3

FAMILY THERAPY AS A DIALOGUE

After more than three decades of traditional psychotherapy research with

randomised clinical trials (RCT), we can conclude that psychotherapy
works (e.g. Lambert, 2013). Overall we can say that about three-quarters of
our clients are better off than those who did not use our psychotherapeutic
services. While RCT research provides sufficient evidence to be confident
that psychotherapy in general works, it only gives us information about
average group effects and does not help clinicians to answer the question,
‘How should I treat this unique client sitting in front of me?’ Furthermore,
RCT research hardly gives answers to the question, ‘What exactly works
in psychotherapy?’ There is a lot of controversy about what works (e.g.
Norcross, Beutler & Levant, 2006). Although psychotherapy research does
not lead to simple answers and it sometimes seems that any point of view
can be backed up by scientific evidence (Wampold & Imel, 2015), still
there is a lot of evidence suggesting that, besides the treatment method,
the effect of which is highlighted by RCT research, non-specific factors are
important to explain the efficacy of psychotherapy (e.g. Lambert, 2013;
Duncan et al., 2010).
It even seems that the quality of the therapeutic alliance as experienced
by the clients is the most robust predictor of therapeutic change (Norcross &
Lambert, 2011). Furthermore, research seems to indicate that it is important
that the therapeutic relationship is flexible and adapted to the specific cli-
ent (e.g. Norcross & Lambert, 2011; Beutler et al., 2004). It seems that what
works in therapy is not this or that quality of the therapist, but the flex-
ibility with which he/she can be responsive and adapt to what the unique
client with his/her own story of suffering and survival needs (Beutler et al.,
2004). So the voice of the client seems to be of paramount importance for
therapy to work well, and collaboration with the client is central (Norcross &
Wampold, 2011).

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 IN THERAPY TOGETHER

THE ALLIANCE AS PREDICTOR OF OUTCOME

For a long time it was not clear if the correlation between the quality of the thera-
peutic alliance and the outcome could be interpreted as a causal relationship. After
all, if the therapy is going fine, this will probably result in a better therapeutic
relationship than if the therapy is not going fine. So it is a legitimate question to
ask: Does the quality of the relationship contribute to therapeutic improvement,
or is it only a consequence of the improvement?
According to Norcross & Lambert (2006), several studies have given a clear
answer to this question: yes, the alliance contributes to therapeutic improvement
(e.g. Barber et al., 2000; Klein et al., 2003; Beutler et al., 2003).

Therapeutic alliance or treatment? Both!

As Norcross (2010) writes, ‘highlighting the therapeutic relationship as a

mechanism of change raises the proverbial temptation to devaluate other
change mechanisms, such as the client’s contribution and the treatment
method’ (p. 114). In this book I want to avoid such simple dichotomies.
For that reason it is good to keep Michael Lambert’s pizza model in mind
(Assay & Lambert, 1999; Norcross & Lambert, 2011). Grounded in an
assessment of the psychotherapy outcome literature, this model estimates
the percentage of improvement in psychotherapy as a function of thera-
peutic factors:

• extra-therapeutic change (characteristics of the client and the client’s

context): 40%
• common factors (incl. therapeutic alliance): 30%
• techniques/model: 15%
• expectancy (hope): 15%.

While the exact percentages of the different factors may not be so important
in this model (as they are estimates, rather than measurements), the pres-
ence of four broad factors and the comparative importance of each of the
factors is.
The first factor, the extra-therapeutic change, refers to the characteristics
of the client (e.g. severity of the diagnosis, motivation, etc.) but also to the
client’s own resources like social support, the therapeutic aspects of the cli-
ent’s ecology, and so on.

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 FAMILY THERAPY AS A DIALOGUE

ON THE IMPORTANCE OF SOCIAL SUPPORT

World renowned psychotrauma researcher Bessel van der Kolk (2015) writes:
‘Social support is the most powerful protection against being overwhelmed by
stress and trauma’ (p. 79). For him, the critical issue in social support is reciproc-
ity: truly being heard and acknowledged by our loved ones and our care takers
(parents, teachers, etc.); feeling that we matter to others and that they care about
our well-being. It is all about a visceral feeling of being safe: ‘Being able to feel
safe with other people is probably the single most important aspect of mental
health’ (p. 79).

The second factor, common factors (variables in all therapies, regardless

of the theoretical model), comprises mainly characteristics of the therapy
relationship such as empathy, warmth, encouragement of risk-taking, and
so on. Interestingly, the client’s perception of the quality of the therapeutic
relationship correlates more with the outcome of therapy than the therapist’s
perception (e.g. Bachelor & Horvath, 1999). Furthermore, it is clear that in
fact the client is first and foremost an active self-healer (Bohart & Tallman,
2010). This surfaces for instance in the research on spontaneous recovery
that shows that people overcome important problems in their life without
any help from a professional (e.g. Assay & Lambert, 1999).
The third factor in Lambert’s model, techniques, refers to the actual treat-
ment method used in the therapy. And then there is the expectancy fac-
tor, the fourth factor: this refers to the client’s belief that because he/she is
treated he/she will experience benefits of the therapy.
Models like Lambert’s are important because they highlight that therapy is
more than the administration of an effective treatment to a docile patient. The
therapeutic relationship is very important (Norcross & Wampold, 2011), as are
the client’s own resources (Bohart & Tallman, 2010). A model like Lambert’s,
integrating different therapeutic factors, can give therapists in practice useful
ideas about how to improve their therapy outcome. Specifically, these seem
to be important recommendations for practising therapists:
• Connect with the resources of the client and his/her social context; and
give enough room to these resources in the therapeutic process. Respect
these resources and seek ways to collaborate with them.
• Listen to the client and find consensus on realistic goals for the therapy.
• Give a lot of attention to the therapeutic relationship, and be responsive
to the way the client experiences the therapy process; and what he/she
prefers, is afraid of, wants to avoid, and so on.

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 IN THERAPY TOGETHER

• Customise your way of working as much as possible to the unique client

in front of you.
• Use empirically supported treatment methods as much as possible.
• And so on.

In general, the most important advice for practising therapists seems to

be: be flexible and avoid one-size-fits-all therapies (Orlinsky, Rønnestad &
Willutzki, 2004; Norcross & Lambert, 2011; Norcross & Wampold, 2011).

FAMILY THERAPY AS AN EMPIRICALLY SUPPORTED TREATMENT METHOD

On the basis of a considerable body of outcome research there is evidence that

family interventions are effective for most child, adolescent and adult disorders
(e.g. Eisler, 2002; Sexton et al., 2013; Stratton et al., 2014).
For children and adolescents, family therapy is proven effective for conduct
problems (e.g. ADHD, drug misuse, self-harm); emotional problems (e.g. anxiety,
depression); eating disorders; somatic problems (e.g. enuresis, encopresis, chronic
physical illness) and first episode psychosis (Carr, 2014a). It is also useful in cases
of loss, abuse and neglect (Carr, 2014a).
For adults, family therapy is effective for relationship distress (e.g. prob-
lems of intimacy, psychosexual problems, couple violence), anxiety disorders,
mood disorders, alcohol problems, schizophrenia and chronic physical illness
(Carr, 2014b).

