SYSTEMIC THINKING A N D P R A C T I C E SERIES

Edited b y David C a m p b e l l a n d Ros D r a p e r

Systemic Therapy

with

Individuals

Luigi Boscolo

and

Paolo Bertrando

KARNAC BOOKS

SYSTEMIC THERAPY

WITH INDIVIDUALS

Other titles i n the

Systemic Thinking and Practice Series

edited by David Campbell & Ros Draper
published and distributed by Karnac Books

Bentovim, A . Trauma-Organized Systems. Systemic Understanding of Family

Violence: Physical and Sexual Abuse
Bor, R., & Miller, R. Internal Consultation in Health Care Settings
Burck, C , & Daniel, G. Gender and Family Therapy
Campbell, D., Draper, R & Huffington, C. Second Thoughts on the
v

Theory and Practice of the Milan Approach to Family Therapy

Campbell, D., Draper, R & Huffington, C. Teaching Systemic
v Thinking
Cecchin, G., Lane, G., & Ray, W. A . The Cybernetics of Prejudices in the
Practice of Psychotherapy
Cecchin, G., Lane, G., & Ray, W. A . Irreverence: A Strategy for Therapists'
Survival
Draper, R., Gower, M & Huffington, C. Teaching Family Therapy
v

Farmer, C. Psychodrama and Systemic Therapy

Flaskas, C , & Perlesz, A . The Therapeutic Relationship in Systemic Therapy
Fruggeri, L., et aL New Systemic Ideasfrom the Italian Mental Health
Movement
Hoffman, L. Exchanging Voices: A Collaborative Approach to Family Therapy
Inger, L, & Inger, J. Co-Constructing Therapeutic Conversations: A
Consultation of Restraint
Inger, L, & Inger, J. Creating an Ethical Position in Family Therapy
Jones, E. Working with Adult Survivors of Child Sexual Abuse
Mason, B. Handing Over: Developing Consistency across Shifts in Residential
and Health Settings
Ray, W. A., & Keeney, B. P. Resource-Focused Therapy
Smith, G. Systemic Approaches to Training in Child Protection

Work with Organizations

Campbell, D, Learning Consultation: A Systemic Framework
Campbell, D., Coldicott, T., & Kinsella, K. Systemic Work with
Organizations: A New Model for Managers and Change Agents
Campbell, D., Draper, R., & Huffington, C. A Systemic Approach to
Consultation
Huffington, C , & Brunning, H . Internal Consultancy in the Public Sector:
Case Studies
McCaughan, N . , & Palmer, B. Systems Thinkingfor Harassed Managers

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SYSTEMIC THERAPY

WITH INDIVIDUALS

Luigi Boscolo

Paolo Bertrando

translated by
Carolyn Novick

Systemic Thinking and Practice Series

Series Editors
David Campbell & Ros Draper

London
KARNTAC BOOKS

This edition published in 1996 by

H. Karnac (Books) Ltd,
118 Finchley Road,
London NW3 5HT
Copyright © 1996 by Luigi Boscolo and Paolo Bertrando
The rights of Luigi Boscolo and Paolo Bertrando to be identified as authors of
this work have been asserted in accordance with §§ 77 and 78 of the Copyright
Design and Patents Act 1988.
All rights reserved. No part of this publication may be
reproduced, stored in a retrieval system, or transmitted in any form
or by any means, electronic, mechanical, photocopying, recording
or otherwise, without the prior permission of the publisher.
British Library Cataloguing in Publication Data

A CLP. for this book is available from the British Library

ISBN: 978 1 85575 094 4

Edited, designed, and produced by Communication Crafts

10987654321

Printed in Great Britain by BPC Wheatons Ltd, Exeter

CONTENTS

EDITORS' FOREWORD vii

PREFACE ix

PART I

THEORY

1 A n evolving theory 3
What we have learnedfromsystemicfamily therapy 3
Back to the individual 10
Inner and external world 13
The evolution of systemic theory and praxis 17
Social constructionism 22
Narrativism 24
The spoken and the unspoken 28
An epigenetic view 33

2 W o r k i n g systemically 41
Indications 41
Assessment, diagnosis, and therapy: a recursive process 46
v
Vi CONTENTS

Goals of therapy 53
Time and change 58
The therapist 67
Ethical issues 83
The philosophy of therapy 87

3 Therapeutic process 91
Dialogue 91
The session 119
The process 128
Language and therapeutic process 135

PART n

CASES

4 Therapy with a predominantly

strategic-systemic approach 157
TeresaS.: Fortune's tricks! 157
Giorgio B.: Who analyses whom? 160
Enrica S.: The lady who was not able to go shopping 162
UgoB,: The sleepless paediatrician 164

5 Systemic therapy cases 167

GiulianaT: Life as control 167
Bruno K.: "Midway along the journey of our life.. " 192
Luciano M.: Prisoner of a family myth 224
Carla V.: Her femininity found again 234
OlgaM.: An existential desert 239
Susanna C: Relational dilemmas 242
Francesca T.: An inextinguishable hunger 278

REFERENCES 293
INDEX 302
EDITORS' FOREWORD

W
hile most systemic therapists have learned their
trade i n the context of family therapy, it is rare to
find a therapist who works solely and exclusively
with families. Most of us have varied our practices out of choice
or necessity, so that many practitioners today apply systemic
therapy to a range of situations, including work with individ­
uals. But there has been very little help available for therapists
shifting from family to individual work. There have been a
few papers written on this subject, but until now no one has
described a comprehensive model that has a theoretical frame­
work, giving rise to therapeutic changes. We believe that this
book is a major contribution to the therapeutic field, and we are
pleased to bring the English edition into our Series.
Boscolo and Bertrando describe the work they are doing with
individual clients in Milan. Locating themselves clearly within
the tradition of the Milan approach and more recent social
constructivist and narrative influences, and articulating con­
tinually a broad systemic framework emphasizing meaning,
problems in context, and relationship, they introduce a range of

vii
Viii EDITORS' FOREWORD

ideas taken from psychoanalysis, strategic therapy, Gestalt

therapy, and narrative work. They describe their model as
brief-long therapy and introduce new interviewing techniques,
such as connecting the past, present, and future in a way that
releases clients and helps them to construct new narratives for
the future; inviting the patient to speak to the therapist as an
absent family member; and working with clients to monitor
their own therapy.
The book is written with a freshness that suggests that
Boscolo and Bertrando are describing "work i n progress", and
the reader is privy to the authors' own thoughts and reactions
as they comment on the process of their therapy cases. This is a
demystifying book, for it allows the reader to understand why
one particular technique was preferred over another.
The book is timely in several ways. A s proponents of differ­
ent models increasingly exchange their ideas, there is greater
mutual influence and breaking down of traditional barriers.
This book demonstrates the value of applying a range of tech­
niques to therapy. The book also addresses the need for
practitioners, and, increasingly, clients, to justify their expendi­
ture of time. The model that Boscolo and Bertrando present
here makes the most efficient use of the therapist's resources
and also the client's pace for therapeutic change.
David Campbell
Ros Draper
London, June 1996
PREFACE

T
he idea of a book on therapy for the individual—rather
than the family—within a systemic framework was sug­
gested to us by David Campbell, co-editor of this Series.
H e explained to Luigi Boscolo that, for a variety of reasons,
some British psychiatric professionals who practise systemic
family therapy found that, often, only one member of the fam­
ily would be involved in the therapy; a book that dealt with
systemic therapy with one person was therefore greatly
needed. The book, according to Campbell, had to outline an
easily transmissible model of such therapy for use in both a
private and a National Health context. The idea was to encour­
age systemic-relational therapists, as well as professionals
inspired by other theories, to practise the new model of indi­
vidual consultation and therapy with which we are currently
experimenting. We accepted the invitation with pleasure, since
we had been trying for some years to adapt to individual
therapy the systemic model developed for working with fam­
ilies.

ix
X PREFACE

The main task we undertook was to describe our therapeutic

practice and its relationship with theory at different stages of
our work, starting from the early 1970s, when we followed the
strategic-systemic model developed by the Milan Research
Institute group. In a second phase, from 1975 to 1985, therapies
were performed according to the Milan systemic approach i n ­
spired by Gregory Bateson's thought. The cases seen after the
mid-1980s reflect a radical shift of perspective due to second­
order cybernetics and constructivism, which gave centre stage
to the observing system (i.e. the therapist) and self-reflexivity.
In the last decade, after the coming of post-modernism and
social constructionism, maximum attention was given to lan­
guage and narrative.
In our therapies of today one can trace the echoes of the
theoretical and clinical experiences of all these years. For us,
systemic therapy now means to enter with the client into a
complex network of ideas, emotions, and significant persons,
recursively connected and explored by the two interlocutors
through language. Since a systemic therapist's thinking is
grounded on the idea of complementarity of lineal and circular
causality, on the importance of a plurality of points of view,
and on giving privilege to asking questions rather than supply­
ing answers, it has the effect, in time, of transmitting to the
client a way of connecting things and persons, events, and
meanings to enable him to free himself of a rigid vision of
himself and of the surrounding reality. The client may thus
1

expand and deepen his sensibility and become open to the

possibility of experimenting and seeing events and stories of
his life in a wider perspective. Thus, if we put ourselves in a
narrative perspective, we may say that the client is freed from a
story that has become rigid and induces suffering, and he be­
comes able to enter in a new story, with greater freedom and
autonomy.

As will become evident from reading this book, we are sensitive to gender
1

issues; we have, however, generally used the masculine pronoun throughout

the book, for purely stylistic reasons. We also choose to use the term "client"
rather than "patient", for reasons that, again, will become clear while reading.
 PREFACE Xi

In certain cases, when the nature and the urgency of the

presenting problems (e.g. a phobic or obsessive-compulsive
behaviour) fit typical strategic-systemic interventions, we limit
ourselves, in a few sessions, to working on the specific problem,
without entering into an in-depth exploration of the client's
story and person.
The result of our efforts—the model's description and appli­
cation—had the effect of allowing us to clarify our ideas (a
recursive formative process) but left us with some worries,
because of the complexity of the connections among the theo­
ries we considered and the practices we derived from them.
Such a complexity, which emerges in the first three chapters
here, may be stimulating for some readers, especially if they are
experienced therapists, but for others it may be difficult and
somewhat wearisome. We suggest that the latter should first
read the extensive clinical examples presented in Part II; these
cases are full of theoretical references and may in themselves
offer a vision of our therapeutic process.
We wrote this book not only for experienced therapists, but
also for younger colleagues who nevertheless have some thera­
peutic experience and are eager for specific knowledge of i n ­
dividual systemic therapy. This book does not deal with the
2

basics of systemic therapy (we assume that the reader already

has a thorough idea of them), nor is it a "cookbook" of specific
therapeutic interventions. It is, rather, a book that puts explor­
ing, thinking, and feeling at the centre of the therapeutic stage,
with the help of several theoretical lenses (filters) that we have
derived from our long practical experience and theoretical re­
search. We hope that the model we outline here is accessible

2
We have not detailed the foundations of systemic theory (general system
theory, communication theory, and cybernetics), since we consider these to be a
part of a common cultural baggage. The reader who needs further assistance
with these notions should consult relevant general books, such as: Pragmatics of
Human Communication (Watzlawick, Jackson, & Beavin, 1967), Paradox and
Counterparadox (Selvini Palazzoli, Boscolo, Cecchin, & Prata, 1978a), Foundations
of Family Therapy (Hoffman, 1981), Milan Systemic Family Therapy (Boscolo,
Cecchin, Hoffman, & Penn, 1987), and The Times of Time (Boscolo & Bertrando,
1993). For the conceptual basis of our model, the reader should consult Gregory
Bateson's works, especially Steps to an Ecology ofMind (1972).
Xii PREFACE

and may serve as a starting point for the reader wanting to

build a working practice.
We first describe extensively a kind of therapy with which
we are still experimenting and which we define as "brief-long"
therapy: it is a therapy limited to twenty sessions, with two- to
four-week intervals between sessions, and an overall duration
of not longer than about one-and-a-half years. We then give
considerable space to the narration of clinical examples. In this
procedure, the basic operation was twofold: first, trying to re­
construct the connection of events, meanings, and emotions
emerging in the therapeutic system at the time when the
therapy or consultation was taking place; second, examining
and evaluating all this a posteriori, according to our present
views. (The reader will, of course, find within the cases pre­
sented the connections he himself wishes to draw from the
theoretical elaboration, thereby creating his own view—which
will probably be different from ours.) We hope that the results
of this operation transmit with clarity our attitude and our way
of working. Everything we put at the reader's disposal should
be read as part of research that has allowed us to enrich our
clinical experiences as well as our theoretical cognitions. We
hope the reader, too, may feel enriched as we have been.
We have tried to remain faithful to some assumptions that
we hope will emerge from the text. One of them is our idea that
working with the systemic model gives great freedom and
stimulates creativity, keeping alive the interest and the enthus­
iasm towards a field of work that still gratifies us. We hope that
the reader will be a little "contaminated" and encouraged to
follow a similar road—no book can be a substitute for the per­
sonal synthesis that we each create through our own personal
work and our own personal reflections upon it.
Luigi Boscolo
Paolo Bertrando
Milan, June 1996
PART I

THEORY

In the first part of our book we present a description of the

development of our therapeutic practice in relation to
certain theories, from the early 1970s on.

