Augustus Napier on Experiential Family Therapy

Augustus Y. Napier: This term really came from Carl Whitaker. The word "symbolic" has to do with the nature of therapeutic experience. Our assumption is that psychotherapy is a kind of italicized experience in that it's heightened. It provides a slice of experience that the client may not have experienced, which is more honest and more caring, with insights, etc., that they haven't had, and the assumption is that these incidents that occur in the psychotherapy interview—in the room itself—have a kind of symbolic importance. The therapist is symbolic, often of a parent or some family-like authority figure, and what we try to provide is a slice of something that's missing from the family's life. You can't reparent somebody who needed twenty years of the kind of parenting they didn't get, but you can provide them experience that is a taste of something that was missing in the family or the individual's experience. In that way, it's like a slice of a pie that goes deep but not broad.

AN: I think by bringing a lot of focus on the here-and-now in the interview—that is, trying to make the experience as real, as immediate, and as powerful as possible. I think families bring a lot of expectations to therapy. Things have gotten pretty bad; there's a hunger for something new, and for help. Often they bring a lot of skepticism and wariness, but they also bring a need that's pretty deep. So the way that the therapist influences the symbolic nature is to, first of all, be aware that what you say, what you do, has more than ordinary importance. This is not a social conversation—this is a deeper level of conversation. So the therapist invests a kind of personal commitment to making the experience in the interview as intense, and as intensely meaningful, as possible. It's taking on a burden of making this more personal, as opposed to technical.

AN: Yes, it does. It means we allow ourselves to be personally involved, and to bring our own feelings, as well as our thoughts, to the process.

AN: Yes, absolutely. I talked recently with a friend whom I had referred to a therapist. My friend said, "He talked about himself—I found that unprofessional." What I think should be emphasized here is that we're well aware of the danger in the therapist's personal involvement. And for that reason, we often work with co-therapists who balance the personal in some way. It's as if you're in a tag-team wrestling match: one of the therapists goes in and works for a while, and then they're sort of rescued by the other one who's been watching and monitoring and being more in his or her head. So we think about psychotherapy as freed up by the therapists being a team; that allows a more personal encounter.

We're also quite disciplined about the structure of the therapy. For example, if somebody walks out of the room to go to the bathroom, we stop the interview because we don't want a second level of interaction. Somebody might walk out to go to the bathroom and the other partner says, "I'm having an affair." So there's a discipline process around the structure. And we maintain control of the structure—for example, who comes in to the therapy—in a way that creates safety.

AN: Well, it's expensive any time you have two therapists in a room working together. Whitaker's analogy is that family therapy is like heart surgery: it's very complex, and you'd better not do it by yourself because you're in over your head. You get sucked into the family's own drama and you lose your perspective—and that really happens to lots of therapists who try to do it alone. It's a bit like speaking to the wilderness: when you try to say this to people whose work is dictated by managed care, for example, they're not going to want to pay for two therapists. So agencies that have some freedom over their budget can do it, and in private practice it can be done, but it is a specialty. And my concern over time about the field is that the demands of this practice, of working with families and couples, are much greater than we had anticipated, and that the therapists need a lot more help, a lot more structure, a lot more support in order to do it well. So there are limitations to being able to work in teams, but I think it's necessary to do a really good job. When trying to work with families and couples alone, I've often found myself triangulated in some way, or compromised by that process, or feeling overwhelmed or discouraged, or induced into the family's own world to too great of an extent. So admittedly this is not an easy approach to do, and it's not easy to teach.

AN: That's my belief. There are individual, intrapsychic, historical issues that need to be worked with, but my sense is that it's best done by starting first with the group that's intimately involved—that lives together, that deals with each other in real time. And the individual work can take place within that context—that is, you can work on the husband or the wife's childhood with the other person in the room. And it takes some work to get there so that there's enough intimacy and safety. But there's a point, for example, in working with couples where conflict breaks down between the couple because it's very clear that a lot of issues come out of their histories. And that's what I would call a depressive period: when, instead of fighting with each other, you have two people who get depressed because they realize, "Oh my goodness, this really comes from childhood and from my other relationships." So there is a phase in which individual therapy in the presence of the other becomes the focus.