The alliance as a process of attunement

Psychotherapy is not simply ‘having a talk with a warm, caring per-

son’. Neither is psychotherapy simply the administration of a treatment
(Bergin & Garfield, 1994). Rather, psychotherapy is a complex process,
in which the therapist has a professional therapeutic alliance with the
client, listens carefully and generously to the client, employs specific
methods; while both the alliance and the methods are customised to the
unique client.
Outcome research supports the view of psychotherapy as a socially situ-
ated healing practice (Wampold & Imel, 2015), in which both the therapeu-
tic alliance and the therapist’s relational flexibility are important (Norcross &
Lambert, 2011; Norcross & Wampold, 2011). The central process in this
alliance is relational attunement: the therapist is sensitive to what the client
experiences and he/she is responsive to the client.

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 FAMILY THERAPY AS A DIALOGUE

ATTUNEMENT

The concept of attunement refers to the tuning of a guitar or another musical

instrument; not only with the aim that it sounds beautiful, but also with the aim
that it is in tune with other instruments of the band or the orchestra to make it
possible to play together.
The concept is often used in the psychological sciences within the frame of
attachment research, and refers to the intersubjective sharing of affective states of
mother and baby (e.g. Stern et  al., 1984; Hughes, 2007). For attachment to be
secure, emotional attunement between mother and infant is a conditio sine qua
non. Mother and infant are oriented towards each other, and in their face-to-face
physical interactions (e.g. mirroring cooing sounds, making funny faces) they seem
to search for some kind of rhythmical synchrony. When their turn-by-turn inter-
actions are in sync, they are also emotionally in sync and this helps the infant to
avoid emotional deregulation and find a physiological equilibrium (e.g. regulation
of breathing, heartbeat). In the long run, emotional attunement helps the baby
to develop an inner sense of self and to acquire a sense of agency (Wallin, 2007).
Emotional attunement is considered the central process of any interpersonal
attachment. Just as a mother and an infant create their interpersonal world
together, the therapist and the client, too, through their turn-by-turn dialogical
interactions, create their world together.

While emotional attunement is an essential concept in attachment theory, it

is also important within a dialogical theoretical frame (Linell, 2009). The pro-
cess of attunement assumes differences between interlocutors and asymmetry
in the dialogue, for instance, between mother and infant. Attunement then
is the process of gradually, through the exchange of moment-by-moment
subtle verbal and, even more importantly, bodily signals, building trust and
security, in a continuous quest to find a way to go on together.

Dialogue and attunement

The term ‘dialogue’ refers to a practice – to something people do together –

rather than to an abstract thing (Linell, 2009). In the field of family therapy,
referring to the work of the Russian thinker Mikhail Bakhtin (1981, 1984,
1986), the concept of dialogue is usually seen as the opposite of monologue,
implicitly suggesting that good therapy is dialogical, while bad therapy is
monological; or arguing that clients enter therapy with fixed, monological
stories, and that therapy consists of dialogising these stories. The concept of

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 IN THERAPY TOGETHER

dialogue in Bakhtin’s work, however, is complex, and simply describing it

as the opposite of monologue does not do justice to the wealth of his work.
Indeed, dialogue is described by Bakhtin not only as a prescriptive concept,
but, first and foremost, as a descriptive concept. In that way the concept
focuses on epistemological issues and highlights the relational and inter-
actional character of all human meaning making: All language is dialogic.
In this perspective monologue can also be understood as part of dialogism,
and we can speak of dialogical dialogues and monological dialogues
(Morson & Emerson, 1990).

BUBER’S PHILOSOPHY OF DIALOGUE

A lot of great thinkers have written about dialogue. Martin Buber’s philosophy of
dialogue, for example, is well known. For Buber, we are essentially beings-with-
others (Buber, 1923, 1947). He made a distinction between the I-Thou relationship
and the more utilitarian I-It relationship, in which the other is related to as if he/she
were an object. Interestingly, for Buber the I is different in the I-Thou relationship
than in the I-It relationship: our being depends on the way we relate to others.
In recognising the other as a subject, we become a subject (Buber, 1923). I-Thou
is characterised by mutuality, directness and presentness (Friedman, 1960). The
I-Thou relationship is a risk, as it is beyond unilateral control and prediction.
If we want to relate with our clients in an I-Thou relationship, this means that
we have to meet our clients as suffering persons in search of meaning, compassion
and relief, instead of as malfunctioning machines in need of repair (Frankl, 1970).

Tensionality

In the context of this descriptive view of dialogue, Stewart, Zediker & Black
(2004) highlight the importance of tensionality in Bakhtin’s work. According
to Bakhtin, in an ongoing conversation there is a continuous dynamic ten-
sion between the monological and the dialogical functions, of which Bakhtin
scholar Caryl Emerson writes: ‘Dialogue is by no means a safe or secure rela-
tion. Yes, a “thou” is always potentially there, but it is exceptionally fragile;
the “I” must create it (and be created by it) in a simultaneously mutual ges-
ture, over and over again, and it comes with no special authority or promise
of constancy. . . . Imbalance is the norm’ (Emerson, 1997, pp. 229–230).
According to Bakhtin, life is an ongoing, unfinalisable dialogue con-
tinually taking place (Morson & Emerson, 1990). Bakhtin (1981) does
not characterise dialogue as something peaceful or at rest, but rather he
calls dialogic life ‘agitated and cacophonous’ (p.  344). What is said in
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 FAMILY THERAPY AS A DIALOGUE

dialogue is the product of dynamic, tension-filled processes in which two

tendencies are involved: centripetal (centralising, unifying) forces and
centrifugal (decentralising, differentiating) forces (Bakhtin, 1981; Baxter &
Montgomery, 1996; Baxter, 2004). Centripetal refers to the structured
order dialogue strives for. This could be a single story, an agreed upon
explanation, an accepted solution, a contract, homogenity, harmony, etc.
The order comes at the expense of things left unsaid, facts overlooked,
experiences not noticed, words remaining unarticulated, etc.. In contrast,
centrifugal refers to the disruption of the order and the messiness of things,
unforeseen complexities, heterogenity, conflict, the scattered details that
are unexplained and that unsettle the account, and so on. In dialogue, these
opposing forces are in constant dialectical tension; one being the antithesis
of the other. Contrary to Hegelian dialectics that prescribe the finalisation
of dialectic tensions in a synthesis, according to Bakhtin these dialogical
processes are unfinalisable: the tension between the two opposing forces
never reaches a final solution. In that way we can characterise dialogue as a
never-ending, interpersonal process.

