The clinical environment is composed of not only a core triangle but a number of interlocking triangles, including (at least) (1) the patient, her/his issues, and the therapist, (2) the family of the patient, (3) the family of the therapist, (4) and the environment/ setting in which the clinical work takes place, e.g., agency structure, insurance policies, U.R. panels, etc. A lot of emotional forces are pulsating through these conduits which connect these triangles. Not only is the therapist responding to these forces, but certainly adding one’s own forces into the mix. “Transference” phenomena, as Dr. Bowen says in his letter, do not do justice to the complexity of the forces. I’ll mention a few of the emotional complexities that can evolve from thinking confusions to land mines, to major catastrophes.
Often unresolved emotional issues from one’s family of origin drive the initial motivation to become a clinician. When does the clinical job become more emotionally important than the clinician’s nuclear family? Can one have an “affair” with work? Can one be more married to work than to one’s spouse? How does the therapist respond to the patient’s thirst for emotional support that cannot be obtained from the patient’s family? What is the distinction between the therapist being supportive and positive vs. emotionally filling a void within the patient? What goes into the conduit from the therapist who says, “I really like that patient?” How does the therapist respond when the clinical environment is more emotionally important for the patient than his or her home environment? Can the therapist clearly articulate what is being put into the conduit with the patient? What is the nature of the clinical responsibility and expertise? (Being “helpful” is not an acceptable answer.) How does the therapist respond if these themes are initiated by the patient? There is no shortage of horror stories, of divorce being triggered by “boundary violations.” Some of Freud’s followers were known to encourage sexual activity outside of the marriage.* There are also some painful examples of how “seemingly” benign social relationships (e.g., playing bridge with a patient and his wife) evolve into something else. There are also examples of a psychiatrist father requiring that his children be in therapy with him.
The whole area of “co-therapy” is full of emotional complications. If the therapist team is a husband and wife, what is the boundary between clinical and family? If the therapist team is not married, how is the professional “closeness” of the team managed?
On a less intense level, how much of the clinical world is brought home for discussion with one’s spouse? Or how much of the therapist’s family is brought into the clinical environment? Are examples from the therapist’s family experiences “shared” in the clinical environment?
Dr. Bowen’s letter of April 1977 is a response to the organizer of a panel for an Orthopsychiatry meeting which was to include therapists and their spouses. In his letter, he articulates some of the challenge and the importance of one’s clarity of functioning in these interlocking triangles. In the absence of one’s ongoing efforts at clarity, the explosion of the land mines is the probably outcome, with multiple casualties.
* See Lawrence Friedman’s biography Menninger, for some of the details.
April 5, 1977
Dear
I intended to write some weeks back but I have been busy—busy—busy, and time has passed too quickly.
My wife, , is not going to be with us at Ortho next week. In the beginning it was if—ey but I thought she would be willing to put in her viewpoint. Now it has worked out that she is not going to be with me in New York. She is involved in her own pursuits and she has other plans. She was real clear on this some weeks ago and I have failed to keep you informed as this year has rushed by.
So, I will be there to convey my viewpoint as best I can. My orientation to this is different than most. Most family therapists are emotionally involved with the families they see clinically, and they are emotionally involved in their own families. What happens in their clinical work is manifested in their own families and what happens in their families is manifested in clinical work. The life effort is then to keep this “emotional undifferentiation” (consisting of clinical families and the therapist’s own family) in some kind of equilibrium.
I have spent my professional life on defining and practicing “differentiation” which is usually misheard as emotional distancing. For me, “Differentiation” involves the ability to remain an emotionally contained entity while in the middle of emotional chaos while relating actively to every person in the field. I have spent decades working toward differentiating my own self from my wife and children and from my families of origin, and from families I see clinically. It was a great period in my life when I was able to walk through emotional chaos in my clinical work without getting depressed when the clinical situation became depressed, nor elated when the situation became elated, and when I could operate effectively without the clinical situation getting into my personal functioning. I achieved a fair level of that in the clinical arena before I was able to do it in my own family. The greatest period in my life came with the definition of the triangle concept which contained the key to differentiation in my families of origin, later presented in the “Anonymous” paper at EPPI in March 1967. That contained the 1-2-3 step by step formula for accomplishing the mission whenever I wished to get outside the emotional system.
Insofar as I am able to practice operational differentiation with my wife and children, and with my extended families, and with the people I see clinically, then I am a free agent in the field, able to relate everywhere without the emotionality in any field interfering with my functioning. I could even handle it if my own family mixed it up emotionally with the families in my practice.
If this happens, I simply “detriangle” the situation. In earlier years my “patients” were real interested in what went on in my family and my family had a kind of interest in what went on in my clinical work—transference phenomenon. After I got mostly beyond transference, my clinical families do not even have fantasies about personal things in my and my family and my own family is never occupied with what goes in my practice, other than very broad general things. I have been able to work professionally and most profitably with a wide circle of personal friends and relatives. There is no way this can trip me up emotionally or professionally.
My wife and I have our own personal life, fairly well differentiated from each other, far better than anything in our early married years. I can relate to her as a person, and she to me as a person, without either of us having to “triangle” in my clinical relationships or her social-friendship relationships. These outside relationships are simply not a part of our lives together.
Over the years I have tried to communicate what it means to stay out of a transference but not many people are able to “hear”. It makes no difference to me whether people prefer to work professionally from “within” the system with a “therapeutic relationship” or whether they wish to master the infinite detail involved in differentiating a self. I do like to be able to communicate my theory and what I do. It is average for people not to hear and to start telling me that I misperceive and “What you really mean is that you handle the transference well.” When this happens, communication is no longer possible, the next move is a few years of “detriangling” before better communication becomes possible. is probably less patient than I with people who cannot “hear” a viewpoint. I have spent years with severely impaired families helping them learn a point here and there. She is not so inclined. She was patient as patience itself with the children when they were small but in relating to adults she is not so patient. She is more inclined to move on to other people rather than get involved in microscopic hassling of small points so characteristic of family therapy meetings. Her life energies and interests go elsewhere. Maybe another year she will be inclined to participate in a meeting such as you have scheduled if she can be convinced that the group wants to hear what she has to say as a person, rather than automatically perceiving her as an extension of me, and the two of us operating as a twosome.
I had no idea of getting into all this when I started the letter. Then I thought I would do a paragraph to state that I will try to communicate at the workshop, and now it has gone too long. I am looking forward to the workshop and to seeing you and all the rest there.
For now,
Murray Bowen, M.D.