And sometimes, toward the end of therapy, a lot of the group issues have been resolved, and somebody wants to work on something that has to do with their own journey or their own individual issue, and then you have enough trust in the group itself for that to take place. But the first step, really, is to get all the key players in the room, and to work on building safety and trust and more intimacy with that group. Then you have tremendous freedom about where you go and what you do. But if you start with an individual, you become that person's therapist, and it can happen in two or three sessions, so that you'd be not available to the family.

AN: Exactly. One of the dangers in doing individual therapy, and I think they're considerable dangers, is that the therapist and the client create a fantasy about life that is a kind offolie à deux in which two people agree, "Oh, the real problem is your spouse," or, "The real problem is your mother-in-law." But when this process goes on for a long time, the client and therapist become a microsociety within which there's agreement and consensus and a kind of coziness. While that can feel good, a problem with what I would call a kind of autistic view of the world is that nobody challenges it. There's nobody there to say, "Oh, but I don't agree about that. You're forgetting about so-and-so," or, "I see you as..." So there's no encounter where an individual's perception is challenged in some way, by somebody else who knows them and is involved with them. So there are two things that can happen with individual work. I mean, there are many things, but one thing is that the family or the marriage or the context defeats the individual.

AN: She's run down. She doesn't have as much money or as much power as her husband. She is helped to feel a little better, but she doesn't have enough power to change the system, so she goes home and essentially plays the role that life casts her in there. So there's the situation where an individual fails to develop enough power to really change the system. Now, sometimes a powerful therapist can help someone change their system, and that really can happen. Usually it's because the therapist is thinking about the system and, in fact, is working with the individual on how to deal with the system. My wife Margaret treated a woman whose husband was well known, rigid, absolutely uninterested in coming to therapy. And I think her work with the wife was so targeted and so thoughtful that it really saved the marriage, even though he never came. So sometimes the issue is: Is the therapist thinking about the system? Does the therapist have a commitment to the life of the system rather than just who's in the room? Of course, it would have been a lot easier of the husband had come to therapy.

AN: The other danger with individual therapy—and this is something tragic I saw sometimes—I remember a woman who came in with her husband. The woman's therapist had asked me to join in because the marriage had deteriorated as the individual work progressed. And by the time I came into that system, it was very clear that this woman had decided with the therapist that the husband was impossible and that she was out of there. And they did divorce. He remarried, she never did, and I think she lived a pretty lonely life after that, without ever having had access to really concentrated work on that problematic marriage. So sometimes individual therapy creates a coalition that really disempowers a marriage. I've seen it be destructive in that way. And it's not that she shouldn't have divorced, but the marriage really never had an advocate in itself.

AN: Yes, and that's really the basis of family therapy: seeing that the problems are not just in the individuals, they're in the complexity of the relationships. And we would say that the family is always your client—that you should be thinking about your work as it impacts that group. But it's a very different way of viewing the world. It's much more difficult to say, "My client is this family. My obligation is to help them as a group." And it's something that I think more therapists should do—that is, to expand their mandate to include the family: "My responsibility is beyond the individual. I'm responsible for what's happening to the kids at home, I'm responsible for what's going on between an adult and their parents," and so forth. So it's an expanded mandate. And I think it's the ethical way to proceed with therapy, is to think in bigger terms than what your obligation is.

AN: That's a great question. I don't think it's necessarily different, from the therapist's perspective. Whitaker used to compare the family to a sports team that's been playing together for years and years: they know each other's moves, so they're powerful in their connectedness. An ad-hoc group is not powerful in that way, unless it's got a longevity commitment together. So an ad-hoc group is relatively superficial in the intensity of the connection, compared with a family. The voltage is so much higher in families; the stakes are so much higher. So with an ad-hoc group, you can develop a lot of intensity, but it tends to be focused on the individuals that make up the group.