Tensionality and attunement

The tensionality of dialogue is the starting point of the process of attune-

ment. Both interlocutors of the dialogue are oriented towards each other and
through their responses to each other – and the small, unspoken interactions
they entail – search for a way to go on together. Attunement in that sense is
a process of responsive interaction. It has two aspects:

• Addressivity: The interlocutors are oriented towards each other, and each
utterance within the dialogue is addressed to the other.
• Responsivity: Utterances in dialogue are also other-oriented in another
sense. Whatever is said is always said in response to what has been said
before (Linell, 2009). Also, everything that is said is an invitation to
the other to respond. In that way the participants shape the dialogue
together. This also connects with the concept of selectivity. As Linell
(2009) writes, ‘[e]very act is selectively responsive’ (p. 167) in the sense
that we don’t respond to everything, but that there is a selection in our
responses: to some things we respond, while other things we neglect.

Within a dialogical frame, attunement can be seen as a process of responsive

interaction in which the participants of the dialogue in their (mostly unspo-
ken) interactions intuitively (without much explicit reflection) adapt to each

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 IN THERAPY TOGETHER

other in a search for ways to live together notwithstanding their differences

and the tensions these differences engender.

Attunement and reflexivity in individual psychotherapy

In this book, we conceptualise therapeutic alliance as a process of attunement

through responsive interaction. This view is summarised in the next simple
diagram, depicting the process of attunement in individual psychotherapy
(Figure 3.1):

Therapist as
Responsive
Client dialogical
interaction partner

Figure 3.1  Psychotherapy

This model clearly portrays the client as an important factor in the thera-
peutic process. Therapy is more than the administration of intervention
techniques to the clients as inert objects (Bergin & Garfield, 1994). The client
is actively present and engaged in the therapeutic process.
In addition to the relational process between the therapist and the client,
there is the personal process of the client during therapy. Based on his quali-
tative research on what clients themselves experience in therapy, Rennie
(1992, 1994, 2001) found that the client’s reflexivity is the basic process that
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 FAMILY THERAPY AS A DIALOGUE

clients find helpful. The client’s reflexivity is a vertical process that consists
of the client’s self-awareness and agency in response to the therapist’s actions
during the process, within the frame of what the client wants to achieve and
what unsettles or frightens him/her. Often the process consists of becoming
aware of one’s unspoken experiences and of the reasons why they have been
left unspoken and unaware until then. Furthermore, invited by the safety
of the therapeutic relation, the client searches for words to express some of
these experiences.
This process of reflexivity can be summarised as follows (Figure 3.2):

Client

reflection reflection

Experiences
that are not yet
talked about
(unspoken)

Figure 3.2  The person

The vertical process of reflexivity is not an autonomous process of the client;

rather, it is continually in dynamic connection with the therapist’s actions
(Rennie, 2001). These actions of the therapist are sometimes experienced as
fitting with the client’s process of reflexivity. Then the client assimilates the
therapist’s actions into his/her work with him/herself. However, sometimes
the therapist’s actions are not experienced as helpful, and then, often, the
client chooses not to correct or criticise the therapist, but rather to toler-
ate the therapist’s actions. The client then chooses to work more privately.
Rennie (1994) talks about the client’s deference: Rather than criticising
43

Licensed to Loreto Paredes ([email protected])

 IN THERAPY TOGETHER

their therapists, these clients try to be self-healers even more than before
(Bohart & Tallman, 1999). It is clear that this is an important question for the
practising therapist: ‘How can I assist the client in his/her self-healing efforts
through reflexivity, rather than being a burden to the client, or abandoning
the client in his/her process?’ While here lies the root of the importance of
systematically working in a feedback-oriented way (see Chapter 5), the gen-
eral answer to this question is: trying to be on the same wavelength with the
client, by being responsive and attuning as much as possible.
The two basic processes of individual therapy, the horizontal process of
responsive interaction (attunement) and the vertical process of reflexivity,
can be integrated into one model (Figure 3.3):

Horizontal process

Therapist
Responsive as
Client interaction dialogical
partner
Vertical process

reflection reflection

Experiences
that are not yet
talked about
(unspoken)

Figure 3.3  The two basic processes of individual therapy

This model concisely describes what is central in individual psychotherapy:

the therapeutic process is focused on the vertical process of the client’s reflex-
ivity: exploring one’s lived experience, finding the right words that can grasp
some of that experience, and integrating/assimilating this experience into
one’s life story. This vertical process is made possible by a horizontal process
of attunement through responsive interaction.
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 FAMILY THERAPY AS A DIALOGUE

But what about family therapy?

We have described the main therapeutic processes in individual therapy. We did
not yet consider the specificity of the multi-actor session that a family therapy
session typically is. While in individual therapy the therapist assists the client in
reflecting on his/her lived experience and his/her storying of these experiences,
the vertical process is possible through the horizontal process of attunement.
In family therapy these same two processes are at work, but the horizontal
process of attunement is more complex because of the multi-actor nature of
a family therapy session:

1. The vertical therapy process resembles the process of reflexivity in indi-

vidual therapy.
2. The horizontal therapy process is more complex, not only because the
therapist has to attune to the different family members, but also because
the family members have to attune to each other.

The more complex horizontal process offers extra therapeutic possibilities

if the therapist assists the family members to share experiences and stories
with each other. The presence of the other family members becomes an extra
therapeutic resource.

Case story: Eric and his family

Eric is a 14-year-old boy with an autism diagnosis. In the session he tells the ther-
apist and his parents how his diagnosis is used by other children in the playground
to disqualify and bully him. The therapist invites the boy to tell the story . . .

Therapist: ‘OK, Eric, can you help me to understand what you mean exactly?’
Eric: ‘We were discussing the world championship soccer yesterday in
the playground, and, whenever I said something, they said: “How
would you know, auti boy?” They wanted me to shut up.’
Therapist: ‘Mmm. And I hear anger in your voice when you say this.’
Eric: ‘Yes, I was angry. In fact, I’m still angry.’
Therapist: ‘Mmm. I understand.’

Here we see how the therapist listens to Eric’s story and tries to be emotionally
close to him. But, in fact, the therapist does more than listen to the story. He
also deepens the story: this means that the therapist helps the storyteller to
find words for what he/she experiences and wants to express. This happens, for
instance, when he inquires about the anger in his voice. This helps Eric to give
words to his feelings. This is the vertical therapy process of reflexivity.

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 IN THERAPY TOGETHER

Therapist: ‘Mmm, yes, I understand you are angry with these boys . . .’
Eric: ‘But I’m not only angry with the boys.’
Therapist: ‘OK. Who else are you angry with?’
Eric: ‘I’m angry with the teacher. She insisted at the beginning of the school
year that I would be open about my diagnosis in the class, and then eve-
rybody could ask me questions. So I told the class that I am autistic . . .’
Therapist: ‘Mmm. And how did you experience that?’
Eric: ‘In fact, it was a relief then. It was only a few months later that
they started to call me auti boy, and that they bullied me.’

