Lily Mailler

“Symptomatic individuals play a functional role on behalf of the equilibrium of the family unit; in other words the symptom serves to regulate the instinctual forces of emotional distance and closeness in the family.”

“In contrast to an individual psychology approach like CBT, the focus in therapy is less on changing or fixing deficiencies in the individual or focusing on the symptom. Instead the therapist aims to expand the view to the emotional process of the family system and to the natural world of which we humans are part of.”

Recently I thought it would be challenging to write a blog that could help me get clearer about the differences between an approach to symptoms that is based on individual psychological theory , for example CBT, DBT, ACT, etc ; and an approach to symptoms that has the family as a focus i.e. The Bowen theory.

Given the prominence of CBT as an individual psychology approach, and my desire to understand it better, I thought it useful to explore how it differs from Bowen theory. Because I am not a CBT expert (while I have done professional development courses in this approach) and this is too narrow a space to do justice to its complexity; I decided to simply stick to describing the basic theoretical assumptions about the nature of human behaviour on which CBT and Bowen theory rest and succinctly look at how these assumptions guide the practitioner in his/her approach to symptoms.

Overview of Cognitive Behavioural Therapy: CBT is based on the cognitive model, I found the following summary useful. CBT uses an “information-processing model to understand and treat psychopathological conditions. The theory is based, in part, on a phenomenological approach to psychology, as proposed by Epictetus and other Greek Stoic philosophers and more contemporary theorists such as Adler, Alexander, Horney, and Sullivan. The approach emphasizes the role of individuals’ views of themselves and their personal worlds as being central to their behavioural reactions, as espoused by Kelly, Arnold, and Lazarus. Cognitive therapy was also influenced by theorists such as Ellis, Bandura, Lewinsohn, Mahoney, and Meichenbaum.” Retrieved from Beckin Institute Blog – Cognitive Behavioral Therapy

Dr Shona N. Vas gives a useful description of this model, based on Beck et al 1979 at Dept. Of Psychiatry and Behavioural Neuroscience (2008-09) Theory and Practice of Cognitive Behaviour Therapy (Power Points slides). Retrieved from PsychClerk

“Negative emotions are elicited by cognitive processes developed through influences of learning and temperament.

Adverse life events elicit automatic processing, which is viewed as causal factor.

Cognitive triad: Negative automatic thoughts centre around our understanding of: ourselves, others (the world), future.

Focus on examination of cognitive beliefs and developing rational responses to negative thoughts.”

The aim of CBT is to modify dysfunctional beliefs underlying dysfunctional thinking and behaviour leading to symptom improvement. Dysfunctional thinking is thought to arise from psychological and biological influences.

A description of CBT, retrieved from Beckin Institute Blog – Cognitive Behavioral Therapy, states that when distressed, individual’s perceptions and thoughts about situations influence their ‘automatic thoughts’. The therapy aims to correct automatic/distorted/dysfunctional thinking so that it is more in keeping with reality thus reducing physiological arousal and improving functioning. The therapy also aims to help clients identify distorted beliefs about themselves, others and the world. It finally explains that the emotional, physiological and behavioural responses an individual has are not only mediated by beliefs but also by the characteristic way she/he interacts with the world as well as by the experiences themselves.

CBT & treating substance abuse: An exploration of CBT’s approach to a symptom, in this case I chose substance abuse, led me to a number of interesting websites. I found useful Chapter 4 of Brief Interventions and Brief Therapies for Substance Abuse. Retrieved from  NCBI

It described the therapist’s approach to the problem as follows:

The therapist collaborates with the client in identifying the antecedents and consequences of substance abuse behaviour, which may serve as triggering and maintaining factors. For example identification of high risk situations and exploring what the person felt and did during and after the situation. The therapist also assesses the client’s strengths and adaptive skills.

The therapist also works, in collaboration with the client, to identify deficits in coping skills. Using manuals, the therapist teaches the client coping skills to deal with high risk situations without resorting to drugs or alcohol i.e.  how to cope with cravings, how to refuse an offer of alcohol or drugs as well as communication skills and coping with anger or depression.

The therapist is also active in teaching the client behavioural skills related to forming and maintaining interpersonal relationships i.e. assertiveness training, how to refuse a drink or how to develop relationships with non substance abusers. This is done through the therapist modelling the effective coping skill and the client participating in a role play scenario, clients are given homework to practice these skills in real life situations and progress is assessed at the beginning of the next session.

Relapse prevention is also addressed by dealing with cognitions that will help the client gain more positive ‘self-efficacy’, this is done through homework tasks aimed at performance accomplishment i.e. client coached to expose him or herself to challenging situations with greater relapse risk without using in order to grow self efficacy. The therapist also challenges the client’s negative attributions in the face of a relapse.

The therapist works at changing the client’s belief in the positive effects of the substance or gets her to pay more attention to her knowledge and experience of its negative effects; this is also done by inviting the client to reflect on the substance’s positive and negative effects.

Lastly, the therapist works with the client to prepare for the possibility of relapse and actions to avoid it through emergency plans that include contact details of individuals supportive of the client’s recovery process. It is mentioned that “including family members in the planning process is important because they are often better able than the client to see the warning signs of an impending relapse.”