AN: You know, it's interesting. Reviewing this video recently, I was surprised at how much time I spent in the interview on insight into the couple's histories. And as I looked at it, I thought I was aware of the fragile nature of the relationship, and was trying to help them gain more insight because I didn't have much time with them. But I think in ongoing work, there's a lot more emphasis on the encounter process between the members. There's a lot less therapist intervention, a lot more sitting back and watching as an episode unfolds. And then there's a point where one comes in and intervenes in a more confrontational or personal way. I started out fairly confrontational in that interview, and then for some reason I backed off and didn't push in the direction I'd been going. So I do think that typical for the experiential approach is an effort to push the family to try some interactions that they haven't been doing, and to lend one's own muscle to getting some different things to happen. For example, in the interview that you're talking about, I pushed the husband to be more assertive. So I do think that there's that component, that is, the focus on the encounter process and making it move somewhere new by adding a coalition from the therapist or by encouraging somebody to go in a direction they've been afraid to go in. But I also think of this work as having a high component of insight.

I started my career in high school reading Freud—not that I knew I was starting a career, but I picked up some paperbacks off a newsstand—and so I came into this field with a keen attachment to the idea that we understand our histories. And intellectually, I'm curious. I think people need to know a lot about themselves and their upbringings. I think this process of becoming more rational about the turbulence of the emotional world is generally a good thing. So I would probably put more emphasis on insight, for instance, than Carl Whitaker would have. But where I joined with his work was believing in getting that history to become present—that is, bringing in the family of origin, and working actively with those key players. And it feels to me that the most powerful, impactful work that I did was bringing together extended families. In some ways it was incredibly easy once you got people into the room, because they had a lot to talk to each other about that they really needed to deal with. And you just helped it along.

AN: Yes. Families where there's a big power imbalance, where there's some abusive process going on, where somebody is floundering, being suicidal. But I think, particularly when there's the danger of abuse, working carefully and confrontationally is sometimes called for.

AN: Well, I think there are many times when psychotherapy goes in directions we didn't anticipate, sort of like a political process—you get surprised by things. Looking back over years of practice, I think that I wish I had been more confrontational more often. I think this is one thing that differentiates experiential therapy—the willingness to be confrontational. And to be openly caring. So that level of emotional involvement is part of what typifies this approach.

AN: That it's vague. That it's too subject to the therapist's own countertransference issues. That it's expensive because it often involves a team. That it's cumbersome if you try to get in people who don't want to come. That it can sometimes be authoritarian if the therapist sets rules about the process. But I think the main criticism is that it's hard to define—it's hard to say what it is. And I think part of that problem is that what it is is complex. It's atheoretical, and it's atechnical—there's generally not a set of techniques that we learn. For example, in structural therapy, there are certain theories about what you do in what situations, and techniques that you can use. And I think experiential therapists do use techniques—I don't think we're entirely pure. But there's a high focus on the therapist's intuitive process. And so when you're trying to teach experiential psychotherapy, it's generally something that's done best with a student in the room with the therapist. That is, we often trained therapists by doing co-therapy with them. And that's a very slow way to teach. It can take years of hanging out with somebody to really teach them what you're doing. I was lucky to get to work side by side with Carl for at least five years. So I think the approach is limited by the personalized way of teaching. And I'm also concerned that it's limited by the fact that it's quite complex.

So I think there are real concerns about the approach. But one of the things that I think make it exciting for the therapist is the permission to be himself or herself in the process. And over time I've begun to think, "Gosh, I have one of the best jobs that anybody on the planet can have." I have a license to say what I feel and think. I'm trying to do something to help people, and I've given myself permission to be myself in the interview, to be real, to say what's on my mind. And that's incredible. When you look around this society, how many jobs give you permission to be honest? To care about the people who are paying you? And I began to think about it as a kind of privileged position or perspective, to be allowed to take a personal involvement with something as intricate and meaningful as a family.

