584-x

Von Foerster, H. (1982). Observing Systems. Seaside, CA: Intersystems Publications.Von Sydow, K. V., Beher, S., Schweitzer, J., & Retzlaff, R. (2010). The efficacy of systemic

therapy with adult patients: A meta-content analysis of 38 randomized controlled trials.Family Process, 49, 457–485. doi:10.1111/famp.2010.49.issue-4

Watzlawick, P., Bavelas, J. B., & Jackson, D. D. (1967). Pragmatics of human communication.A study of interactional patterns, pathologies and paradoxes. New York, NY: W.W. Norton& Company.

Watzlawick, P., Weakland, J. H., & Fisch, R. (1974). Change: The principles of problemformation and problem resolution. New York, NY: Norton.

White, M., & Epston, D. (1991). Narrative means to therapeutic ends. New York, NY: Norton.

16 L. LORÅS ET AL.