These are processes that resemble individual therapy: through the horizontal
process of attunement, the therapist tries to help the boy to find words to
describe his experience (vertical process of reflexivity).
In family therapy, the therapist has the opportunity to broaden the per-
spective, as the other family members are present. For instance, when a story
is told in the session, the therapist can address the other family members,
and explore their responses to the story.

Case story: Eric and his family (continued)

This is an example of what the horizontal process in family therapy may look
like. In the session with Eric and his parent, this is exactly what happened:
Therapist (addresses the parents): ‘When you hear this, what are you thinking
about?’
Mother: ‘This is so painful. Eric, you never told us . . .’
Eric shrugs.
Silence.
Therapist: ‘Painful . . . yes. What else?’
Father: ‘As if it is his choice that he is autistic . . . As if it is a joke . . .’
Therapist: ‘Mmm.’
Mother: ‘In fact, I feel guilty. I told the teacher about his diagnosis, and,
when she inquired if it would be OK to talk about it in the class,
I didn’t object. I thought it was the right thing to do.’
Therapist: ‘Can you talk about this with Eric?’
Mother (addresses Eric): ‘Euh, Eric, I don’t know if you know that your teacher
talked to me about being open in the class . . .’

Family therapeutic process

So, in our conceptualisation of family therapy as a dialogue, we can distin-
guish between two processes:
1. The vertical process is an exploration in depth: the therapist helps a
family member to explore his/her experience in order to find words
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 FAMILY THERAPY AS A DIALOGUE

to express what has not been said before. In this exploration the other
family members are in a listening and reflecting position.
2. The horizontal process in family therapy is not only a process of attune-
ment; it can also be a process of witnessing, sharing and acknowledging
the other. The therapist can tap into this resource by mobilising the
other family members for an exploration in width: the therapist explores
the responses of the other family members in order to find support and
empathy. In this exploration the therapist invites the family members to
respond to each other; to connect and to interact.
In most family therapy sessions, there is a flexible movement from an ori-
entation towards a vertical reflexivity process, to an orientation towards a
horizontal process, and back again.

Complexity in family therapy

In family therapy, the therapist works in a multi-actor setting in which

every family member has his/her own experiencing and each family member
reflects on what can be shared in the session. This is reflected in this diagram,
depicting the vertical and horizontal processes in a family session for a fam-
ily with two parents and one child (a son) (Figure 3.4):

Therapist
Re nter
ct ve

sp act
i
ra si
n

on io
te on
io

siv n
in esp

e
R

Experiences

(unspoken)
that are not
Experiences
that are not

yet talked
(unspoken)

yet talked

about
about

Mother Father

Re e
int spo siv
era ns on on
cti ive e sp acti
on R te r
in
Son

Experiences
that are not
yet talked
about
(unspoken)

Figure 3.4  Family therapy

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 IN THERAPY TOGETHER

As is clear from this diagram, family therapy in practice is complex. In

this complexity, every session at any given time is unique. For the thera-
pist, the complexity of the first session has to do with different things.
For instance, the therapist has to flexibly oscillate between the two posi-
tions towards the family: a position of proximity in which the therapist
participates in the conversation, and a more distant position in which the
therapist observes the interactions and reflects on the meaning of what
he/she observes and on the next steps to take. In the proximity position,
the therapist interacts with all family members and is immersed in the
family dynamics. He/she sees, hears, feels what happens in the interaction
with the family and experiences what it evokes in him/her (Rober, 2011).
In the more distant position, the therapist retreats into his/her inner
conversation (Rober, 2005a) and processes what he/she sees, hears and
experiences. From this distant position, he/she reflects on the concerns
of the family members, tries to understand their hesitations to engage in
therapy (Rober, 2002a) and hypothesises about family functioning (Rober,
2002b), as he/she aims to find ways to be useful for the family in their
search for a good way to deal with their concerns and worries. The flexible
oscillation between these two positions, the close position and the more
distant one, which has been described as a dance (Whitaker & Bumberry,
1988), is a real challenge for the therapist. Continually, he/she must move
from participating to reflecting, from interacting to hypothesising, from
responding to integrating.

The complexity of the therapeutic alliance

Another important challenge for the therapist has to do with the complex-
ity of the therapeutic alliance in marital and family therapy. While alliance
as a non-specific therapeutic factor is as important in family therapy as it is
in individual therapy, the therapeutic alliance in family therapy is different
from the therapeutic alliance in an individual therapy setting (Sprenkle,
Davis & Lebow, 2009; Friedlander et  al., 2011). For one thing, the thera-
peutic alliance in family therapy is not limited to the relationship between
the therapist and the family members, but extends also to the relationship
between the family members (e.g. Pinsof & Catherall, 1986; Friedlander
et  al., 2011). Friedlander, Escudero & Heatherington (2006) speak about a
shared sense of purpose (p. 125). This refers to the family’s history together
and their allegiance that precedes the development of the alliance with the
therapist. Still, as the alliance with the therapist develops, it is the therapist’s
goal to also enhance the family’s shared sense of purpose.

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 FAMILY THERAPY AS A DIALOGUE

Because a family therapy session is a multi-actor dialogue, it is filled with

tensions that are enacted by the family members (Seikkula, Laitila & Rober,
2012; Rober, 2005b). While these tensions are more or less implicitly present
during the whole therapy, the tensions usually surface in the first session
(see Chapter 2). To give one example: While in individual therapy the start-
ing point of the therapeutic process is an individual who chooses to go into
therapy to address a problem he/she experiences, in family therapy usually
the different family members’ willingness to engage in therapy differs. Often
they don’t agree on the existence of a problem, or on the definition of the
problem, or on the necessity of family therapy to address the problem.
Friedlander et  al. (2011) mention in this context, for instance, that some-
times one family member feels like a therapy hostage (p. 93): ‘I don’t want to
be here, but if I don’t come there will be consequences.’ The therapy hostage
in family therapy is often a child or a young person, as typically the parents
want therapy and the children come along, with some degree of compliance.
Forming an alliance with children or youngsters is often a challenge for
family therapists. Qualitative psychotherapy research shows that children
often do not understand exactly why parents think that therapy is neces-
sary. Often they are reluctant to join in the identification of problems and
the search for possible solutions (Hutchby & O’Reilly, 2010). Furthermore,
research suggests that, if the therapist does not specifically attempt to engage
with children, children don’t succeed in taking the conversational floor
from an adult in a family therapy session (O’Reilly, 2008). Based on their
interviews with children after their first family therapy session, Moore and
Bruna Seu (2011) state that children often take positions that complement
the parents’ position: while the parents say that they want therapy, the child
hesitates. The authors warn family therapists against assuming unquestion-
ing docility in children. They recommend that family therapists are aware
of the different positions that their child clients may adopt in a family ses-
sion. They also recommend that therapists find good ways to explain their
approaches to children, in order to establish a fruitful therapeutic relation-
ship with them (Moore & Bruna Seu, 2011).

