The current clinical environment that therapists practice in is driven by crises management, medication monitoring, HMO and insurance criteria, all which focus on symptoms. One result is a vicious circle of the therapist defining the patient as his symptoms and the patient defining self as his symptoms. There is little focus and very little interest in addressing emotional processes that drive the symptoms. How does one conceptualize the relationship between problem-solving and “symptomatic relief?” What makes problem-solving a “therapeutic method”? How does one focus on problem-solving when anxiety is high and the pain is very real?
Dr. Bowen saw families and couples in group setting called “multiples.” This letter addresses inherent practical problems in doing “multiples.” This letter of October 8, 1969 is to a person who was a participant in a multiple group. He clearly speaks to the issues of symptoms and problem-solving.
October 8, 1969
Dear Mrs.
Thank you for the note about terminating the multiple family therapy. I had suspected you were moving toward termination but I wanted to hold your place as long as you wanted to work on the issues.
Enclosed is your bill. In the total series of appointments, the missed more sessions than is average, for which I charged the regular fee. This is a good example of an old issue which has come in sharp focus with me the past two years. On principle, I am opposed to charging for missed sessions, especially in unavoidable situations. I have always had a liberal policy for cancelled and missed appointments. There were always enough people waiting for free time to fill cancelled appointments on short notice. The liberal policy was not possible for multiple families. I have limited time for private practice, a single multiple session requires a 2½ hour block of time, and there is no way to utilize unused time for those who wait. There were enough multiple sessions with only two families, and occasionally only one, that it impaired flexibility, professional efficiency, and income. I had either to return to one family sessions or charge for all scheduled multiple family sessions. Since overall results with multiple are better, and results are important to me, you know my answer to that.
I have one idea about the which might offer you something for the future. In only 12 scheduled sessions you achieved a good level of symptomatic relief which is a good record for any “therapeutic” method. However, your orientation stayed more on seeking relief from problems than finding ways to solve problems; more on avoiding problems than finding ways to meet them; or more on hoping problems would go away than in being challenged by them. It is a “giant leap” from one orientation to another, attained one small step at a time. It is hard for man to develop problem solving methods unless he has a problem on which to work. Perhaps you can keep enough of a problem on hand to keep you working toward a goal. Best wishes in your continuing future efforts.
Sincerely,
Murray Bowen, M.D.