Chapter 1 describes the evolution of our theoretical model

and of the experiences connected to it, starting from the
use of a psychodynamic model, to arrive—through the
strategic-systemic, systemic, and constructivist phases—at
our present-day model, which we describe as "epigenetic"
(the reason for which will become apparent).

Chapter 2 deals with the general methodology of individual

systemic therapy, i.e. the framework for the therapeutic
practice. We give special attention to the operational
(indications, diagnosis, goals, duration), ethical, and philo­
sophical issues of therapy.

Chapter 3 deals with the therapeutic process: the guide­

lines for conducting the session (hypothesizing, circularity,
circular questioning); the phases of therapy, from the initial
evaluation to the final session; and last, but not least,
the recent and stimulating contributions related to the
linguistic (semantic, rhetoric, hermeneutic) issues of the
therapeutic dialogue.
CHAPTER 1

A n evolving theory

WHAT WE HAVE LEARNED

FROM SYSTEMIC FAMILY THERAPY

O
ur current model of systemic therapy, that which gives
us inspiration in our work with individuals, was devel­
oped through a series of experiences in research, con­
sultation, and therapy with families and couples. From 1971 to
1975, we used the strategic-systemic approach of the Mental
Research Institute (MRI) of Palo Alto. In the following ten
years, we worked with the Milan Systemic Approach, based
mainly on Bateson's cybernetic epistemology. After 1985, the
model was particularly influenced, first, by constructivism and
second-order cybernetics and, later, by constructionism, narra­
tivism, and hermeneutics. A l l of these theoretical contributions
inevitably left their mark on our current model, which, for this
reason, we would define not only as a systemic model, but also
as an epigenetic one (see p. 28, n. 12).
Due to a series of particular and fortunate circumstances that
came to pass at the beginning of the 1970s, the senior author
had the privilege of working for about ten years in two very

3
4 THEORY

different situations under the same roof. The first was that of a
psychoanalyst's private office. In this room, three days a week,
he conducted long-term Freudian analyses as well as face-to­
face psychodynamic therapies, with sessions once or twice a
week and lasting from one to three years. The second was the
work environment of the so-called Milan Approach team
(Selvini Palazzoli, Boscolo, Cecchin, and Prata). This team did
research on and therapy with families and couples in three
rooms: the therapy room, in which the members of the family
or the couple and the therapist sat; the observation room, sepa­
rated from the therapy room by a one-way mirror; and the
discussion room, where the whole team would confer at the
end of each session to formulate a systemic hypothesis and
create a possible intervention to conununicate to the family
(Boscolo et al., 1987).
In the period in which the group worked with the MRI
model of short-term therapy, they coincidentally had the direct
supervision of Paul Watzlawick for about two weeks. A s a
general rule, the team worked with families for a maximum of
ten sessions, with very good results. Very few families, mainly
those with a chronic psychotic member, would need further
sessions. The differences in terms of frequency of sessions, d u ­
ration of therapy, and results between individual therapy and
work with families conducted by a team were so great that,
while this comparison did not quite leave the senior author in a
state of shock, it did bewilder him and provoke his curiosity. 1

H e felt that, when he was alone in his office with the client, it
was as if he were in the middle of a large river in which the
water flowed slowly towards a rather distant sea, while when
he worked with the team and families, it was as if he were in a
rapid mountain stream, in which the water, which at times
would suddenly accelerate, was directed towards a nearby des­
tination. In a certain sense, this metaphor could be used to
illustrate the very different relationship between time and
change in the two types of experiences. This was to be a stimu­

*In this period, systemic family therapy had much influenced and trans­
formed the way of dealing with the symptomatic individual. However, the
previous experience of individual psychoanalytic therapy had some influence
on systemic family therapy, although limited to the content of some hypotheses.
 A N EVOLVING THEORY 5

lus for both authors to look into the important and fascinating
question of time in therapy (see Boscolo & Bertrando, 1993).
The senior author was working in two different types of
situations, using two very dissimilar theories—psychodynamic
therapy and strategic-systemic therapy—which were diametri­
cally opposed, both in their conceptions of human beings and
the nature of their problems and in their therapeutic goals and
the ways to reach them. As time went by, he found it very
difficult to do therapy remaining faithful to the theoretical
premises and technical requirements of both theories. Later on,
when we set up a training course in systemic family therapy,
we noticed this same phenomenon in trainees who had previ­
ously had training in psychodynamic therapy. A t first, they
were confused as they tried to connect very heterogeneous
elements. Later, they gradually began to get their bearings and
came to a systemic vision, which, however, did not cancel out
all of their previous experience. In fact, as time went by, they
managed to make use of both theories, consciously or uncon­
sciously, in certain circumstances. (Nowadays, we call this the
"non detto"—"the unspoken"—and we discuss this in depth
later in the chapter.) They thus substantiated Gregory Bateson's
aphorism that two eyes see better than one, in that they can
perceive depth.
A t a certain point, in order to extricate himself from the
disturbing sensation of feeling split in two, the senior author
began to introduce certain ideas and techniques of the strat­
egic-systemic approach into his psychodynamic individual
therapies. A m o n g these were symptom prescription, the use of
paradox, and reframing. His intention was to see whether the
very impressive, characteristic discontinuous changes by leaps
would occur. In psychodynamic therapy, this kind of change is
rare. Usually change takes place slowly, in a more continuous
manner, through lysis—through dissolution of problems—
rather than through crisis.
His first attempts had a disastrous effect! Instead of getting
better, the clients either got worse or else therapy entered an
impasse, which thus forced the therapist to backtrack. In two
cases, the clients had verbalized their bewilderment and disap­
proval. One wondered aloud whether, perhaps, the therapist
6 THEORY

was trying out a new method of doing therapy (sic!). The other
said, "This isn't your own work—right? D i d you perhaps just
recently go to a seminar and listen to other therapists who had
different ideas?" It is significant (and maybe one could even
say that it is obvious) that the "guinea p i g " clients had reacted
to the introduction of different ideas with bewilderment, con­
fusion, and more or less evident rejection. The therapist recog­
nized that he was paying a high price to satisfy his scientific
curiosity, i.e. the creation of a confused situation that was un­
dermining the therapeutic relationship. H e was making more
or less the same errors that orthodox analysts at one time attrib­
uted to so-called " w i l d analysts". One could add that the thera­
pist had adopted an attitude of uncritical eclecticism, rather
than gradually integrating elements of the two models when
the situation would allow it.
A t this point, we would like to describe the main differences
that existed, at that time, between these two ways of thinking
and doing therapy. We will limit ourselves to describing what
2

we feel were the distinctive features, and we apologize in ad­

vance for the necessary schematism and inevitable simplifica­
tions.

1. In the psychodynamic model, the symptom was considered an

epiphenomenon of an unconscious conflict, and the primary
goal was the resolution of the conflict rather than the disap­
pearance of the symptom. In contrast, in the strategic-systemic
approach, which was based on a viewpoint of circular causal­
ity, the symptom and its persistence were considered within
the social context in which the "attempts to resolve it" became
the problem. Therefore, the goal was to break the rigid, repeti­
tive patterns in which the symptom was embedded, so that
new, more "functional" patterns could evolve.
2. Already this first distinction suggests a profound difference.
Psychoanalysis dealt with semantic aspects of communication,
meanings, metaphors, symbols, and, above all, more with
thought than with action. Thus, insight was the therapeutic

W e e m p h a s i z e the p h r a s e " e x i s t e d at that t i m e " , because b o t h m o d e l s h a v e

2

since undergone modifications.

 A N E V O L V I N G T H E O R Y 7

instrument par excellence. In contrast, the strategic-systemic

approach was based on pragmatic and behavioural aspects,
more on action than on thought. Therefore, the prescription of
behaviours for changing other, undesired behaviours was one
of the most important therapeutic instruments. The "black
box" theory sealed this distinction between thought and action
(behaviour). According to this theory, an observer could ob­
serve only behaviours and behavioural patterns, but he could
not see what was going on inside people's heads.
3. In the psychodynamic model, the main interest of the therapist
was drawn towards exploring the ways in which the client
related to himself, to others, and, above all, to the therapist
[transference]. According to the theory, these relationships re­
flected the client's relationships in childhood with "primary
objects", particularly relationships with members of the family
of origin. Therapy had the aim of resolving unconscious con­
flicts of the past, connected through transference distortions
with the relationships in the present, a source of anxiety, suffer­
ing, and symptom development. The therapist had to deal with
the unconscious resistance of the client, which required a great
deal of therapeutic work.
In the strategic-systemic model, however, the goal of the
therapist was first to ask the client to define and decide which
problems he wished to resolve, and then to explore the unfruit­
ful attempts at resolution already made by the client and by
the significant persons with whom he had relationships. The
therapist helped the client to reach this goal through a series of
ad hoc strategic interventions made in a limited amount of time
(from one to ten sessions; most frequently in four to six ses­
sions). The disappearance of the symptoms led to the termina­
tion of therapy and was the only criterion for defining a
successful outcome. We want to emphasize that, in this ap­
proach, no distinctions were made between normality and
pathology. The client's problems were considered to be simply
existential problems. In conformity with a cybernetic view,
these problems were not attributed to causes other than the
attempts at solution, which had become part of the problem. In
other words, the strategic-systemic therapist did not deal with
8 THEORY

the various aspects of the client's personality, like motivations,

fantasies, thoughts, or emotions. The therapist also did not
deal with the client's past and the client's story but, rather,
only with his current social relationships, in which rigid and
repetitive behaviours connected with the symptom became the
therapist's targets for strategic interventions. Therapeutic opti­
mism, a positive view, directing one's attention and efforts to
the client's resources and strengths, and the frequent use of the
one-down position were characteristic of strategic brief
therapy. Milton Erickson was acclaimed as a master in avoid­
ing resistances or, better, avoiding the creation of resistances.

4. Finally, we want to emphasize two of the most important dif­

ferences between the two models—the therapist's goals and
the time of therapy.

(a) Therapist's goals

In psychodynamic therapy, the job of the therapist was to ex­
plore with the client unresolved conflicts and problems con­
nected with his current difficulties aind sufferings as well as the
ways in which these might have developed and taken centre
stage in the client's psychic and social life. The therapist-client
relationship, joint exploration, and insight were the ways and
instruments for resolving these conflicts. In contrast with stra­
tegic therapy, the factors common to all models of therapy
(listening, empathy, trust, etc.) were of primary importance. In
the strategic model, the therapist's goals were identical to
those of the client, i.e. getting rid of the symptoms!

(b) Time of therapy

It is not surprising that the amount of time necessary for con­
cluding therapy was longer in the psychodynamic model than
in the strategic-systemic one. (Therapy with the latter model
rarely exceeded ten sessions.) 3

3
In p s y c h o d y n a m i c therapy, the n u m b e r of weekly sessions w o u l d usually
r u n to between fifty and a h u n d r e d or more. Short-term, time-limited psycho­
d y n a m i c therapies r u n from twelve to forty sessions, according to different
authors.
 A N EVOLVING THEORY 9

In psychodynamic therapy, a great deal of time is required for

the exploration of the past life of the client and its relationship
with the present, and of the relationship with significant
others, including—of course—the therapist. In strategic ther­
apy, on the other hand, time is devoted only to the solution of
the presenting problems.