Our conceptualisation of family therapy

We conceptualise family therapy as being in therapy together. Usually a

family therapy starts like this: One family member phones us and asks for
an appointment because he/she is worried about something in their life.
A mother, for instance, calls and says: ‘My daughter doesn’t talk anymore. We
are worried that she might do something stupid. We tried everything. But she

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 IN THERAPY TOGETHER

only talks to her friends, not to us. We cannot go on like this anymore.’ This
is an example of a typical request for family therapy: it is about the worries
of some family members, and their desperation about not being able to go on
like this. “They have tried everything but their attempts to be helpful have
not stopped their worries.”
While family therapy starts with worries, it ends when the family mem-
bers have the feeling that they can go on together again. So the therapy is
not aimed at the solving of problems or the treating of disorders (although
often problems and disorders are central in the worries); rather, it is aimed
at giving hope and confidence to the family members that they can proceed
with their lives together, without the assistance of professional helpers.
We can summarise this conceptualisation of family therapy in the follow-
ing figure (Figure 3.5):

Life
Going on
Worries together

Family
therapy

Figure 3.5  The conceptualisation of family therapy

In this figure, what happens in the family therapy sessions is still blank and
the question can be posed: ‘What is the process of family therapy?’ Here we
return to the concept of attunement, which we presented above. The central
process of a family therapy session is a process of attunement between the
different participants (family members and therapist). These participants are
in dialogue with each other, and this dialogue is experienced by them as use-
ful or helpful in some way – not necessarily because it solves their problems,
but because they feel that it makes sense to talk together about their worries.
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 FAMILY THERAPY AS A DIALOGUE

MORE THAN PROBLEM-SOLVING AND TREATING DISORDERS

The model that is the backbone of this book is not only about the treatment of the
classical disorders at which psychotherapy is aimed (e.g. anxiety disorders, mood
disorders, etc.), as nowadays the work of a family therapist is much broader and
richer than the providing of treatment for discrete disorders or problems. Family
therapists work in diverse contexts, and the solving of problems or the treatment of
disorders does not capture the essence of their work. Let’s take the family treatment
of chronic psychiatric conditions like schizophrenia as an example. Family therapy
can’t heal schizophrenia, but family therapy with families of schizophrenic patients –
in parallel with other treatments – has good outcomes (Carr, 2014b). Families with
schizophrenic family members often find family sessions useful. Family therapy has
its rightful place in other contexts than psychiatry, too. For instance, more and more
family therapists work in medical contexts in which they counsel families struggling
with cancer, diabetes, or other chronic conditions. Outcome research proves that
their work in these contexts can be very useful. For instance, family therapy proves
to be very effective in the treatment of chronic physical illnesses (Carr, 2014b).

Family therapy as a dialogue

If the solving of problems or the treatment of disorders is not the main aim of
a lot of family therapies, what is the sense of family therapy then? The feed-
back we got from families who were in therapy in our team seems to indicate
that dialogue – talking together about what weighs on us – is very important for
them. These are some examples of moments in a family therapy session that
were experienced by our clients as healing moments:

• John gives words to his experience of feeling guilty after his best friend
committed suicide. This is the first time he has spoken about this feeling of
guilt: ‘These feelings did not have words yet,’ he says in the next session.
• Irma talks about her loneliness and the other family members listen
empathically.
• Johan talks about his autism and the other family members listen atten-
tively. Later Johan says that it had only been possible to speak about his
autism in this way because the therapist was there as a witness.
• Father and his 17-year-old son talk about their conflicts and disagree-
ments. ‘At home,’ Mother says afterward, ‘such a conversation would
turn into a fight. Probably it would escalate into violence. But in the safe
context of the family therapy session, and with the help of the therapist,
they started to understand each other better.’

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 IN THERAPY TOGETHER

• A father, diagnosed with prostate cancer, is worried about sharing the

bad news of his diagnosis with his two children: ‘They lost their mother
last year. Breast cancer,’ he explains to the therapist. The therapist talks
with Father about ways in which he might talk with his children about
his diagnosis. Then he proposed to the father to do a family session in
which the father would talk with his children about his diagnosis. Father
is relieved and agrees to make an appointment for a family session.
• In a family therapy session, a mother, for the first time, tells the story
of her childhood fears, while her nine-year-old daughter Amy, who was
referred for an anxiety disorder, listens carefully. ‘I felt less alone when
I heard my mother has struggled with the same fears as I,’ she tells the
therapist the next session.
• And so on.

These are all examples of how a family therapy session – conceptualised as

dialogue – can be a relief for family members, although the actual presenting
problem is not solved. Very often the family therapy session is experienced
as a context in which things can be talked about that are difficult to talk
about at home, or in which things can be talked about in a different way
(safer, warmer, etc.) than at home. For me, this is the essence of what family
therapy can do: it can create a space in which the not yet said (Anderson &
Goolishian, 1988) can be said (Figure 3.6).

Life
Going on
Worries Dialogue together

Therapist

Figure 3.6  Family therapy as a dialogue

52
 FAMILY THERAPY AS A DIALOGUE

The motor of this dialogue is the process of attunement. This refers not only
to the attunement between the therapist and the family members, but also
to the attunement between the family members.
In that way our figure of the family therapy process becomes more com-
plex (Figure 3.7).

Life
Going on
Worries Dialogue together

attunement

Therapist

Figure 3.7  Attunement between family members

Respect

So family therapy is a dialogue between family members in which the thera-

pist tries to be useful as a facilitator of this dialogue through a process of
relational attunement. The therapist’s focus is not on analysis of problems;
nor is it on coming up with solutions. Rather, the focus is on having a rich
dialogue with all family members about their worries; in such a way that ver-
tical and horizontal therapeutic processes are invited and supported. In line
with Buber’s I-Thou stance, however (Buber, 1923), the first aim is that the
family members feel respected and understood.

53

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 IN THERAPY TOGETHER

This is an email I received from a mother after a first family session.

Hi Peter,

Thank you for the session yesterday.

We all felt good when we drove home. I myself had expected to be exhausted after
the session, but that was not how I felt. I could get some breath again. As if there
was more oxygen in the air.

We are nowhere nearer to a solution, and God knows that there probably is no solu-
tion for our problem, but we felt – for the first time in our long career of consulting
psychiatrists and psychologists – understood, rather than blamed. These profession-
als don’t understand how all their hypotheses about the causes of our problems
and all their advice about what we should do have hurt us. They did not seem to
see how much we have done already. They even did not seem to be interested in
how we suffer.