Bowen Theory contrasted to CBT: In contrast to CBT, The Bowen theory is based on a natural systems view of the human, “… the human as a phylogenetic development from the lower forms of life.” Dr Bowen believed that the study of human behaviour had the potential of becoming a science “….if we could see the human as related to other living things” (M. Bowen in Ruth Riley Sagar (ed) Theory and Practice1997, p102)

The background to Bowen’s theory were his years of reading on all the disciplines about human behaviour, i.e. science, psychology, sociology, anthropology, astronomy, evolution, physics and biology, amongst others; his intention was to find “ common denominators on which the disciplines were based”, coupled with this was his research with families at the NIMH where  “ every conceivable safeguard was used to keep observations on verifiable fact rather than subjective impression ……Predictable action that repeated over and over, in all families, eventually found their way into concepts……concepts were framed in the orientation of the human as a biological-evolutionary creature.”  (M. Bowen MD “Subjectivity Homo Sapiens And Science” in Ruth Riley Sagar (ed) Theory and Practice 1997, p19).

Dr Bowen observed that families operated as emotional units and that individuals had functional roles directed by the emotional process of the family. Through his observations he came to the conclusion that symptomatic individuals play a functional role on behalf of the equilibrium of the family unit; in other words the symptom serves to regulate the instinctual forces of emotional distance and closeness in the family.

From a Bowen systems perspective symptoms are embedded in the emotional process of the family and “..all symptoms are a product of the family emotional unit” (D.Papero in Ruth Riley Sagar (ed) Theory and Practice 1997, p123).

In sum: “A core assumption in this theory is that an emotional system that evolved over several billion years governs human relationship systems. People have a ‘thinking brain,’ language, a complex psychology and culture, but people still do all the ordinary things other forms of life do. The emotional system affects most human activity and is the principal driving force in the development of clinical problems.” (: Kerr, Michael E. “One Family’s Story: A Primer on Bowen Theory.” The Bowen Center for the Study of the Family. 2000. http://www.thebowencenter.org.)

In contrast to an individual psychology approach like CBT, the focus in therapy is less on changing or fixing deficiencies in the individual or focusing on the symptom. Instead the therapist aims to expand the view to the emotional process of the family system and to the natural world of which we humans are part of. The therapist becomes a consultant to the individual’s/family’s efforts to observe and talk about the facts of their predictable/emotional/ instinctual actions in the face of relational tension; those patterns of interaction that Bowen observed as repeating over and over in all families.

The clinician’s work is not to diagnose any family member but to be clear about what he/she will be willing and not to do in the face of the family’s invitations to fix and diagnose. The assumption here is that people have the ability to think for themselves, if only the therapist can down regulate their emotional/instinctual tendency to ‘fix’, when faced with the clients’ anxiety about the problem. The therapist’s job is to get genuinely curious about the facts of the client’s relationship system, i.e. who, what, when, how, where, thus inviting the client to become a better observer of self in the family.

A Bowen theory approach to the problem of substance abuse

In contrast to an Individual psychology approach, the problem of substance abuse is viewed as a family system issue and not just as an individual’s problem i.e. beliefs, cognitions. Substance abuse is seen as a way in which the anxiety and emotionality that belong to the family is bound in a particular individual but every important family member is seen as playing a part in the dysfunction. The symptomatic member does not necessarily have to be part of the therapy for the symptoms to be alleviated.

The Therapist views the symptom as a way in which to understand the reactions, patterns and needs of the family i.e. the instinctual/emotional interconnections of the family. Dr A. McKnight, describes this well:

 “From a systems view alcoholism is a human condition that is an outcome of a relationship process across many generations. The anxiety of the family is bound by this symptom, which develops a function in its emotional life. When a drinking problem becomes a starting point for exploring the relationship system as a whole, the family no longer focuses solely on the alcoholic. Rather the contours of his or her life are seen to fit like a jigsaw puzzle with the needs, reactions and patterns of the family. Any person in the system who functions differently can rearrange the pieces of this puzzle.”  (A. McKnight Family Systems with alcoholism; A case study’ in Titleman P.(ed) Clinical App of Bowen Family Systems Theory 1998, p 297)

 The therapist engages with whoever is motivated in the family to change his/her part in the patterns of emotional functioning. During sessions an exploration takes place of the family relationship system to understand how the addiction has played a part in managing and regulating the emotional life of the family, i.e. patterns of distance and closeness, underfunctioning /overfunctioning reciprocities, boundaries the need to feel independent; all of which sit in the emotional process or instinctual interconnectedness of family members.

Clients are invited to observe and identify how they react to each other, when tension rises in their close relationships, and to speak about these emotional reactions in session.

Questions are asked about:

– Their ability to manage automatic/emotional reactions and their ability to be less relationally sensitive and more thoughtful in their responses.

-The facts i.e. The who, what, where, when and how of feelings and behaviour and its links to functional roles of family members.

The idea in therapy is that the more a person can understand how they fit into the emotional process of family and the functional role they play in it, the more they can begin to take responsibility for down-regulating instinctual reactions and develop principle determined behaviours versus using substance abuse to regulate interactions.

Conclusion

Whilst the CBT approach holds a number of variables as ‘responsible’ for the symptom i.e. a cause and effect model, The Bowen theory describes and defines multiple interacting variables without assigning cause which in turn allow a wider view of the problem i.e. a symptom as an outcome of a relationship process across many generations.

Finally another important difference between a Bowen theory lens and an individual psychology approach is that the focus is not on technique but rather on the self of the therapist. The idea is that we are all part of nature and as such under the same emotional forces in family as our clients. A therapist will struggle to be a resource to their clients if they have not observed the facts of emotional process in their own family and the part they play in it as well as made an effort to change that part. Technique can’t teach us how to be less subjective and less emotionally involved with our clients; this has to do with a way of thinking, i.e. a sound theory, that informs one’s way of being and doing in session.

‘Contrasting approaches – CBT and Bowen Theory applied to treating substance abuse’ – Lily Mailler