We return to these two subjects—goals and time—in Chap­

ter 2. Some case histories treated within the systemic-strategic
model are presented in Chapter 4.
In 1975, something occurred that led to a great change in our
way of viewing and doing therapy: we read Gregory Bateson's
book, Steps to an Ecology of Mind, which opened up new hori­
zons. Our attempts to apply Bateson's cybernetic epistemology
in a clinical field led us to a new, exciting territory. Our thinking
changed radically and became more complex. We went beyond
the strategic thinking and praxis to develop a " p u r e " systemic
model, which became known as " T h e Milan Approach". We
wrote in our book, The Times of Time:

Compared with the Palo Alto approaches we were then us­

ing, the systemic view of Bateson's original writings seemed
both purer and more complex. The distinction between map
and territory, the logical categories of learning, the concept
of mind as system and system as mind, the notion of cyber­
netic epistemology and the introduction of semantics—all
became extremely important. The clinical application of
these ideas led to new information collection and processing
methods and new types of intervention in human sys­
tems. Three principles were drawn up for the conduct of
sessions—hypothesizing, circularity, and neutrality—which
later became the distinctive features of the Milan Approach
[Boscolo & Bertrando, 1993, p. 85] 4

This radical change in outlook led to a change in the goals of

therapy. Our interest moved from symptoms and behavioural

4
In 1979, Selvini and Prata left the Centre and continued their research with
families and couples, developing new ideas, different from those described in
this book.
10 THEORY

patterns to epistemological premises and systems of meaning,

and from the present to a time framework that included past,
present, and future. The therapist's job became that of creating
a context for deutero-learning (i.e. learning to learn) i n which
the client could find his own solutions. Chapters 5 and 6 of this
book give a sample of the evolution of our therapeutic and
consultation practice.

BACK TO THE INDIVIDUAL

In the early 1980s, different schools of therapy began sharing a
common trend. O n the one hand, several individual therapists,
such as psychoanalysts, cognitivists, and Ericksonian thera­
pists, began to show interest i n family and couple therapy,
some of them taking inspiration from the strategic-systemic
models. Similarly, several systemic family therapists, who pre­
viously had focused on the relational system between members
of a family or a couple, started paying attention also to the
members themselves, i.e. to individuals (and, incidentally, to
emotions). This evolution in the field of systemic therapy was
triggered by the epistemological revolution brought by second­
order cybernetics and constructivism, which put the observer—
i.e. the individual—in the forefront. Later on, in the late 1980s,
social constructionism, with its emphasis on language, made
inevitable the need to move beyond the dichotomy of indi­
vidual versus family. The theoretical frames—such as narrativ­
ism, hermeneutics, linguistics, and conversational analysis—
that currently inspire our work with the individual, with fam­
ilies, and with other systems are described further on.
A s is well known, a theoretical model develops not only
from theory, but also from experience. In our experience as
systemic therapy trainers, our interest i n individual therapy
came from our trainees, who, during the systemic family
therapy training course, at times brought, in supervision, cases
of individual therapy conducted in their work contexts. They
reported that they often had to comply with their agency's
requirements, i.e. to deal with clients in individual therapy, at
weekly rather than monthly intervals.
 A N EVOLVING THEORY 11

A s is often the case, with a trained eye one distinguishes

things that previously went unnoticed. Thus, once our interest
had been stimulated, we noted more and more that in some
cases, especially those of young teenagers and adults, indi­
vidual systemic therapy could be indicated as the therapy of
choice, or this could follow family therapy or even be carried
out in parallel with it.
A s a result of these theoretical and experiential inputs, we
decided to get down to business. We began by exploring the
vast literature on individual therapy, in particular examining
the similarities and differences among the various models. This
interesting survey led us to focus our attention on some signifi­
cant issues.
We observed that certain therapeutic models, such as the
strategic models, make a distinction not between pathology
and normality but, instead, between problem and solution. These
models, grounded on the principle of circular, rather than lin­
eal, causality, connect recursively the problem to the solution.
The recursive circuits of problem-solution are dealt with using
strategic interventions that interfere with it, thus allowing
problem-solving in a short amount of time. The results are
visible and assessable while therapy is going on, as the present­
ing problems gradually disappear. The goal of problem-solv­
ing requires an attention by the therapist on the present and
future time rather than on the past. These brief therapies,
aimed at the solution of specific problems, have also been
called "technological" therapies (Goudsmit, 1992).
Another group of models considers the person as the focus
of therapy. The main interest is not in solving problems but,
rather, in the client's changing the epistemological premises
(Bateson, 1972) of his " w o r l d view", or, in other words, in
changing the story in which the client is embedded. In these
cases, the therapeutic technique is very different. Exploration is
used, a process in which therapist and client cannot predict
changes. Changes take place freely in dialogue, and it is only
a posteriori that a judgement can be made about the result of
therapy. Aspecific therapeutic factors, such as exploration, em­
pathy, attentive listening, and human warmth, are particularly
relevant in therapies centred on the exploration of the person.
12 T H E O R Y

These models are based on a time-frame that gives preference

to the relationship between past and present (as in psycho­
analysis) or the more complex past-present-future relationship
(as in the systemic model that we follow).
A s a result of our theoretical evolution and clinical experi­
ence, we could say that in our individual therapies we feel
closer to the second group of models. However, we do recog­
nize that occasionally we use some techniques associated with
the strategic approaches, especially the Ericksonian one. These
techniques are clearly successful in resolving specific problems
afflicting some clients, especially when they have a paralysing
or incapacitating effect, like, for instance, in phobias, in panic
attacks, and in some obsessive-compulsive behaviours.
In cases in which these techniques have led to the disappear­
ance of the symptoms over a short period of time, the therapist
and client evaluate whether to terminate or continue therapy. If
the client decides to continue, then both therapist and client
proceed jointly to explore the client's story. Attention is fo­
cused on significant conflicts and themes in the client's life,
which can lead (in post-modern terminology) to the appear­
ance of alternative stories that do not require the client to pay
such a high price in terms of distress and suffering.
We are aware that these remarks may provoke bewilder­
ment and rejection by some of our readers, who would find
unacceptable the idea of working with two such different mod­
els. To these legitimate criticisms of inconsistency, we may re­
ply that to try to be consistent by choosing one type of therapy
to the exclusion of the other would be limiting. Why should we
abandon a way of working that has shown itself to be simple
and effective in a certain number of cases? Why abandon some­
thing that has also given us a great deal of satisfaction during a
certain period in our clinical work and research?
Here we could express an opinion that is shared by many
others. One model is not necessarily the best choice for all of
the cases treated. There are situations that respond better to a
model of brief therapy based on problem-solving (see Chapter
4) than to a model that proposes to change the client's world
view or story.
 A N EVOLVING THEORY 13

For example, i n the cases of persons who meet up with a

transitory crisis, a long-term therapy would have the iatrogenic
effect of bearing out a self-fulfilling prophecy (first by the
therapist, then by the client) that a long period of therapy is
absolutely necessary, when, in fact, a short-term intervention
on the symptoms might well have been sufficient to overcome
the crisis.

INNER AND EXTERNAL WORLD

The new interest i n the individual necessitated a rethinking

about theory and praxis, especially by those who worked i n the
field of family therapy. For many years, family therapists dealt
with the most important social context of the individual, i.e. the
family. They were positive that to change a person, it was
sufficient to change his or her family's relationships. The indi­
vidual's inner processes were intentionally overlooked. This
was due both to the complexity and vagueness of these proc­
esses as well as to doubts about their usefulness, since the
presenting problems were attributed to external causes (rela­
tions) and not to internal ones. We believe that this lack of
interest i n the individual was due to the acceptance of the well­
known "black box" theory (Watzlawick et aL, 1967). For several
years, the Milan group contributed to the exclusion of the indi­
vidual's world by giving priority to the holistic aspects of
Gregory Bateson's thinking, to the exclusion of other aspects
that deal with the importance of the inner world, the uncon­
scious, and the emotions (Bateson, 1972).
Bateson wrote:

The individual mind is immanent, but not only in the body.

It is immanent also in pathways and messages outside the
body; and there is a larger Mind of which the individual
mind is only a subsystem. . . . Freudian psychology ex­
panded the concept of mind inwards, to include the whole
communication system within the body. . . . What I am say­
ing expands mind outwards and both of these changes re­
duce the scope of the conscious self. [p. 467]
14 THEORY

The following quote reveals Bateson's immanentistic pas­

sion and his opposition to all dichotomies. This has had a sig­
nificant influence on our way of thinking and working.

It is the attempt to separate intellect from emotion that is

monstrous, and I suggest that it is equally monstrous—and
dangerous—to attempt to separate the external mind from
the internal. Or to separate mind from body, [ibid., p. 470]

If for many years our interest was directed at the "external

m i n d " , at the observable interpersonal relationships, more re­
cently we have been paying overdue attention to the "internal
m i n d " . Both the therapist's and the client's inner and external
world and the relationship with the social systems in which
they are embedded have become the territory to be explored.
Self-reflexivity has taken a central position. 5

Some systemic family therapists have used psychodynamic

concepts to connect the individual's inner and external world.
According to Breunlin, Schwartz, and MacKune-Karrer (1992),
therapists who have tried to integrate the two worlds have
turned mainly to object relations theory. This theory aban­
doned the Freudian concept of drives i n favour of a viewpoint
that was more compatible with relational theories (Nichols,
1987; Scharff & Scharff, 1987). However, they point out that
object relations theory still contains too many of the same as­
sumptions about individual deficiencies and pathology that
had had the effect of distancing the pioneers of family therapy
from psychoanalysis.
We are in agreement with the conclusions of these authors.
We also found some of the ideas of the existential psychoana­
lyst Ronald Laing quite interesting. In the 1960s, he was one of
the few psychoanalysts who were interested in systemic theory
and therapy. In his book The Politics of the Family (1969), Laing
distinguished the real family from the internalized "family".
(In the book, he used quotation marks around the word " f a m ­

A n exploration of the therapist's inner world that has particularly inter­

5

ested us deals with his construction of theory and experiences. This is dealt
with in detail in this chapter in the sections entitled "The Spoken and the
Unspoken" and " A n Epigenetic View".
 A N EVOLVING THEORY 15

i l y " to denote the internalized family.) His main idea is that the
" f a m i l y " is an introjected set of relations. H e maintained that
one does not internalize isolated elements (objects) but, rather,
relations between elements.

Elements may be persons, things or part-objects. Parents are

internalized as close or apart, together or separate, near or
distant, loving, fighting, etc.. .. Members of the family may
feel more or less in or out of any part or whole of the family,
[p. 4]

We feel that this last feature can usually be found in seri­

ously pathological cases, as, for instance, in psychotics, charac­
terized by a sense of differentness and alienation. Laing also
links the internalized "family" to parameters of space and time,
which we, too, dealt with i n our recent research work. Laing
wrote:

The family as internalized is a space-time system. What is

internalized as "near" or "far", "together" or "divorced" are
not only spatial relations. A temporal sequence is always
present.... As Sartre would say, the family is united by the
reciprocal internalization by e a c h . . . of each other's inter­
nalization, [pp. 4-5]

Two fundamental concepts of Laing's are internalization

and transformation-externalization (projection). Internaliza­
tion consists of transferring patterns of relations from the exter­
nal world to the internal world. Laing concentrates on the
relationship between the individual's ego and the internalized
" f a m i l y " . A person tends to project the introjected patterns of
the internalized "family" onto the external world. (Already in
the 1960s, Laing felt that it was necessary to study flesh-and­
blood families in conjunction with internalized "families".)

In very disturbed people, one finds what may be regarded as

delusional structures, still recognizably related to family
situations. The re-projection of the "family" is not simply a
matter of projecting an "internal" object onto an external
person, It is the superimposition of one set of relations onto
another: the two sets may match more or less. Only if they
mismatch sufficiently in the eyes of others, is the operation
16 THEORY

regarded as psychotic. That is, the operation is not regarded

as psychotic per se. [p. 9]

Our re-reading of Laing gave us a feeling of pleasure. It was

as though we had re-discovered something familiar, something
that we somehow knew without being conscious of it. It was as
if these notions were dormant in our minds and were part of
the "non detto" [the "unspoken"]. If we look at this from an
epigenetic viewpoint, we could say that the ideas of authors we
read later (those that dealt with problems of relationships be­
tween the Self and the external world) had made us forget
about Laing's ideas (which now seem to us so very incisive and
deep).
Constructivism and, to a greater extent, constructionism
had raised doubts about the concept of the Self as a monolithic
unit and had favoured the view of the Self as a community
(Minsky, 1985). For example, Varela (1985) felt that it would be
more appropriate to speak of Selves rather than the Self.
Schwartz (see Breunlin et al., 1992) developed a rather naive
model of the Internal Family System (IFS). In this model, the
mind, instead of being a unitary entity, is a collection of " s u b ­
minds or sub-personalities", which are all connected but are
relatively autonomous. A person has, i n addition to this group
of parts, a Self. The Self is a unit that is on a different level from
the other parts. It has the task of "directing" the internal parts
as a conductor directs the musicians in an orchestra. According
to this complicated theory, the Self does not develop through
stages nor is it the result of introjection. It is present with all of
its ability for guiding the sub-personalities. According to the
author, the aim of therapy should be that of helping the client
reorganize the internal system, such that the Self would be the
guide and the other parts would cooperate with it. This model
seems very concretistic to us. It seems full of what Bateson
(1979) called "dormitive principles".
Karl Tomm, at a conference held at our Centre in 1995, pro­
posed a model that has some points in common with Laing's,
although it has been constructed within the framework of so­
cial constructionism. In Tomm's therapeutic praxis, much at­
tention is paid to the Self as a community of internalized others.
 AN EVOLVING THEORY 17

This reveals a conception of the Self as pluralistic and multiple.