Thank you.
Jenny (the mother of Annie)

The therapist’s specific expertise is in listening to what is said, and in cau-

tiously contributing to the development of an intersubjective space in which
there is room for some of the things that have been left unspoken until then.
The therapist addresses the family members as human beings trying to do
their best to make their lives together worth living. Having such a dialogue is
often a relief for family members as it strengthens their bonds as well as their
individual agency. Such a dialogical conceptualisation of family therapy
allows us to meet the family members as living persons, with their concerns
and their fears, with their love and their pain, with their anger and their joy
(Rober, 2005b).

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 In the attic, in the dark 2

It is getting dark
and the colours disappear.
Everything is grey first,
and then black.
Where do the colours go?
Will they come back in the morning?

This room in the attic

was a gift for my seventh birthday.
You’re a big boy now, my father said.
From this day on, you will have your own room.
I used to sleep with my older sister in one room.
But she wanted her own room.
So I moved to the attic
and now I sleep alone.

It is darker here than in my sister’s room.

And the cracking noises are louder.
I do not know why.
Perhaps because it is one floor higher.
Closer to the moon and the stars.
Closer to the night.

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 4
FOCUS ON WORRIES1

When a family therapist asks family members what brings them to therapy,
sometimes one of the parents starts to recount what are the most press-
ing problems in the family according to him/her. A mother might say, for
instance, ‘I feel like a bad mother, because I can’t find a way to communicate
with my daughter.’
A problem-focused therapist might then concentrate on helping the
mother find ways to communicate with her daughter. In our dialogical
approach, maybe we would do the same, but first we would focus on the
mother’s worries about being a bad mother: ‘Can you help us understand
what you mean when you say you feel like a bad mother?’ Also, before we
focus on the communication with the daughter, we would probably ask
other family members what they are worried about. As I explained in the first
chapter, an important part of the first session is used to map the different
worries that exist within the family.
In order to map the worries of the different family members in the session,
my colleague Karine Van Tricht and I developed a simple questionnaire: the
Worries Questionnaire (WQ) (see Appendix A). We email the questionnaire
to the family immediately after we have made the appointment for the first
session.
As can be seen in Appendix A, the instrument has a specific form. It starts
with a simple explanation of what we consider to be the task of a family
therapist: ‘A family therapist is someone who talks with families, when some-
one in the family is worried about something.’ Within this framing, worries,
rather than problems, are central. This is a crucial change of emphasis: a
problem is something that exists objectively and can be identified in a sup-
posedly unbiased way with the help of experts. In contrast, worries are sub-
jective. They can be discussed and understood. The statement that therapy
resolves around worries, rather than around problems, in that sense makes a

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 FOCUS ON WORRIES

big difference for those family members who are not convinced that there is
a problem, or that the way the problem is described by Mother or Father is
the most appropriate description of what is difficult in the family.
After this description of who the family therapist is, with a focus on wor-
ries, the family members are invited to answer a few questions. We mainly
ask two questions:

1. According to you, who in the family is most worried, how worried is this
person, and what is this person worried about?
2. How worried are you, and what are you worried about?

Using this questionnaire in the first session makes tangible the challenge
for the family therapist of dealing with the differences between the family
members. In the Sax family, whose first session I will discuss in detail further
in this chapter, all family members agreed that Mother was the one who was
most worried. She was mainly worried about her 13-year-old daughter Eva’s
eating habits, of which she wrote, ‘It is as if she has anorexia.’ Irma, Eva’s
ten-year-old sister, wrote in the questionnaire that she was most worried
about her mother, who seemed depressed: ‘We have to talk about mother,
because since our father left her, she seems depressed and I’m afraid that she
drinks too much.’
This is a summary of what the different family members filled out in their
WQ (Figure 4.1):

The most worried family member You

How worried? How worried?

Who? About what? (0–10) About what? (0–10)

Eve's eating. She hardly

Mother Me eats anything. It is as if 10
she has anorexia.

She does not trust me and she controls

Eva Mother About me. 10
me all the time.
7

We have to talk about mother, because

Irma Mother She is worried about Eve. 8
since our father left her, she seems
8
depressed and I’m afraid that she drinks
(sister)
too much.

Figure 4.1  The Sax family WQs

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Typically in the first session – after we have made acquaintance with the
different family members – we lay out on the table the WQs filled out by
the different family members, and we ask the family, ‘What surprises you
about what you have written?’ This question often opens space for the fam-
ily members to reflect on what brings them to therapy without the narrow
focus on what the official problem is, as defined by the most worried family
member.

The first family therapy session: a protocol

As in Chapter 2, I will present a detailed case story of a first family therapy

session in this chapter too, to show how I focus on the worries of the differ-
ent family members. Again, I will use the protocol in six steps I introduced
in Chapter 2:

1. Informally meeting the family

2. Introducing myself
3. Each family member introducing him/herself
4. Discussing the hesitations about going into therapy
5. Discussing the worries, and the reasons why therapy might be useful for
the family
6. Closing the session.

More than in Chapter 2, in the first case story in this chapter I will specifi-
cally focus on the way I deal with worries (step 5 in the protocol) and how
use of the WQ can help the therapist to systematically map the worries of
the different family members.

Case story: the Sax family 1

The Sax family was referred to me by their family doctor. He wrote, ‘Eva (13
years old) seems to be at risk of developing an eating disorder.’
When I went to pick them up in the waiting room, I saw Mother biting her
nails. Irma was reading. Eva was looking out of the window. She seemed to be
lost in thought.
I shook hands with Mother and introduced myself. Then I shook Irma’s hand,
but, when I wanted to shake Eva’s hand, I sensed reluctance on her part. She
hardly looked at me and dutifully offered me her hand to shake.
‘Nice to meet you all,’ I said.
We went into the consultation room.

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The first meeting with the family

As I explained in Chapter 2, when the family therapist first meets the family
in the waiting room, usually he/she is immediately confronted with things
that stand out and surprise. In the case of the Sax family, the way in which
Eva presented herself was special: she seemed reluctant to shake hands. It was
as if she didn’t want to be there. This is important information for a family
therapist, as his/her aim is to develop a good alliance with all family mem-
bers. Already, in the waiting room, the therapist can get a sense of where the
challenge lies for the specific family he/she will work with in a few minutes.

Case story: the Sax family 2

Entering the consultation room, Irma immediately chose a seat. Eva stalled at
first, and then she sat down. Irma sat in the middle, with Mother to her right
and Eva to her left. I chose a chair opposite the family, with a small table
between the family and me.
I welcomed them and introduced myself: ‘I’m Peter. I am a family therapist.’
As I said this, I looked alternately at the three family members.
I addressed Irma and Eva while I said, ‘Kids have told me that the word “fam-
ily therapist” is a difficult word. Let me briefly tell you what a family therapist
does. A family therapist is someone who talks with families, when someone in
the family is worried about something.’
I left a short break, and then continued: ‘So if you came here today, I assume
that at least one of you is worried about something in the family.’
I smiled and continued: ‘And today we are certainly going to talk about these
concerns, but first I’d like to get to know each of you a bit better.’