So I think this approach has the promise of expanding the experience of the therapist. You're not doing a series of techniques—you are putting your own life mixed in with other lives, and it's incredibly rich emotionally. So I found the work exciting. I was always curious about what was going to happen, what this new family was going to be like. I always felt like I was learning and being forced to learn. I felt like I was being forced to confront my own devils in my own family.

And that reminds me that another part of this approach is the assumption that the therapist will have therapy—that if you do this approach, you'll find yourself having to go back to therapy because this family looks so much like the one you grew up in, or this person reminds you so much of... And the field is so charged. It's hard to distance yourself from it.

AN: Yes—having your own therapy, having a consultation group, like a peer supervision group, and having an actual consultant with you in the therapy session. In cases where co-therapy was prohibitively expensive, we arranged within our practice group to do drop-in consultations for each other, where every four or five sessions the other therapist would come in and essentially say, "How are you doing? Has Gus gotten on somebody's side yet?" and so on. So the balancing of the personal with disciplined professional structure is what makes it really possible.

AN: Rigidly authoritarian families have real trouble with it, because usually they're dominated by an individual who doesn't want his or her power disrupted. Often it needs to be disrupted. So people who are personally rigid or systems that are personally rigid are threatened by this approach. They want you let them identify the problem and then have you solve it. And often it's, "Fix our adolescent son or daughter." And without the freedom to challenge that scapegoating dynamic, golly, it's really tough. One of the things we learned that helped us work with that kind of authoritarian structure is to find the vulnerability of the powerful person--being careful not to humiliate this person—but basically forming an alliance with them that says, "I know life is hard for you, too. Tell me your perspective. Where are you worried?" The aim is to co-opt that power position by going for support.

AN: Particularly with rigid men, you've got to tiptoe around their pride sometimes. And sometimes just getting them to come to the session is a victory. So you tread carefully with them. But at some point you know you'll have to challenge the family, and an individual in the family. You have to challenge their authority. And you guard yourself for that moment: "Okay, when's the showdown going to be?" And it's probably wise of the family to challenge the therapist, because they need to know if you can stand up to them. They need to know that you have enough strength to take the chaos beneath the surface. And sometimes it's an adolescent who's elected to challenge by refusing to come to the session or by being flippant, insulting. But often it's one of the parents who's threatened by the process.

AN: Yes. It's really a critical moment in therapy, and usually the family sort of sighs with relief: "Oh, we feel in safer hands." At the beginning of therapy, the family is needy but not trusting, and they have to put you through a series of tests to find out if they can trust you. Can you challenge the dominant person in the family? It may be a bratty four-year-old. Can you be honest? Can you maintain neutrality, or can you be sucked into somebody's side? I remember a couple I worked with in Madison, one of the first ones I saw there. And I realized I was really getting on the wife's side. I didn't have a co-therapist—they couldn't afford it and I didn't have students at that time. So I got up my nerve and I said, "Listen, I am getting on your wife's side, and you've got to help me see something more sympathetic about your position."

AN: The wife said, "Yes, I'm really good at getting people to be on my side and making him look bad." So we had a laugh, and he began to be more self-revealing. But what I'm just describing is one of the critical elements in this approach to therapy: there's this moment where the therapist says, "Do I have the nerve to say this?" And it's really the ultimate therapeutic moment, when the therapist says, "Okay, I'm going to say this. It's not going to be popular." I remember a family where the husband, a successful lawyer, was in the process of leaving his wife—affair with the secretary and so forth. I got him to bring in his mother and siblings. One of his siblings was obviously gay and frightened at being in the session, and one of the siblings was a kind of hostile-looking good ol' boy. And the husband who was leaving his wife was just one of the crowd, here. But I realized the sister was afraid of her brother's scorn and so forth, and she said something that indicated that she was gay. So, in order to make this perfectly explicit, I said to the good-ol'-boy brother, "How does it feel to have a sister who's gay?" And there was this huge silence.