According to Tomm, the individual's identity is spread i n the
community by means of the internalizations that are made by
the persons i n contact with this individual. Tornm's model is
vaguely reminiscent of Bateson's theory of M i n d , whereby the
Self could be located i n the reflexive circuits that unite various
inner worlds and external worlds into a community.
To translate these theoretical speculations into practice, we
found it useful to use the metaphor of the inner "voices" that, as
we claim with our clients, are inside all of us. We relate the
client's and our inner "voices" to significant persons of our past
and our present. These "voices" can be punishing, guilt-induc­
ing, critical, negative ones—or supportive, comforting, con­
firming, positive ones. This technique allows for the creation of
an interaction among the three system in our therapeutic dia­
logue, i.e. therapist, client, and inner voices. We examine this
procedure i n more detail in Chapter 3 as well as in the discus­
sion of clinical cases, especially that of Luciano M . in Chapter 5.
Another clinical case that richly illustrates this procedure is that
of Nancy B., i n our previous book, The Times of Time (1993).

THE EVOLUTION

OF SYSTEMIC THEORY AND PRAXIS

The new interest for the individual and his inner world in the
evolution of systemic theory and practice emerged i n the 1980s.
Gregory Bateson's cybernetic epistemology had previously
provided a basis for the work of most family and couple thera­
pists. Cybernetics has undergone a series of mutations over the
years, followed by the development of new ways of seeing and
thinking, which had a considerable effect on the language, the
theory, and the practice of family therapy.
Family therapy, at the beginning, was based on first cyber­
netics, which was later called "first-order cybernetics". It as­
sumed that it was possible to separate the observed system
from the observing system. First-order cybernetics,, based on
control mechanisms (Wiener, 1948), was focused on the concept
of negative feedback related to deviation-counteracting proc­
esses. This was considered to be the means by which systems
18 T H E O R Y

maintained their own stability, by compensating for deviations

with retroactive mechanisms (homeostasis or morphostasis).
Subsequently, second-order cybernetics was introduced. This
was better suited for application to living systems (Maruyama,
1963), because it was focused on the way in which living sys­
tems modify their organization through a deviation-amplifying
process and therefore by positive feedback or "feedforward"
(morphogenesis).
The ideas mentioned above were stimulating to different
groups of therapists, some of which exclusively dealt with fam­
ily and couple therapy. A m o n g them was the original Milan
team, which stood out for being "systemic purist" in the appli­
cation of Bateson's ideas. The description of the so-called "fam­
ily games", i.e. the family system's specific organizational
modalities, was one of the major goals. The Milan team worked
with individuals only in exceptional cases, when it was i m ­
possible to convene the family (Selvini Palazzoli et al., 1978a).
Others, especially the MRI group (Watzlawick et al., 1967), also
working within a systemic-cybernetic framework, were influ­
enced by Milton Erickson's original ideas and techniques. They
generally conducted short-term individual therapies, i n which
the individual was seen as a part of a significant relational
system that was connected with the presenting problem. A n
MRI therapist typically tried to interrupt communication pat­
terns connected with the presenting problems by making use of
various techniques, such as the prescription of the symptom,
the prescription of other behaviours, and the use of paradox
and reframing. The therapist's goal was to make it possible for
6

new and more desirable patterns to emerge.

The strategic approach, too, has been influenced by constructivist thinking.

6

"One begins with the conviction that the psychic and behavioral disorder is
determined by the subject's perception of reality, i.e., from the viewpoint that
makes him/her perceive (or rather, construct) a reality to which he/she reacts
by changing in a dysfunctional or so-called 'psychopathologic' way" (Nardone
& Watzlawick, 1994, p. 27). "The strategic therapist's focus of attention is the
relationship, or rather, the interdependent relationships that every individual
has with himself/herself, with other persons, and with the world. The aim is to
make these relationships function well, not in general or absolute terms of
normality, but in very personal realities that are different from one person to
another and from one context to another"(ibid, p. 26).
 A N EVOLVING THEORY 19

In the 1980s, some basic changes i n systemic therapy came

about which restored to the individual the role that had been
denied it i n the preceding period. Most importantly, the "black
box" theory—according to which an observer could see only
interaction among people, i.e. input and output—began to be
questioned. The first family therapists had adopted the black
box theory to eliminate the complexity inherent in personality
theories, particularly psychoanalytic theory, which not only
influenced but actually monopolized the field of psycho­
therapy. However, dealing with the "relationships among ele­
ments within a b o u n d a r y " — i n keeping with the simplest
definitions of a system whereby the elements correspond to
persons, whose motivations, fantasies, and emotions had to be
ignored—had a reductionistic flavour and was remiscent of
behaviourism. The individual's intra-psychic life, thus, was i g ­
nored. Breunlin et al. (1992) had the following to say about this:

It is true that, while the pioneers of family therapy were

struggling to develop maps of the totally unfamiliar territory
of family process, they needed to focus on these "external"
interactions exclusively and could not afford to be distracted
or confounded by efforts to incorporate each family mem­
ber's internal dynamics into their formulations, [p. 57]

These authors emphasized that the interest in family therapy

was a reaction to the inadequacy of the models based on intra­
psychic processes and their inherent pessimism. Hence, the
search for a practical, shorter, and more optimistic way of con­
ducting therapy:

It seems that, to differentiate themselves from the individual

therapy establishment, from which many of them had come,
these pioneers in family therapy became rigidly externally
focused and felt justified in doing so, because they had dis­
covered the power of external context and believed that
changing a person's family would sufficiently change his or
her internal life. [pp. 57-58]

Breunlin et al. concluded that, since in the systemic-cyber­

netic theory there were no particular reasons to exclude inter­
nal processes i n human systems, the time had come to broaden
the view to include both external and internal processes.
20 THEORY

A t this point, a theoretical problem came up. According to

which model should the individual be viewed? Was it sufficient
to avail oneself of the systemic model that had been created,
tested, and used by family therapists and extend it to include
also the individual and his psyche? Some authors felt that it
was sufficient. For example, the MRI group, having enriched
their model by adopting a constructivist point of view, d i d not
face major upheavals or shake-ups in theory and continued in
the same direction. For these therapists, there was no substan­
tial difference between working with an individual or working
with a family. Even when they worked with an individual, the
goal was the same, i.e. breaking the communication pattern
associated with the presenting problem. They thereby avoided
dealing with the whole person, i.e. with his story, and with his
fantasies, emotions, and premises.
For others, the transition from working with the family to
working with the individual was more problematical. The sys­
temic model, born together with family therapy and for a long
time associated with it, did not seem to have a sufficient degree
of complexity to explain individual and collective intrapsychic
processes. Nonetheless, as the reader will see in Chapter 2,
Bateson's ideas on the Self and the unconscious were adequate
for giving such a theoretical support. Some authors suggested
the use of theories coming from the field of individual psychol­
ogy and personality theory, theories that had already been con­
solidated in other disciplines and in therapy with individuals.
Specifically, they felt that they could utilize ideas from
psychodynamics, cognitive psychology, or Kelly's theory of
mental constructs. 7

For many years, we deluded ourselves that we were systemic purists, who
7

dealt only with patterns, relationships, networks, and so on, leaving in the
shadows the elements of the systems, i.e. the individuals. However, having
been exposed in the past to a "strong" theory, such as psychoanalysis (the
senior author had indeed conducted many classical analyses and psycho­
dynamic individual therapies in the 1960s and 1970s), we could not but take
into consideration the individual's inner world in doing systemic family ther­
apy. We call this effect the "unspoken" and discuss it at length further on in this
chapter. What belongs to the conscious process of the therapist is but a part of a
larger body of thoughts, experiences, and skills.
 AN EVOLVING THEORY 21

A n interesting development within the systemic model has

been suggested by Steve de Shazer (1991), who in the past had
been inspired by the M R I group. H e has recently modified his
own model following the development of post-structuralism
and linguistics, emphasizing the central role of language and,
in particular, Wittgenstein's theory of linguistic games. For de
Shazer, and for those writers influenced by social construction­
ism, the constructivist revolution had not been sufficiently
revolutionary, i n that it maintains the dichotomy between sub­
ject and object.

Ln post-structuralist thought, in contrast to structuralist

thought, "language constitutes the human world, and the
human world constitutes the whole world". . , . That is, the
world is seen as language... in post structuralist thought,
our world, our social context is seen as created by language,
by w o r d s . . . . von Glasersfeld's radical constructivism is not
radical enough; it seems to draw, once again, the methodo­
logical boundary around the client, who is the individual
cognizing subject. . . .
A more radical interactional constructivism is needed,
8

when the methodological boundary is drawn around the

therapeutic situation. A social or interactional theory of
knowledge, such as developed by Wittgenstein,... and the
post-structuralists will prove more useful in describing what
is going on within that particular context, [de Shazer, 1991,
pp. 45-48]

In the last ten years, new theories, based on linguistics, on

hermeneutics, and on social constructionism have made it pos­
sible to connect the individual and the group. These theories
stand out for their elegance and simplicity, as well as for their
creativity in dealing with the problems of complexity. Some
noted therapists have more or less abandoned systemic­
cybernetic theory, while embracing with enthusiasm these new
theories, e.g. L y n n Hoffman, Harry Goolishian, T o m Andersen,
Harlene Anderson, to mention a few. Others have developed a

8
It is hard for us to grasp the distinction between radical interactional
constructivism and social constructionism!
22 THEORY

main interest i n narrative theory, e.g. Michael White, David

Epston, Carlos Sluzki, A l a n Perry; the first two authors have
also been influenced by the thought of the French philosophers
Foucault and Derrida.

SOCIAL CONSTRUCTIONISM

Second-order cybernetics, introduced at the beginning of the

1980s by Heinz v o n Foerster, radical constructivism, developed
by Maturana, Varela, and von Glasersfeld, and post-modern
thinking all contributed to bringing attention back to the indi­
vidual system. The reader who is interested in in-depth de­
scriptions of these important contributions should consult
Bocchi and Ceruti (1985), Hoffman (1988), Maturana and
Varela (1980), v o n Foerster (1982), von Glasersfeld (1984, 1987),
Watzlawick (1984), and our own book, The Times of Time (1993),
in which we have thoroughly described the evolution of sys­
temic thinking after the constructivist revolution. We would
like, however, to discuss a more recent trend that came to the
forefront at the beginning of the 1990s: social constructionism.
Constructivism left unresolved the dichotomy between the ob­
server and that which is observed, which were conceived
as two distinct entities (Fruggeri, 1995). Seen in this light, the
systemic view moved from a viewpoint external to the indi­
vidual ("outsight") to a viewpoint inside the individual ("in­
sight"). The resolution of this dichotomy involved a change
9

of perspective, from constructivism to social constructionism.