Introducing oneself

As I explained in Chapter 2, while the first session is focused on the worries

of the different family members, I postpone the discussion of these worries
because I want to make room first to introduce myself (step 2 of the proto-
col), and then invite the family members to introduce themselves (step 3 of
the protocol). I do that only after I have reassured the family members that
I will listen to their worries later in the session.

Case story: the Sax family 3

‘. . . Today we are certainly going to talk about these worries, but first I’d like to
get to know each of you a bit better. Who will start?’

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Irma took the initiative and said, ‘I’m Irma. I’m ten years old. I’m in fifth
grade. Uh . . . Also I go to ballet and ride horses.’
‘Yes,’ Mother added, ‘she loves horses. In her room she has a lot of posters of
horses.’
Irma smiled. ‘All black horses,’ Irma said. ‘I love the movie of Black Beauty.’
Eva sighed ostentatiously, and Irma gave her a push.
‘OK, thanks, Irma,’ I said.
I looked at Eva and then at Mother. ‘It’s time for the next one. Who’s next?’
‘You. You go next,’ Eva said with a head movement towards her mother.
I looked at Eva and then at Mother.
I said nothing.
‘OK,’ Mother said. ‘I’m their mother. I’m a teacher. I teach French. I used to do
a lot of sports, but nowadays I don’t have time for it anymore.’
She hesitated, glanced at me, and then said, ‘I’m a sole mother and I have to
take care of my children.’
‘It might do you some good, Mom, if you went to the gym again,’ Irma said.
‘Yes, I used to work out at the gym a lot. But that was long ago.’
‘Two years ago,’ Irma added.
Mother smiled at Irma. ‘Yes, two years ago.’
Silence.
I wondered what was left unsaid.
‘OK,’ I said, ‘who’s next?’
‘Eva’s next,’ Irma said.
Eva sighed and seemed reluctant to speak.
‘Eva?’ I said. ‘Can you tell me something about yourself?’
She sighed again and said, ‘I’m Eva. I’m in the first year of high school and
I’m studying Latin and Greek. They say I’m smart, and I think I am.’
‘You are smart?’ I said.
‘I think I am. I get good grades and I don’t have to study too hard. So I have a
lot of time with my girlfriends.’
‘What do you do when you are with your girlfriends?’
‘We talk about fashion and make-up.’
‘And boys,’ Irma teased.
Eva gave her a push.

After everybody has introduced themselves (step 3 of the protocol), it’s time
for the discussion of the hesitations (step  4 of the protocol) and the wor-
ries (step  5 of the protocol). In the therapy with the Sax family, because I
used the WQ, the discussions of the hesitations and the worries were closely
connected.

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 FOCUS ON WORRIES

Case story: the Sax family 4

‘You have now introduced yourselves. So now we can make time to talk about
your worries. As I said in the beginning, families come here when someone in
the family is worried about something. So I assume that in this family, too,
there is someone who is worried about something. I have sent you a question-
naire for each of you to fill out. You have done so and here they are.’
I put the three printed-out WQs on the small table in front of us and left a
silence.
Then I said, ‘What surprises you when you look at what you have written?’
They took some time to look over the papers.
‘Everybody agrees that I am the one who is most worried,’ Mother said.
‘Yes, and you took the initiative to go into family therapy?’ I asked.
‘Yes, I called a few weeks ago to make an appointment. Doctor Janssens gave
me your number.’
‘OK, so it was your initiative to choose family therapy. I wonder, tell me . . .
Was it difficult to convince the children that family therapy might be useful
for you as a family?’
Mother hesitated.
‘Irma’s first reaction was very positive. Eva at first did not want to go. She says
there is nothing wrong with her.’
There was a moment’s silence.
‘But you are worried about her?’ I asked Mother.
‘Yes. As I wrote in the questionnaire, I worry about her eating, or, better, I
worry about her not eating.’
Eva looked closed off, sitting deep in her chair, arms crossed.
I noticed that Irma and Mother also looked at Eva.
They seemed to wait for Eva to speak.
I addressed Eva: ‘I gather from what you wrote in the questionnaire that you
are not worried about yourself but rather about your mother not trusting you?’
Eva shrugged and kept silent.
‘You prefer to keep silent?’ I asked.
‘What’s the use in talking?’ Eva said.
‘Have you tried to talk? ’ I asked.
‘It’s no use. We tried, but she always gets worked up and she starts to yell. So
it is better not to talk.’
Mother intervened and said, ‘We need to talk!’
Then she addressed me: ‘You see, I am worried that Eva does not eat enough.
That’s why I keep an eye on her, and I make a note of everything she eats, and
it’s not much.’

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‘And you nag about my eating, especially at dinner.’

‘Especially at dinner? ’ I ask.
Silence.
Irma breaks the silence. ‘Mother drinks wine with her dinner. She sometimes
drinks too much and when she starts to complain about Eva’s eating not
enough, she keeps on going on, and she does not listen to reason anymore.’
Silence.
I addressed Irma: ‘Yes, I read in your questionnaire that you worry that your
mother drinks too much?’ I said.
‘Yes, she has been depressed since our father left,’ Irma said.
‘Maybe we have to talk about that,’ Eva added.

For the rest of the session, we talked about Father who left two years ago, and
about how Mother felt abandoned and alone since then. The children talked
about their worries and Mother cried silently. The session ended with a com-
mitment from all family members to have a second session to talk more.

Again, the dialectics of yes and no

As I explained in Chapter 2, for families, going to therapy is usually fraught

with ambivalence. This usually surfaces in the first session when usually
there are voices in the family that say yes to therapy, but there are also voices
that say no. This becomes explicit when the WQ is used. Let us return to the
way the Sax family filled out their WQs (refer back to Figure 4.1).
In the Sax family, everybody agreed that the mother is the most worried.
Everybody also agreed that she is worried about Eva. Mother thus expressed
the yes towards therapy for the family. It was indeed Mother who initially
contacted the family doctor about Eva’s eating habits, and then later called
me for an appointment. As often happens, after the family doctor listened
to Mother’s story and her worries, she was mobilised to refer the family for
therapy.
The no, or the hesitation to go into therapy, is usually expressed by a child,
often the child who is identified as the problem. In the WQs of the Sax fam-
ily we see that Eva is less worried and that she reframes her mother’s worries
about her eating habits as a lack of trust and as control.
Let’s take another example to illustrate the dialectic of the worries and
the hesitations to go into therapy. These are the WQs as filled out by the
Tex family. They were referred to our services by the psychiatrist of Tom, the
18-year-old son, diagnosed with schizophrenia. This is how the Tex family
filled out the WQs (Figure 4.2):

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 FOCUS ON WORRIES

The most worried family member You

How worried? How worried?