AN: But it was one of those moments where my heart was in my throat. It's like, "If I can't say this, if I can't challenge the lie in this family, then I'm not earning my keep here." So there was a little talk—this was her coming out in the family. They hadn't been able to talk about it. They did talk about it, and then we moved on to other things. I ran into her years later, and she said, "You know, you asking one question changed the whole course of my experience with my family. They all warmed up to me, and they reconnected," she said. "Everybody except my brother. He never really accepted me." But the experiential approach has this demand on the therapist to be courageous in moments where there's something not being said. And I think that's the essence of the approach, really—to push yourself as the therapist to break the rules about what's permissible within the family. And it's really hard to do.

AN: Well, part of it is cultural in that the family is more fractured. Families have trouble finding time to eat a meal together. They're fractured by time demands, stresses of work, and so forth. So the whole idea of family unity is under attack by the society. We know of families who don't even have a dining table—they eat fast food sitting on the floor. So there's that cultural aspect. I think the whole idea of family loyalty has been challenged, as well, by geographic mobility. My daughter lives in Argentina, another lives in Boston; my son's in Albany, New York. So going to college, going into the military, is a lot of geographic separation, and that runs counter to families seeing each other and being involved with each other on a daily basis.

But I also think that we have failed as a profession to train family therapists adequately. I don't think we've done a good job of preparing people to do the very difficult work of family therapy. Sometimes in the latter stages of my lecturing, I depressed people because I said, "Listen, our field is failing to make family therapy work. We're letting ourselves be defeated by the insurance companies." And of course, that's another factor here: the family system as patient is in fact often prohibited. That idea was never really embraced by the insurance companies. But I don't think we did a good enough job in giving young therapists enough support to stay with it and to develop their own skills. I just think it takes so much more than we estimated. A resident I worked with in the psychiatry department at Madison said, "Family therapy is doomed because it's too difficult to do. I don't think it will ever work." And he had obviously tried it and found it too daunting. I'm debating about writing a television series based on a family therapist's life. Maybe that will rejuvenate interest. But I think a lot of forces have conspired against family therapy. And you know, it exists in pockets, and certainly there are training programs that do an excellent job, and there are people who do it. But I think the issue of enough support is what has made this so difficult. And it's discouraging to see.

AN: Absolutely. Murray Bowen was the master at this. He would work with a family member for a while, and then he'd say, "I want to see this other one over here." So he would work serially with family members, or he would work with an individual on how to change their direction with the system, and he did that in his own family. So if you think in terms of your client as being a family, you can find a way to work with them. I was amazed that my wife could work with this really difficult, rigid husband through his wife. But he changed over time, so I think in spite of all the obstacles to getting families into the room together, if we can think about the system as something we're responsible for helping, then I think we can help them. I think the critical thing is thinking systems.

AN: Well, yes, indeed—both. I think that the responsible thing if you're practicing individual therapy is to meet at least the spouse before you start the process, so that you're not dealing with some kind of myth. You see a real person here, and you don't allow a massive distortion of the other. You also learn about an individual client by seeing how they interact.

It's also possible to go in the other direction. Say somebody starts seeing a woman who can't get her husband to come to therapy, and that goes pretty well for a while, and she begins to feel more powerful and she challenges him, and the marriage begins to deteriorate. There is a way to make a transition to working with a couple or a family in this way, which is to bring in another therapist.

AN: Well, maybe in the beginning. But really it allows the therapist, who has gotten captured by the individual client, to retreat a little bit and to involve the spouse. It's quite a delicate process to go from an individual therapy process to a couples therapy or family therapy process, but it can be done. It takes another therapist's involvement, I think. I've seen too many cases where an individual therapist tried to bring in a spouse and was so biased that it just went sour very quickly.

AN: Absolutely, yes. If the therapist who's been committed to the individual now spreads his or her loyalty to the other spouse, the one who's been the patient feels abandoned. So it's very tricky. Most therapists would say, "Okay, I'm going to hold myself in reserve and refer you to a couples therapist to start again with." That's also very problematic, because you're basically saying to the individual patient, "I'm going to abandon you." So my sense is that it's so much better to start with a minimal unit being the couple. I didn't see individuals in the beginning who were married. I said, "I just don't do it—I know it's going to be trouble. You've got to bring your spouse. And I'll work with you on how to do that, but we're not going to do psychotherapy—we're going to work on how to get your spouse to come to therapy for maybe five sessions."