Social constructionism followed close upon constructivism,
and it seems to us to be in a conquering, prominent position
among many therapists. It emphasizes the sharing and the so­
cial genesis of knowledge, which is an aspect that was implicit
in constructivism, though not sufficiently developed. L y n n
Hoffman (1992), a theorist and therapist, who pays close atten­
tion to epistemological changes, summarized the differences
between the two almost homophonic models as follows:

9
We owe this definition of "insight"/"outsight" to Brian Stagoll (1987).
 AN EVOLVING THEORY 23

Although many persons, including myself, have frequently

confused [social constructionism] with constructivism, the
two positions are quite different. There is a common ground
in that all take issue with the modernistic idea that a real
world exists that can be known with objective certainty.
However, the beliefs represented by constructivists tend to
promote an image of the nervous system as a closed ma­
chine. According to this view, percepts and constructs take
shape as the organism bumps against its environment. By
contrast, the social construction theorists see ideas, concepts
and memories arising from social interchange and mediated
through language. A l l knowledge, the social constructionists
hold, evolves in the space between people, in the realm of
the "common world" or the "common dance". Only through
the ongoing conversation with intimates does the individual
develop a sense of identity or an inner voice, [p. 8]

In other words, while constructivism emphasizes the ob­

server and his mental constructs, social constructionism high­
lights the idea of relationships. These relationships, however,
are seen in a different light from those of the early cybernetic
theories, i.e. no longer as expressions of behavioural structures
or patterns, but as systems of language and meaning. This
change can already be seen in the writings by Bateson (1972), in
which he, wondering about what mind is, wrote the following:

. . . We may say that ''mind" is immanent in those circuits of

the brain which are complete within the brain. Or that mind
is immanent in circuits which are complete within the sys­
tem, brain plus body. Or, finally, that mind is immanent in
the larger system—man plus environment. . . .
Consider a man felling a tree with an axe. Each stroke of
the axe is modified or corrected, according to the shape of the
cut face of the tree left by the previous stroke. This self­
correcting (i.e. mental) process is brought about by total
system, tree-eyes-brain-muscles-axe-stroke—tree; and it is
this total system that has the characteristics of immanent
mind. .. .
But this is not how the average Occidental sees the event
sequence of tree felling. He says, "I cut down the tree," and
he even believes that there is a delimited agent, the "Self",
24 THEORY

which performs a delimited "purposive" action upon a de­

limited object, [pp. 317-318]

In this example, Bateson can see the action both from the
point of view of the observer (the man) or from a "meta" view­
point which considers the mind to be immanent in the recur­
sive sequence of actions. This two-level view permits one to see
the individual as observer at one level (constructivism). A t the
level of the mind intrinsic i n the system, it connects the ob­
server to that which is observed (constructionism). The ex­
ample of the man who cuts down the tree (which we have
found one of Bateson's most illuminating) permits us to see the
complementary relationship between lineal causality and cir­
cular causality. It also underscores the difference between the
description of an observer (insight, i.e. a vision from the inside)
and a description of the total relationship involving all the ob­
servers who are embedded in the system (outsight, i.e. an out­
side vision). With regard to theory, constructivism can be
related to cognitivism, which is a theory of individual psychol­
ogy, while constructionism can be associated with social psy­
chology.
In terms of our own theoretical position, we have described
in our book, The Times of Time, our most recent stage of devel­
opment: while maintaining a systemic-cybernetic frame (sec­
ond-order cybernetics), we have introduced into our theory
and practice many of the contributions coming from linguistics
and narrativism. 10

NARRATIVISM

O u r interest i n narrative theory is derived mainly from our

own research on time and language in human relationships
(Boscolo & Bertrando, 1993; Boscolo et aL, 1993) and from con­
tact with fellow therapists, among them Michael White, David

Since 1990, we have been involved in a study on language and change and
10

the relationship between them, and we have published an initial article, "Lan­
guage and Change: The Use of Keywords in Therapy" (Boscolo, Bertrando,
Fiocco, Palvarini, & Pereira, 1993).
 A N EVOLVING THEORY 25

Epston, Harlene Anderson, Harold Goolishian, Carlos Sluzki,

L y n n Hoffman, and T o m Andersen.
These authors, together with the reading of Bateson's, de
Saussure's (1922) and—particularly—Jerome Bruner's (1986)
writings, led us into the exciting world of narrative and stories,
how they come to be and how they are constructed. De
Saussure contributed to this development with his notion of a
"synchronic view", based on observation i n the present (i.e. the
observation of rigid relational patterns i n the present, charac­
teristic of the strategic-systemic approach), and a "diachronic
view", which implies the flow of time. Just as the opening of the
black box, in the mid-1970s, had caused us to become interested
in meaning systems, so the opening of the temporal frame led
us to connect events and meanings i n time. We explored how
our clients would connect events and meanings of their past to
explain their present situation in a linear-causal deterministic
manner, which would limit their future perspective. We have
amply illustrated (Boscolo & Bertrando, 1993) how human
systems that produce symptoms and suffering tend to coop
themselves up i n deterministic stories that can become like
straitjackets. A s we explore with our clients their stories, with
the idea of a reflexive loop between past, present, and future,
we can go back and forth in time, so that the linear-causal
deterministic explanations that the clients construct give way
to the emergence of new, hopefully more "healthy", stories.
Our interest in time and human relationships puts us i n a
position close to that of Michael White and David Epston's
(1989):

In striving to make sense of life, persons face the task of

arranging their experiences of events in sequences across
time in such a way as to arrive at a coherent account of
themselves and the world around them. Specific experiences
of events of the past and present, and those that are pre­
dicted to occur in the future, must be connected in a lineal
sequence to develop this account. This account can be re­
ferred to as a story of self-narrative. The success of this
storying of experience provides persons with a sense of con­
tinuity and meaning in their lives, and this is relied upon for
26 THEORY

the ordering of daily lives and for the interpretation of fur­

ther experiences, [p. 19]

According to these authors, suffering that induces persons to

seek therapy can be read as an expression of incongruity be­
tween the stories persons tell about themselves and their own
current experience; alternatively, it can be interpreted as the
expression of a discrepancy between their experience and the
stories that others tell about them. The therapeutic process then
becomes a process of re-narration of stories (re-storying): cli­
ents may recover the possibility and capability of being authors
of stories that are positive for them and reduce their suffering
or at least give a new meaning to it.
More recently, psychoanalytic and cognitive models, too,
have opened up to narrative and hermeneutics. However, it
must be emphasized that, already in an earlier period, i n psy­
choanalysis metapsychological thinking and typologies under­
went a crisis. A number of groups arose that tended towards a
view of the analytic process as a hermeneutic (Ricoeur, 1965),
narrative (Spence, 1982), or empathic exercise (Kohut, 1971;
Schafer, 1983). The key points in a narrative view of psycho­
analysis were illustrated by the Italian psychoanalyst Novel­
letto (1994) as follows:

The initial phase of the analyst's hegemony on the story was

followed by a phase of repossession, by the analysand, of the
competence of narrating his/her own story. The following
hermeneutic phase was prompted by theoretical needs of
analysts who were dissatisfied with Freud's psycho-biologi­
cal conceptions. This phase essentially aimed to favor the
analysand's capacity of self-interpretation above the ana­
lyst's capacity, based on his/her "presumed knowledge".
Finally, there was the phase . .. that gave back to the two
participants all of the dignity of an irreplaceable collabora­
tion, on equal terms, in the reconstruction of the analysand's
subjective story, albeit leaving to the analyst the difficult task
of offering the client the recomposition of the many irrecon­
cilable "stories" produced by his/her splitting. [1994, p. 27]

However, some psychoanalysts (see Jervis, 1989) disagree

with an extreme view of narrative that focuses the interest
 A N EVOLVING THEORY 27

exclusively on the here-and-now meanings emerging i n the

relationship, with the exclusion of all typologies, both Freudian
and post-Freudian, as well as other methodological issues.
A similar evolution has occurred in cognitive therapy, which
has been traditionally considered less open to a hermeneutic
tendency. Villegas (1994) has pointed out that, between the
1980s and the 1990s, cognitive therapists too began to entertain
the idea of therapy as a creation of shared narratives and aban­
doning the traditional position of the therapist's omniscience i n
favour of a dialogic model. Stories told by the patient are first
deconstructed and then reconstructed until narratives are cre­
ated that can furnish the client with metaphors that are more
suitable for creating new images of himself in the past, present,
and future (1994, p. 35).
Characteristically, a cognitive therapist pays particular at­
tention to the detailed procedures i n the deconstruction and
reconstruction process as well as to the use of specific tech­
niques. A n interesting technique of self-observation has been
developed by Vittorio Guidano (1991), a distinguished Italian
cognitive therapist. He helps the client to think back over dif­
ferent periods of his life by concentrating on small details (the
technique of "zooming") or by slowing down events to analyse
them better (the technique of "slow motion"). Thus, the client,
in trying out a new way of utilizing his memory, may reach a
new or a better awareness of his own construction of his inter­
nal consistency (narrative).
This pluricentric interest in narrative models goes along
with a general tendency towards convergence among models
of therapy in this period. Some authors (Broderick & Schrader,
1991) predict that this tendency will lead to a gradual homog­
enization of different schools of therapy into a single "inte­
grated model".
Laura Fruggeri (1992), a teacher at the Milan Approach
School, sympathetic towards social constructionism, has this to
say:

In the systemic approach, social constructionism has gen­

erated conceptual and methodological revision. Many thera­
pists, starting from pragmatic, strategic, and structural back­
28 THEORY

ground, are now in the middle of a transitional phase. They

are attempting to integrate old and new models, old certain­
ties and new sets of premises. The new scientific paradigm
raises some questions that do not merely pertain to therapeu­
tic techniques. Instead, they challenge the very notion of
psychotherapy and the identity of the therapist. It is, in fact, a
thinking that questions the foundations on which psycho­
therapy, both as a scientific and as a social phenomenon, is
based, [p. 41]

THE SPOKEN AND THE UNSPOKEN 11

If we watch an experienced therapist (a "maestro", as an Italian

would say) at work, we could say that he sees and does many
things that fall outside of the scope of his theory. What the
therapist sees and does could be attributed to other theories as
well. In other words, an external observer would utilize his
own experiences, prejudices, and theories for grasping the con­
nections between what the therapist does and theories that are
different from the one the therapist claims to use. Generally,
the therapist is not aware of these connections. We call this
phenomenon, which belongs to the unconscious, the "un­
spoken".
One could liken this situation to that of driving a car. Every
now and then, we might be absorbed in our thoughts or in a
conversation with a passenger and not be aware that we are
driving, since the "automatic pilot" (our unconscious) is deal­
ing with the driving. Likewise, a great deal of what the thera­
pist sees and does is outside his immediate consciousness,
even though it, or part of it, can be reconstructed or recovered

This is the literal translation of the expression "il detto e il non detto"—what
11

is said and what is not said in the conversation.

The use of this concept has been suggested to us by our reading of an
12

article by Lyman Wynne, according to which "Our use of the concept of

epigenesis was in accord with its most general meaning, referring to events of
becoming (genesis) that build upon (epi) the immediately preceding events".
Applied to a view of human development: "The interchanges or transactions of
each developmental phase build upon the outcome of earlier transactions"
(Wynne, 1984, p. 298).
 A N EVOLVING THEORY 29

later, when the therapist reflects on what he has done. In our

experience, it is the therapeutic team behind the one-way mir­
ror or a supervisor who may help the therapist to become
aware of the unspoken. When this happens, it is easy to rec­
ognize how much intuition and experience, rather than just
theoretical precepts, have guided the therapist's perception,
choices, and actions.
Every therapist, regardless of the theory to which he holds,
functions according to an epigenetic principle which leads
12

h i m to integrate the most diverse experiences and theories.

Seen in this light, theoretical purism is simply a myth. A n d it is
a myth, because all of the workers in our field have been ex­
posed constantly to the influence of different theories, from
those they were exposed to during the university years to those
picked up from the professional literature and the mass media.
The following anecdote might, better than any description,
illustrate the topic we are dealing with. Recently a well-known
child psychiatrist told us that, during a visit he had made in the
early 1970s to the Milan Centre for Family Therapy, he had
observed the work of the original Milan team from behind the
one-way mirror. H e had been struck by the great zeal and by
the "systemic rigor" that the group used in discussing and in
creating hypotheses and therapeutic interventions. But what
struck him most was the difference between what was explicit
and what was tacit in the descriptions by the Milan team. They
used a new vocabulary in defining their concepts and their
actions (manoeuvres, pattern, relationships, circular causality,
systems, etc.). However, the way in which the hypotheses were
created and related by the Milan team implied to h i m psycho­
analytic concepts and assumptions, which, nonetheless, were
not made explicit as such. According to this fellow profes­
sional, the "spoken" by the team was somewhat different from
the "unspoken".
It is well known that, at the beginning of their research, the
team had decided to adopt the systemic model and to be " p u r ­
ist", i.e. to avoid the contamination with other theories. A s a
matter of fact, in trying to become rigorously systemic, the
Milan team of that time had tried to abandon not only the
psychoanalytic model used previously in their clinical work,
30 THEORY

but also the psychoanalytic language. The formulation of hy­

potheses to be tested was a central aspect of their activity. In
their team discussions, simple hypotheses, often based on a
lineal-causal view, were connected in more complex hypoth­
eses, until the team finally arrived at the so-called systemic
hypothesis, based on a circular view, which was supposed to
reflect (according to a first-order cybernetics conception) the
organization of the observed system. The content of the hy­
pothesis reflected the knowledge of the team's members,
which could come from psychology, psychoanalysis, psycho­
therapy, literature, cinema, and life experiences.
Even when systemic therapists considered themselves "sys­
temic purists", they inevitably utilized elements from theories
of individual psychology. A t the end of the 1980s, following the
contributions of the feminist critique to the Bateson's view of
power in human relationships, Paul Dell (1989), who is perhaps
the purest of purists among systemic therapy theorists, had to
admit that the incommensurability between systemic theory
and individual psychology was only an illusion. H e wrote:

First, I would argue that individual psychology always has

been, and always will be, inextricable from the practice of
family therapy. Virtually every school of family therapy
makes extensive, albeit often implicit, use of individual psy­
chology. . . . Second, much of my past theoretical work has
been a rigorous effort to disentangle the psychological and
the experiential from "pure" systemic explanation. . . . In
retrospect, it seems to me that much of my conceptual work
(of "purifying systemic theory) was possible only because so
many family therapists had mixed individual psychology
(which they instinctively sensed was necessary) into sys­
temic thinking, [p. 11]