Who? About what? (0–10) About what? (0–10)

The trauma of our son

because of his
I want to find an alternative for a
Father Son hospitalisation in 10
psychiatric hospitalisation.
10
psychiatry and
medication.

Mother Father Psychosis son. 8 How can we understand and help him? 8

My parents. They don’t

Son Me understand me.
8

Father who is unhappy and obsessed by

Sister Father Future son. 8
his son.
8

Obsession of father and his (un)health.

Brother Father Future son. 7 This therapy will only have sense if we 3
address father’s problems.

Figure 4.2  The Tex family WQs

This table summarises the way the different family members filled out the
WQ right before the first session. In fact, it tells the story of the Tex family as
it was at that moment. If we look at the first column, referring to the family
members’ ideas about who was most worried, we see that Father was wor-
ried about his son who was hospitalised with the diagnosis of schizophrenia.
According to Father, his 18-year-old son is most worried, but then, when he
explains what he is worried about, it seems that he is not talking about his
son’s worries, but rather about his own and his wife’s worries (he refers to
‘our son’, for instance). Mother, sister (20 years old) and brother (22 years
old) agree that Father is the most worried. And Tom says he himself is most
worried. But he is not worried about his own condition; rather, about his
parents who don’t understand him.
Then we can look at the columns on the right. They represent the way
the family members describe their own worries. Father is very worried (10)
and he wants an alternative for the classical psychiatric hospitalisation.
Mother is also worried (8), but she is worried about understanding her
son, and in that way she seems to sense that he does not feel understood
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 IN THERAPY TOGETHER

by his parents. So the yes and the no in this family are not about the ther-
apy itself (do we want therapy or don’t we?), but rather about what should
be the objective of therapy: there seems to be a dichotomy between help-
ing the son and understanding him. That is also the dichotomy with which
I was presented at the start of the first session when Father talked about
his worries.

Case story: the Tex family 1

‘I’m most concerned about Tom,’ Father said. ‘He did not get the right treat-
ment, and he became even sicker during the hospitalisation. Of course, the
medication also made it worse. All these pills, they are poisonous. They destroy
his brain cells one at a time.’
‘You don’t understand me,’ Tom replied. ‘You have never understood me.
Nobody understands me.’
Mother takes a handkerchief to dry her tears.
‘Your psychiatrist didn’t help you. He pushed you deeper in the dirt,’ Father
insisted.
As a therapist I felt caught in the middle in this discussion. Luckily I had the
filled out WQs. I put them on the table in front of us and I said, ‘What strikes
me most about the way you filled out the Worries Questionnaires is the way
Eric (Tom’s brother) and Ann (Tom’s sister) filled them out. Let me show you
. . . What surprises you?’
I showed the filled-out questionnaires of Eric and Ann to the family members.

In their WQs, Eric and Ann presented a view that in some way transcends
the dichotomy between the parents and the IP by presenting a completely
different object of therapy. Their worries are not about helping or under-
standing their brother Tom, but rather about helping their father, who is – in
their view – obsessed by his youngest son and unhappy. By focusing on the
worries of Eric and Ann, the session moved in the direction of talking about
Father and his problems.

Case story: the Tex family 2

‘Yes, Eric and Ann are concerned about me,’ Father said, ‘but I’m OK. There’s
nothing wrong with me.’
‘We are worried about you because every day we can see that you drink too
much,’ Eric replied. ‘Last week I found you passed out on the sofa in the living
room with an empty bottle of wine next to you.’
‘We know you are unhappy, daddy,’ Ann added. ‘We know it. We see it.’

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 FOCUS ON WORRIES

Mother looked at her children and seemed surprised.

‘You don’t have to worry about me,’ Father said. ‘I’m going through a difficult
period in my life.’
Silence.
‘Can you tell me something about this difficult period in your life?’ I asked.

For the rest of the session, we talked about Father. He’d had an important
position in a bank, but then – it was during the bank crisis of 2008 – he’d
lost his job. This was a big blow for him. To help his family get by finan-
cially, he worked as a bartender in a club in Brussels. Talking about this,
Father started to cry. Tom was silent, but the others were very compassion-
ate. The father said that he had contemplated suicide several times during
the last year. The only thing that kept him alive, he said, was his son Tom
who needed help.
At the end of the session, all of the family members were relieved and
surprised that they had succeeded in talking about this sensitive issue.

Case story: the Tex family 3

‘I’m relieved that we could talk about this,’ Eric said. ‘We were all worried
about daddy, but nobody said anything.’
‘Yes, daddy, I’m also relieved. I had not expected this,’ Ann added, addressing
her father. ‘Let’s not keep it silent again.’
‘Yes, it’s good that we have talked about this,’ Father said, ‘but next time we
have to talk about Tom. It’s his future I’m concerned about, not mine.’
‘Yes, it’s good that we talked about this, but there is still a lot to talk about,’
Mother said.
Tom nodded in agreement.

Worries and dialogue

The WQ is not a diagnostic instrument. It does not measure anything. It is

a conversation tool (Sundet, 2010, 2011) meant to help the family and the
therapist to broaden the dialogical space and to talk with each other in a
way that is not possible at home, or to talk about things that can’t be talked
about at home.
For our conceptualisation of family therapy as a dialogue, more important
than the WQ is the therapist’s focus on worries, rather than on the so-called
problem or on the diagnosis of the identified patient.

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 IN THERAPY TOGETHER

WORRYING IMPLIES CARING

Imagine . . .

Situation 1: 
A mother who says to her daughter, ‘You have a problem. You don’t
eat enough.’
Situation 2: 
A mother who says to her daughter, ‘I’m worried about you. You
don’t eat enough.’

It may be a subtle difference, but a daughter will probably feel it.

In situation 1, having the problem is implicitly described as something that is
true. It is also said as if it is an objective observation; an establishment of a fact.
The mother speaks from a detached position.
In situation 2, the mother says something of her relationship with her daughter:
‘I worried about you [because I care about you].’ Implicitly there is a commitment to
the daughter. This is a big difference.

A focus on the worries (plural!) in the family creates a warmer atmosphere

in the session, and automatically invites dialogue, as the differences
between the family members are given a frame within this atmosphere.
The therapist makes it clear to all present that he/she is interested in
hearing each of the family members’ voices and perspectives; those who
worry a lot, those who worry about something else, and those who don’t
worry at all.

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 In the attic, in the dark 3

Grandpa killed himself in the attic,

my nephew said,
and then he walked away.
I don’t know
if it’s true.

The noises in the dark scare me,

and I wonder,
How did he commit suicide?
Did he hang himself
from one of those beams?
Is that why they are creaking,
as it gets dark?

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