So my sense was that marriage is the irreducible client—that we owe a certain loyalty to give that relationship an advocate. And that's really an ethical belief.

AN: I think in a pretty devastating way. It's not just family therapy that got medicalized—it's the entire psychotherapy process. Psychotherapy got devalued as medicine became the easy way to treat individual distress. In Wisconsin where I was trained, we had a group therapist, we had a family therapist, we had a psychoanalyst, we had a behavioral therapist. And when I went back ten years later, gosh, it all looked medical. It was all focused on medicine and biology and so forth. So I think the medicalization of psychotherapy affected the whole field, not just family therapy. But family therapy was hit particularly hard, because when you say the problem is inside the individual, and it's a biological problem and it's treatable by medicine, it doesn't leave much place for a family system. So I think medicalization of psychotherapy in general has been a tragic thing.

Fortunately, the research is now showing that the most effective treatment even for individual issues may be both medication and psychotherapy. So there's more balance at least, in the promoting the benefits of talking to somebody.

I think this medicalization trend fits also with the depersonalization of our world—that we've got big anonymous cities and big anonymous systems, so the whole project of human connection has been depersonalized.

AN: Well, you know, families are moved around from place to place. People work in corporations where they're pretty anonymous within those big organizations where there's a lack of a human community. People live in suburbs, miles away from any intimate relationships. And they live online. So there's this huge machinery here of interfering with the intimate relationship, the small town, the family that lived on three blocks in New York City. That whole world has changed.

I think in some ways the Internet is a countervailing trend in that it tries to connect people in ways that really facilitate more communication. I mean, I'm on the phone or on iChat with my kids from Argentina and so forth. So we have this other thing—that, in the face of anonymity and abstraction, we have the capacity to connect with each other. So I feel the Internet has many negative things, but it's also got this possibility.

AN: I don't know about doing family therapy over the Internet. Maybe that's possible.

AN: Yes. Once Margaret and I were working with a family, and the husband had left the family and moved to London, and he left behind three very hurt teenage sons. And his ex-wife was a therapist, so she brought her kids and we worked on the absent dad stuff and the boys' grief. So I decided to do a speakerphone interview with him. We had the speakerphone sitting in the room on a chair among the family, and his voice would come out of that thing. These boys would look at it with this combination of rage and hurt. And he looked so diminished sitting there.

AN: Golly. Give me a minute... I think the main thing we can do here is to provide deeper levels of support to therapists. You're going into the equivalent of systems warfare here, and you need a lot of support and help—you need to be able to work with people who believe in your world. So we start out with building in for the therapist a community of support, and we legitimize for therapists the need for support—intellectual support, peer supervision, supervision, psychotherapy—and help the therapist seek support, and validate the need. It's important not to underestimate what it's like to go into a clinic where nobody's doing family therapy and you're trying to do it. So that's the individual work with the therapist. So how do you negotiate the conditions of your job? How do you try to set conditions that are favorable to your being successful? Most of that has to do with having some buddies who believe in the way you do, and staying in touch.

The other tack is legislative and large-system intervention in ways that would validate psychotherapy and family therapy. I think we could do a better job of educating the public about the benefits of psychotherapy and family therapy. Most people haven't heard of the family approach. So I think legislatively we can work to get, for example, insurance reimbursement, and our big associations can help with that. We could do a much better job of educating the public, and we could do a much better job of supporting the struggles of young therapists. So there's a lot of work to be done there.

AN: I think so. But we need to start with belief that this is a valid thing to do, that it's important to do: some sort of ethical commitment to the world of psychotherapy and family therapy. It's not just a trade—it's something like a calling.

AN: I didn't have any worry about having enough to say, thanks to your excellent questions! This has been fun.