It goes without saying that Dell's reflections can be con­

nected to what we have defined as the unspoken of the sys­
temic therapist. One could speak of a sort of "occupation" of
the clinical contents of a model (systemic) by elements coming
from diverse models (such as the psychodynamic, cognitivist,
strategic, and structural models). The old Milan team, strug­
gling to remain "purist" in the development of their brand of
 A N EVOLVING THEORY 31

systemic model, emphasized its formal aspect. In other words,

the focus on the formal aspect of the model left i n shadow the
content of the hypotheses, connected with the diverse theories
and experiences just mentioned.
Lately, in accordance with post-modern thought, therapists
from different schools are working more and more in an a­
theoretical frame, focusing the attention on the here-and-now
of the therapist-client relationship. Lai (1985, 1993), a well­
known Italian psychoanalyst, appeals for a "technique without
a theory", which he calls conversazionalismo ("conversational­
ism"). This is a technique that disregards, in the therapeutic
conversation, theoretical organizations and typologies that de­
rive from the Freudian libido, object relations, Kohutian narcis­
sism, and the like. It remains to be seen if this is possible, if one
can make a tabula rasa of one's previous knowledge. W e won­
der what may happen to a neophyte therapist who has not been
exposed to clinical theories! We are convinced that an experi­
enced therapist like L a i can do very good work, since he can
rely on a very rich and articulated "unspoken".
The same objection could be made to those therapists (such
as T o m Andersen, L y n n Hoffman, Harlene Anderson, and
Harold Goolishian) who, inspired by post-modernism, decon­
structionism, and social constructionism, maintain that the
main position of the therapist should be that of "keeping the
conversation open" and of "not knowing", i.e. forgetting one's
own knowledge, ignoring all the typologies referring to the
individual and his systems. O'Hanlon, an American brief thera­
pist, referring to those colleagues who take inspiration from the
Milan approach, once made a comment that is perfectly suited
to this position. H e said that if a hypothesis occurs to a thera­
pist, he should get up and leave the room and stay out until this
idea gets out of his head!
A crucial doubt that arises about conversational theories is
whether it is sufficient for a therapist i n training to learn only
how to keep a conversation open and to converse, or whether
the only people who can become successful conversational
therapists are those who have had training in the most impor­
tant clinical models and who can then abstract from them and
work in the here-and-now in a pure hermeneutic framework.
32 THEORY

A s the reader will understand from this book, our position is

not that of pure conversationalism, in that we believe that hy­
potheses and typologies relating to the client and to the
therapist-client relationship are useful as long as they do not
become Truths with a capital " T " (Cecchin, Lane, & Ray, 1992).
If we agree that each therapeutic endeavour is the result of
the interaction of the personality of a therapist with the experi­
ences and theories to which he has been exposed, we r u n the
risk of eclecticism, as a mere acceptance, on the grounds of the
uniqueness of each therapist, of any personal synthesis, to the
detriment of theory. In our opinion, what has been said so far is
relevant to training. While the expert therapist tends to go be­
yond theory, and may apparently seem to abandon it, this,
however, is not possible for the beginner, who must first learn
the theory.
Bateson (1972) wrote:

Samuel Butler's insistence that the better an organism

"knows" something, the less conscious it becomes of its
knowledge, i.e. there is a process whereby knowledge (or
"habit"—whether of action, perception or thought) sinks to
deeper and deeper levels of the mind. This phenomenon,
which is central to Zen discipline,... is also relevant to all
art and all skill [pp. 134-135]

For example, the artist (but this could also refer to a therapist i n
training)

. . . must practice in order to perform the craft components of

his job. But to practice has always a double effect. It makes
him, on the one hand, more able to do whatever it is he is
attempting; and, on the other hand, by the phenomenon of
habit formation, it makes him less aware of how he does
it. . . . The skill of an artist, or rather his demonstration of a
skill, becomes a message about these parts of his uncon­
sciousness, [ibid. pp. 138-142]

The above makes it possible to understand how it is that,

when we watch an expert therapist at work, part of what we
can recognize are words and actions that could be attributed to
theories and praxes other than those declared. Although here
we are talking about technical abilities, this is also valid for the
 A N EVOLVING THEORY 33

theoretical knowledge with which praxis is recursively con­

nected.
If the unspoken could be exhaustively analysed, then a
therapist's seemingly most idiosyncratic traits could be traced
back to the complexity of his personal and professional training
and to the multitude of models that he refers to. What appears
to be the mystery of the therapist's creativity is the synthesis he
makes of all these experiences.
The explanation of the unspoken is consistent with our
epigenetic point of view. A s time flows, there piles up in the
therapist, layer upon layer, all of his experiences and theoreti­
cal knowledge. A s he works, these experiences and this knowl­
edge are transformed into words, emotions, and therapeutic
possibilities, although their origin often remains wholly or par­
tially unconscious. In any case, the final choice of the idea that
is meaningful in therapy derives from the interaction with the
client. Afterwards, it is the client who indicates—with words,
metaphors, silences, and emotions—the possible paths that the
therapist can take.
We would like to emphasize that no therapist can be effec­
tive in all cases. Sometimes, the personality of the therapist and
the theories he holds may not fit with the personality and prob­
lems of a particular client. The therapist must be aware of this
and be humble enough to give up if and when therapy enters
an impasse. This awareness can help him to cope with a danger­
ous symptom for a therapist, i.e. his feelings of omnipotence.

AN EPIGENETIC VIEW

A t this point in time, in our theoretical journey, we still con­

sider the systemic model based on Bateson's ideas to be our
leading metaphor. A s we have mentioned, the model has been
enriched by the contributions of constructivism, second-order
cybernetics, and social constructionism. More recently, an i n ­
terest in time, language, and narrative has taken a central stage.
Entering into the Batesonian world prompted us to over­
come all dichotomies. Bateson's view, based on systemic epis­
temology, refers to the recursive circuits that connect the
34 THEORY

observing to the observed system, according to the two

modalities already described: the first one could be identified
in the constructivist view, in which the individual observes and
constructs, the second one in the social constructionist view,
whereby the observing and the observed system are, at the
same time, "constructed" and "constructing" the relational and
cultural context in which they are embedded.
A problem we encountered on our journey, which for some
time led us into an impasse, was whether the individual with his
inner world could be conceptualized within the systemic
frame, as the family had been, or whether a different theory
from the systemic one was required. It seemed necessary for us
to find, among all theories we knew, the one that could explain,
on the one hand, the individual and the complexity of his intra­
psychic world, and, on the other, the relational system to which
the individual is connected. For a while, we thought of adding
an established and long-experimented theory of the individual
to our systemic theory of the family.
Slowly, we came out of the impasse, and it seems possible to
find a way of thinking that would allow us to get out of our
dilemma concerning the dichotomy of individual vs. family,
psyche vs. system. "Reality" could be seen from different
points of view. One could see things from a reductionist per­
spective (e.g. by directing his attention at behavioural pat­
terns), or at the level of experience and meanings, or at the level
of symptoms, and so on. In other words, it is possible to use a
number of reductionistic frames, without, however, losing
sight of the holistic frame. Hofstadter (1979) compared the dia­
lectic between holism and reductionism to the perception of
Bach's fugues.

Fugues have that interesting property, that each of their

voices is a piece of music in itself; and thus a fugue might be
thought of as a collection of several distinct pieces of music,
all based on one single theme, and all played simultane­
ously. A n d it is up to the listener (or his subconscious) to
decide whether it should be perceived as a unit, or as a
collection of independent parts, all of which harmonize, [p.
283]
 A N EVOLVING THEORY 35

Our current attitude permits us to make this inversion of

figure-ground—from holism to reductionism—at any time. A t
present, it seems to us that our new way of thinking and work­
ing has led us to resolve, for the most part, the dilemmas we
had faced about conflicting ways of conceiving the individual
and the family system. This way of working is consistent with
the emerging paradigm of complexity (Bocchi & Ceruti, 1985;
Morin, 1977) i n the humanities and sciences, according to
which the most appropriate way of seeing and understanding
the world is through a network of theories. Thus, things can be
looked at from the point of view of a particular theory, or from
the interface between one theory and another. 13

We consider our view neither static nor absolute, but rather

capable of evolving through the contribution of other theories
we have yet to encounter. In other words, this is an epigenetic
outlook, created by accumulation rather than by negation of
what was previously accepted. 14

In our conceptual and practical work, we tend to reject ex­

tremism. By "extremism", we mean the tendency to fall in love
with " n e w " ideas and wipe out everything else so as to be true
to these new ideas. Although extremism may be useful i n mak­
ing clear one's position and i n bringing forward new models,
one runs the risk of losing everything positive that was created
in the past by theorists and therapists (including one's own
work).
Rather than such progress " b y leaps and bounds", we prefer
an epigenetic evolution, in which every change in theory or
practice connects up with those experiences that have proven
themselves useful. This manner of theorizing is not a simple

13
We must, however, try to avoid drowning in a sea of theories, i.e. to avoid
a confusing eclecticism. Our chosen lifeboat is the systemic model.
14
The idea of an epigenetic outlook has some similarity with Piaget's concept
of genetic epistemology (1970). Piaget considered the child's development of
intelligence as the result of a dynamic interaction between the child and the
environment (by means of the action of various regulatory mechanisms, such as
accommodation, assimilation, and equilibration). However, this is a mere anal­
ogy, because we refer to a more general meaning of the word "epigenetic" (see
Wynne, 1984).
36 THEORY

linear process of accumulating new ideas over time, but rather

(in harmony with our systemic-cybernetic view) a system of
concepts and of experiences recursively connected and in con­
tinual evolution.
Our evolution cannot but be directed by contextual, social,
political, and conceptual circumstances. For example, in our
work as trainers, we deal with trainees who mostly work in
public institutions. These institutions require cooperative ac­
tion among different workers who may hold diverse ideas
about theory and practice. In working together, it is necessary
that these workers find a common language and have mutual
respect for the different points of view that each one holds. This
situation is similar to that of a multi-cultural and multi-ethnic
society, in which every citizen must be respected for his cul­
tural difference, who at the same time has to accept the com­
mon values of the country in which he lives. For this to be so, to
avoid the confusion of the Tower of Babel, it is necessary to
develop a common language, with each person respecting the
position of the others.
In our opinion, it is possible to achieve coherence among the
diverse languages of the various theories, by developing a
meta-language that permits us to work in spite of our differ­
ences. Thus a respectful relationship among professionals is
possible, from those adopting a psycho-biological orientation
to those with a conversational or social orientation. Naturally,
we have to remember the importance of listening to our clients.
Their voices should receive an equal, if not greater, respect than
the experts voices and should be listened to with care by all
7

professional workers. This premise is always accepted in prin­

ciple, but often disregarded in practice!
By accepting all these voices, we can free ourselves from
rigid attitudes and from diagnostic moralism, thus avoiding an
either/or confrontational positioning. We all go along with a
both/and position, which allows us to take into consideration
different points of view, explanations, and experiences, in ac­
cordance with one of the key concepts of systemic epistemol­
ogy. For example, we are supporters of the biopsychosocial
paradigm (Engel, 1977) which is slowly spreading in medicine,
and we can dialogue both with other professionals who adopt a
 A N EVOLVING THEORY 37

biomedical model (especially psychiatrists) and with those who

find inspiration in psychosocial models. Our choice changes
from person to person and from moment to moment, and we
do not consider it to be a dogma or a "truth". It is simply an
option whose relativism we are aware of. We tend to put our­
selves in a multiversal position, in which every " t r u t h " is con­
textual, connected to a pragmatic and social context and to a
judgement about its suitability. One can say that for any con­
text, there is a " t r u t h " that is more appropriate than the others.
This "ecumenical" development helps to resolve the d i ­
chotomies and the contrapositions present in the various mod­
els of therapy, which—as one may expect—can frequently have
the effect of poisoning the relationships among the health
workers in the institutions, negatively interfering with the care
delivery. We are aware of the difficulty met by the inexpert
therapist who tries to put into practice this way of thinking and
doing therapy. We believe that learning to do therapy should
take place in two phases. In the first phase, the trainee should
learn a model, and while learning it, it is necessary for him to be
a "purist" with regard to that model, i.e. to adhere strictly to its
premises, methodology, and techniques. In the context of train­
ing, to avoid confusion this should be seen not as a limitation
but as a necessity: one cannot simultaneously learn to ride a
bicycle riding and to ski. However, once the model has been
learned, tried out, and assimilated, it is possible then to learn
about other models in a more or less skilful way. A s a conse­
quence, this new learning will inevitably contribute to enrich­
ing the thinking and practice of the therapist, whether or not he
is aware of this. Slowly the trainee, as he becomes acquainted
with the model, and with more and more practice, will develop
a mastery in the use of it and eventually find an appropriate
distance from it, thus freeing his own autonomy and creativity.
In other words, in time the relationship with a theory turns
from being a constraint to becoming resource. To learn to do
15

15
The same thing can be said of the relationship between the therapist and
his prejudices. One of the goals in training is to make the trainee aware of his
own prejudices, into which he may enter in the same kind of dialectic relation­
ship as that just described and eventually transform them into resources
(Cecchin, Lane, & Ray, 1994).
38 THEORY

therapy is comparable to learning any other kind of skill, such

as driving a car. A t first the beginning driver must concentrate
on the pressure on the pedals and on any movement of the
steering wheel if he wants to avoid an accident; but, in time,
these learned skills sink into the unconscious (Bateson's "hab­
its"), and driving the car becomes so automatic that one is no
longer aware of putting into practice those sensorimotor skills
acquired in the training with so much diligence and effort.
A s we mentioned earlier, an interesting late development
among therapists who, in the past, had adhered to the systemic
model based on Bateson's ideas and on the Milan approach is
the shift from the systemic view to a "purist" narrative­
conversational model, inspired by social constructionism. A c ­
cording to this model, the task of the therapist is to "keep the
conversation open" while avoiding hypothesis-making, thus
constantly maintaining a "not-knowing" position (Anderson &
Goolishian, 1992).
In our opinion, it is an illusion to believe that the therapist
can act from a not-knowing position, since, just as it is impos­
sible to not communicate, it is also impossible to not make
hypotheses, using, consciously or unconsciously, the knowl­
edge acquired previously (see the section on the "unspoken").
Moreover, it is an illusion to shed the role of expert, in that this
role is conferred by the context in which the therapist works,
even if, strategically, he may act in the relationship as if he were
not an expert. In the role of a non-expert, the therapist can be
16

facilitated in opening up dialogic space for the client to recon­

struct his own story, limiting as much as possible his (the thera­
pist's) contribution to this story.
Nonetheless, we think it is confining to try to be "purists"
within the narrative-conversational model, which may lead to
a vague and not very productive neo-Rogerism and force the
therapist to wipe out all of that theoretical and practical knowl­
edge which has, in the past, demonstrated itself to be pertinent
and effective.

Strategic-systemic therapists often use the position of "non-expert". Jay

16

Haley calls this a "pseudocomplementary position". This is reminiscent of the

characteristic one-down position of the MRI's strategic approach.
 A N EVOLVING THEORY 39

We are i n agreement with Minuchin's (1987) pertinent meta­

phor of the "inner voices" representing the most innovative
and creative fellow professionals each therapist listens to. In
our work we find inspiration i n the meaningful voices to which
we have been exposed during our professional career. In ac­
cordance with our epigenetic view, we integrate within our
more recent version of the systemic model the theories learned
in the past, and all the meaningful "voices" (professional or
simply human) that inspire us i n our daily practice and life. The
new insights help us to evaluate earlier theories in a new light,
discovering new connections and new stimuli. A t the same
time, the aspects of these earlier theories which are no longer
coherent with our current praxis are rejected, and what seems
valid is accepted and integrated. For example, parts of Pragmat­
ics of Human Communication by Watzlawick et al. (1967), Strat­
egies of Psychotherapy (1963) and Uncommon Therapy (1973) by
Jay Haley, Paradox and Counterparadox by Selvini Palazzoli et al.
(1978a), or Steps to an Ecology of Mind (1972) and Mind and
Nature (1979) by Bateson keep a great deal of validity and i m ­
portance for u s . 17

In our epigenetic view, the concept of "integration" has an

important role. It helped us, for instance, to resolve the disturb­
ing question of eclecticism (Villegas, 1995). One could define
eclecticism as the indiscriminate use of heterogeneous tech­
niques, which come from diverse models of therapy, without
correlating them every now and then with the various theoreti­
cal assumptions of the same models. In contrast, integration is
the capacity of availing oneself of a well-experimented theo­
retical model one feels comfortable with and that has given
satisfactory results. Whenever we get into a therapeutic impasse
and are unable to come out of it with the systemic model, we
avail ourselves of other models, which may offer a different
view of the situation in impasse and indicate a way out of it.
Once this goal has been reached, we can return to our preferred
model.

Similarly, readings from the classics of psychoanalysis and cognitive

1 7

therapy, as well as contributions by recent authors, have enriched our knowl­

edge about therapy.
40 THEORY

To be systemic, for us, means to listen not only to the

"voices" of our mentors, colleagues, and clients, but also to the
"voices" coming from the client's and our culture. Particular
attention is paid to gender issues, to power, to ethnicity in the
history of the client, filtered through the premises, prejudices,
and sensibility of the therapist. A therapist open to this per­
spective may be more aware of the effect of the cultural influ­
ences and prejudices that condition his descriptions and
explanations.
We are aware that the multiplicity and diversity of areas
explored up to this point may have left the reader in a state of
perplexity, if not confusion, in the attempt to give sense to the
heterogeneity of the theoretical material. The temptation of the
reader might be that of rejection, based on an idea of relativism
(a criticism also made of the models inspired by constructivism
and constructionism) or it might be that of limiting himself to
selecting particular aspects of our model as it has developed
over time.
We trust that a careful reading and attempts to put into
practice the ideas we have exposed will allow the readers to
broaden their horizons and to enrich their praxis. As far as we
are concerned, we feel the need to state that we are still faithful
to the systemic model, because of its usefulness and creativity;
it has given us the possibility to exercise also our creativity and
to find solutions in a variety of situations, especially in the most
difficult ones.
CHAPTER 2

Working systemically

T
his chapter deals with the methodological, operational
(i.e. indications, diagnosis, goals, duration), ethical, and
philosophical issues of individual systemic therapy.

INDICATIONS

In the early 1970s, at our Centre (Selvini Palazzoli et al., 1978a),

the original Milan team used to draw a clear distinction be­
tween family therapy and individual therapy, and chose to do
family therapy with all clients referred. There were only a very
few exceptions. For example, if during family therapy some
family members did not want to continue therapy, the team
would eventually decide to go on working with one individual,
who usually happened to be the person who had made the
request for therapy or, sometimes, the identified patient. None­
theless, the meetings with the one client alone were still de­
fined as family therapy sessions, in order to avoid transferring
the label of "patient" from the family to the individual.
A t that time, the indications for individual therapy as such
came down to only two. The first was when the client d i d not

41
42 THEORY

want to come with his family and put this condition as the sine
qua non for initiating therapy. The second was when the client
could not bring his family members or spouse, either because
they refused to participate or because they were unable to for
organizational, logistic, or financial reasons. Nonetheless, this
was an uncommon situation, since our Centre was known as a
private institution that specialized in family and couple ther­
apy, and therefore the clients were referred and motivated by
other professional to come as a family or as a couple. The
clinical context was different for our trainees; at their work­
place, they often had to make compromises, especially if they
worked for public health agencies in which psychotherapy was
traditionally done with individual clients rather than families.
O u r Centre has been dealing with families and couples for
over twenty years. The single most important reason that moti­
vated the original Milan team to treat the family or couple
system in order to deal with the problems (or symptoms) of the
individual was related to the idea that symptomatic behaviour
was related to the behaviour of other family members. In fact,
according to Bateson's cybernetic epistemology, any change i n
the family system would inevitably encompass all of its mem­
bers, including the so-called identified patient, even if the latter
refused to participate i n the sessions. For many years, this con­
viction had brought us to consider family and couple therapy
as the intervention of choice. It was thought that dealing only
with the individual patient restricted the therapist's possibili­
ties for helping the client.
Later on, the Milan team became more flexible and began to
see families even when one or more members were not attend­
ing. More than that, the separate convocation of one or more
members for the next session, according to the hypothesis of
the moment, became one of the most important interventions.
A t the end of the 1980s, the authors of this book, while still
working mainly with families and couples, began to develop a
deeper interest in individual therapy. They were impelled by
1

Since the beginning of the 1970s, the senior author had been conducting
1

individual therapies on his own, experimenting, from time to time, with ideas
and techniques stemming from the teamwork with systemic family therapy.
 WORKING SYSTEMICALLY 43

the same kind of curiosity that had characterized the earlier

Milan Team's stimulating and profitable excursion into the
new and (at least in Italy) little-explored territory of family and
couple therapy.
A s the Milan team had successfully adopted the systemic—
strategic model developed by the Palo Alto group in working
with families, similarly, to work with individuals, we had to
develop a more complex model, which could connect inner
world and external world, meanings, actions, and emotions,
and the individual to the significant others.
From 1990 on, we have been experimenting with a particular
type of individual systemic therapy, with a duration varying
from one to twenty sessions, with an interval of two to four
weeks between sessions. We were curious to explore whether
individual systemic therapy would have different effects, com­
pared to family or couple therapy, on the symptomatic client
("identified patient" according to the old systemic vocabulary).
We also wanted to explore the important issue of indications
and contraindications for one type of therapy or the other.
The kinds of clients for whom we now would advise indi­
vidual systemic therapy as the treatment of choice are the fol­
lowing.

1. Adolescents or young adults who have terminated a family

or couple therapy, and have more or less resolved the fam­
ily conflicts responsible for the collective or individual dis­
tress, but could benefit from individual therapy for dealing
with problems outside the family and dilemmas about their
identity and their future. (See the case of Bruno K. in Chap­
ter 5.) 2

2. Adolescents or young adults who, from the beginning,

refuse family therapy. (See the case of Giorgio B. in Chapter
4.) Pre-adolescent children, however, are best treated with
family therapy or, sometimes, by working only with the
parents in order to avoid the effects of attaching a pathologi­
cal label onto the children.

2
In this chapter and the next, we refer directly to clinical cases presented in
Part II by the name and last initial of the client.
44 THEORY

3. A person who requests a couple therapy, but whose partner

refuses to participate. (See the case of Carla V . in Chapter 5.)
4. A separated or divorced person who, from the first consul­
tation, requests family or couple therapy, with the ex­
spouse involved, with the pretence of resolving a problem
(real or not) with a child or children, but with the secret aim
of negating the separation.
5. Cases in which family members openly refuse to come to
therapy, citing insurmountable financial or organizational
difficulties.
6. Apart from the above-mentioned "second-choice" indica­
tions for individual therapy (i.e. cases in which it is impos­
sible or inadvisable to do family therapy), our research on
individual systemic therapy has led us to single out "first­
choice" cases for individual systemic therapy. These are
cases of adolescents and adults of all ages who may show
any of a large range of symptoms but who, at the first ses­
sion, seem to us to be in a more or less advanced stage of
separation from the family. (Naturally, we feel that family
therapy is the treatment of choice in cases of adolescents
and adults who do not show these signs, such as cases of
psychosis, of infantile personality, or of symbiotic relation­
ships.)

A m o n g the circumstances that stimulated our interest in i n ­

dividual systemic therapy, one came from the ever-increasing
frequency with which most of our trainees brought their indi­
vidual therapy cases to us for supervision. Many of them were
employed by a public or private agency that did not expect or
even discouraged family therapy. Others, working in private
practice, mainly dealt with referrals for individual therapy, or
they themselves preferred to do individual therapy because
they felt it less stressful than family therapy. We again remind
the reader that, over the past ten years, our interest in systemic
individual therapy has been intensified not only by force of
circumstance, but also by the flux in the development of sys­
temic theory due to the influences of second-order cybernetics,
constructivism, and social constructionism, which have high­
 WORKING SYSTEMICALLY 45

lighted the position of the individual(s) as observer(s). A s an

effect of this evolution, our interest spread out from the family
as a system to the individual and larger systems. For example,
lately the senior author has been involved in consulting with
public and private health organizations as well as with busi­
ness organizations.
A frequently neglected—or more or less purposely ignored—
topic in evaluating the indication for therapy is the careful
consideration of a therapist's personality characteristics and the
therapeutic model adopted in relation to an individual case, i.e.
there are certain personal characteristics of the therapist and
certain theories that may be more appropriate to certain kinds of
clients than to others. A s a rule, and especially in the past,
psychoanalysts adopted and applied very meticulously a set of
criteria to evaluate a candidate for a psychoanalytic treatment.
Today's proliferation and competition among therapists, at
times with not much training and supervision, have blurred the
rules concerning indications for therapy, leading frequently to
accepting any client who applies. Sometimes, when no progress
is made in therapy in spite of many attempts to break out of the
impasse, therapists attribute this failure to "resistances" by the
client, rather than to their own personality characteristics, to
their inexperience, or to the model used. Models of therapy are
like fishing nets: no one net can catch every type of fish.
Catamnestic surveys are very eloquent about this (for a com­
3

prehensive review, see Gurman & Kniskern, 1981; Alexander,

Holtzworth-Monroe, & Jameson, 1994). However, these studies
must be regarded with a critical eye because they reflect the a
priori assumptions of the persons doing these studies.
For example, several catamnestic inquiries state that certain
types of therapy are more useful than others for certain kinds
of presenting problems. Experimental research in couple
therapy, for example, has demonstrated that, for moderate
marital problems, behavioural couple therapy gives the best
results in a short period of time; however, for more severe
problems, other types of therapy, such as systemic therapy or

3
Studies involving the reconstruction of the life story of a patient after the
end of therapy.
46 THEORY

emotionally focused therapy, give more stable results, while

behavioural couple therapy appears to be less effective over a
long period of time. Other studies have shown that structural
family therapy is effective for substance abuse or addiction, but
a systemic or a psycho-educational intervention is more effec­
tive in families with a psychotic member.
Individual characteristics of both therapist and client, the
specific problem (diagnosis) of the client, and the therapist's
experience and theoretical premises must all be considered
when evaluating a client as well as during the course of
therapy. It may happen that the sum total of these factors indi­
cates insurmountable difficulties, and the therapist should be
aware of this. For example, an inexperienced therapist should
be cautious about taking on a case of psychosis. In such a case,
the therapist should get supervision from a more expert col­
league and discuss the various decisions to be made with him.
If this is not possible, the best advice would probably be to
dismiss that case.

ASSESSMENT, DIAGNOSIS, AND THERAPY:

A RECURSIVE PROCESS

Assessment, typologies, and "diagnosis" in our model

Assessment and diagnosis differ according to the theoretical

convictions of the therapist. To assess and diagnose implies
making distinctions. Some therapists distinguish between
health and illness, others between well-being and suffering,
and yet others between problems and solutions. This variation
is due to differences in the models on which these professionals
base their therapy. Some models stipulate distinguishing be­
tween normality and pathology (e.g. psychoanalysis and cogni­
tive therapy), others between well-being and suffering (e.g.
"humanistic" therapy, narrativism, and constructionism), and
yet others between problems and solutions (e.g. MRI strategic
therapy and problem-solving therapy).
 WORKING SYSTEMICALLY 47

Generally, strategic-systemic therapists prefer a distinction

between problem and no problem, and this distinction is made
by the client rather than by the therapist. Clients are asked to
specify which are the problems they wish to get rid of, and, at
the end of therapy, it is they who decide whether or not their
problems have abated or disappeared; therefore it is the client
who specifies the degree of success of the therapy. It is easy to
take this attitude when considering problems that are not diffi­
cult to recognize and are likely to be agreed upon. However, it
becomes more complicated when there are problems that are
unlikely to be agreed upon by both therapist and client. A n
example is the case in which the client's presenting problem
might be that an external force is trying to control h i m by
transmitting electromagnetic waves into his brain (in psychiat­
ric terms, a delusion of control). This sort of problem is per­
ceived differently by the client than by other persons, including
the therapist. It is easy to see the limits of the idea of working
on the problem that the client wishes to resolve in this sort of
case. The problem/solution attitude is applicable to a certain
group (the majority) of clients, who are able to indicate the
problem they would like to free themselves of, but not to per­
sons who are not in contact with a shared reality (e.g. psy­
chotics) and thus for whom therapy and its goals have no sense.
The latter usually end up with a D S M psychiatric diagnosis. 4

After having made a diagnosis and having begun therapy,

many therapists, especially those with medical training, tend to
look for the underlying causes—i.e. the " r e a l " causes—of the
pathology. They get involved in a search that, due to the cur­
rent lack of knowledge, may well turn out to be all in vain. It
may even be dangerous because it tends to freeze attention on
the "illness" to the detriment of what may be seen as " n o r m a l "
or "healthy".

4
The American Psychiatric Association's Diagnostic and Statistical Manual of
Mental Disorders (DSM). In the United Kingdom, D S M is not so widely used,
and preference is given to other systems, such as the World Health Organiza­
tion's International Classification of Disorders (ICD-10).
48 THEORY

We feel that while communicating a specific diagnosis either

to other professionals or to our clients, we should be very sensi­
tive and at the same time use non-verbal channels to communi­
cate hope and faith in the future. Otherwise we risk evoking
visions of a future dominated by the idea of pathology and
illness, based on what is negative; the patient then tends to be
seen as an invalid and is relieved of responsibility for his future.
Illness is emphasized to the detriment of the client's potential
resources. The client is led to see and reify what is not working
in h i m . A l l of this can turn into a self-fulfilling prophecy
(Watzlawick, 1984). The consequence of this may be a length­
ening of the course of therapy as well as a worsening of the
situation, with the risk of reaching an impasse or an intermin­
able therapy. 5

Initially, the original Milan team related symptoms or prob­

lems of one or more members of a family to a pathological
"family game". Biological factors were not considered to be
very important, and the pathological situation was linked to
family relationships. Besides diagnosis, the Milan team dealt
extensively with pathogenesis, i.e. how specific symptoms de­
veloped from specific conflicts and relational patterns. This was
in line with first-order cybernetics, in which the observer and
what was observed were separate, and the task of the therapist
was to "discover" the pathological game (the term "game"
meant a specific modality of organization of a given family).
Later, with the appearance of second-order cybernetics and
constructivism, our ideas on diagnosis changed considerably.
Maturana (1970) maintained that systems can behave only in
accordance with their structure; therefore, one cannot speak of
pathological systems. The idea that "reality" emerges in lan­
guage through consensus and thus is co-created made the idea
of pathology appear inappropriate. Anderson and Goolishian
(1988, 1992) refused to think in terms of pathology or diagnosis

5
T h e p o s s i b i l i t y of s u c h consequences is p a r t of w h a t l e d u s to choose, i n the
m a j o r i t y of cases, a t y p e o f t h e r a p y l i m i t e d to n o t m o r e t h a n t w e n t y sessions,
s c h e d u l e d w i t h r a t h e r l o n g i n t e r v a l s o f t i m e b e t w e e n t h e m , i.e. f r o m t w o t o f o u r
weeks.
 WORKING SYSTEMICALLY 49

altogether. They adhered to a constructionist view, which fo­

cused on language and systems of meanings. This means that
we should not try to change the individual, the family, or the
society. Instead, we should try to change the systems of mean­
ings, which are mediated by language and created over time in
relation to the presenting problem. This is defined as "the prob­
lem-determined system" (Anderson, Goolishian, & Winder­
man, 1986).
In line with these ideas, one could view diagnosis as a pro­
cess of linguistic attribution. If "reality" emerges in language
through consensus, then ideas of pathology and health as well
as diagnostic categories are also the fruit of consensus in a
community of experts. Other authors who consider language to
be the basis of what we call reality arrive at similar conclu­
sions. A m o n g them are White and Epston (1989), who adhere
to Foucault's concept of dominant discourse (1970). The list
also includes Anderson and Goolishian, Hoffman, and T o m
Andersen, who have been stimulated by narrativism and social
constructionism, as well as others who are inspired by Wittgen­
stein's theory of linguistic games (1953), like de Shazer (1991).
We, too, are partially in accord with this view (Boscolo et al.,
1993).
One peculiar linguistic game, i.e. psychiatric diagnosis, leads
to reification and the consequent simplification of a complex
reality. Sometimes this reification has drastic pragmatic effects.
This is because a diagnosis, particularly a severe diagnosis, can
introduce an idea of timelessness. Once a diagnosis has been
stated, it tends to become part of the identity of the person, and
the person will never get rid of it. (As the saying goes, "Once a
schizophrenic, always a schizophrenic") The diagnosis may
also translate into an all-encompassing idea, in which the per­
son becomes the illness and the illness becomes the person.
In order to avoid these dangers, we, as well as many other
therapists who adhere to different theoretical models, use a
depathologizing type of language. For example, we avoid
words and expressions that are connected with illness and i n ­
stead use words and metaphors that imply the presence of
personal resources, capabilities, and autonomy.
50 THEORY

In the mid-19705, the original Milan team wrote an article

entitled "Hypothesizing-Circularity-Neutrality: Three Guide­
lines for the Conductor of the Session" (Selvini Palazzoli,
Boscolo, Cecchin, & Prata, 1980), which very soon became one of
their most influential works. In this paper, they stressed the
6

importance of making systemic hypotheses for ordering all of

the information the therapists have about a given family. The
plausibility of a hypothesis is then evaluated by means of the
therapists' questions and their clients' answers. The clients'
feedback also permits the therapists to formulate new hypoth­
eses. This way of working is the diametric opposite of making a
traditional diagnosis, which per se is static. Instead, hypothesiz­
ing permits therapists to bring attention back in time to a specific
context.

A diagnosis is a description which claims to be objective.. . .

A psychiatrist believes in a diagnosis.... His/her techniques
of intervention will vary according to the diagnosis made.
With a hypothesis, a therapist introduces diverse ele­
ments. Above all, since it is a conjecture, it is not a reification.
In fact, if a hypothesis becomes reified, it then becomes a
diagnosis. In that a hypothesis is a conjecture, it also elimi­
nates temporal indefiniteness. "At this moment, I am putting
information together in this way." . . . What we are doing is
putting question marks on all of the definitions of pathology
that come to us, and thus we pass from a diagnosis to a
hypothesis. [Boscolo & Cecchin, 1988, pp. 20-21]

Seen from this point of view, diagnosis is no longer a concept

to accept uncritically, but neither is it an idea to fight, as the
anti-psychiatry movement would have it (Jervis, 1975). It sim­
ply becomes one of the various possible punctuations of reality.
We consider the more drastic positions in favour of non-pathol­
ogy as possible punctuations along with other punctuations.
A s time went on, our attitude about this became one of not
making a problem over whether there was pathology or not.
We feel more at ease working within the framework of a model
that does away with dichotomies, such as psychic versus so­

For details about the process of hypothesizing, see the section "Principles
6

for conducting the session" in Chapter 3.

 W O R K I N G S Y S T E M I C A L L Y 51

matic, normal versus pathological, emotional versus cognitive,

and biological versus relational.
Overcoming dichotomies is useful in practice. We, as thera­
pists who work in different situations, are conscious of the
necessity of communicating with other specialists who believe
in diagnosis and continually use diagnostic labels. We would
be discredited by them if we simply ignored their diagnoses.
We do not make objections about clinical diagnoses made by
fellow therapists or brought by clients. We respect the various
points of view about diagnosis. N o point of view in the field of
behavioural disorders can be considered absolute truth. Be­
sides, only by having a multitude of points of view is justice
done to the complexity of the theories and languages of the
components of a given therapeutic system. It would be ideal if
all professionals involved with a case were to respect the views
of all of the others involved. This certainly would enhance the
efficacy of psychiatric agencies.
We feel that it would be a good idea if therapists who work
in public health agencies had a knowledge of the most widely
used diagnostic systems and categories, and particularly of
D S M , which has become the basic manual. Knowing various
diagnostic systems will not only allow a therapist to communi­
cate with colleagues who adhere to different models, but also
keep him from definitively "marrying" (and thus reifying) any
one diagnostic or typological system and becoming imprisoned
in this one frame of reference.
Sometimes we are asked, in congresses or workshops, if we
believe in pathology. In our answers, in addition to emphasiz­
ing the idea of going beyond dichotomies, we stress the danger
of "pathologizing". Over time, this process—as communication
among specialists, members of the family, the peer group, men­
tal health agencies, etc.—becomes a dominant discourse
(Foucault, 1966) in the specific context in which the client is
embedded. Sometimes this discourse becomes all-encompass­
ing and almost takes on a life of its own, thus fostering the
maintenance of the problem rather than favouring its resolu­
tion.
In our view, diagnosis is an evolving assessment process. It is
recursively connected to the therapeutic effect of the therapist's
52 THEORY

investigation of one or more persons considered in their rela­

tional and emotional context. We thus consider the diagnosis to
be the various hypotheses that are made as therapy progresses.
About 30 years ago, well before constructionism and narra­
tivism had exerted their influence on the field, Ronald Laing
(1969) described diagnosis as follows:
Diagnosis begins as soon as one encounters a particular situa­
tion, and never ends. The way one sees through the situation
changes the situation. As soon as we convey in any way (by a
gesture, a handshake, a cough, a smile, an inflection of our
voice) what we see or think we see, some change is occurring
even in the most rigid situation.... What one sees as one
looks into the situation changes as one hears the story. In a
year's time.. . the story will have gone through a number of
transformations.... As the story is transformed as time goes
by, so what one sees undergoes transformations. At a par­
ticular time one is inclined to define the situation in a par­
ticular w a y . . . . One's definition of the situation may
generate different stories. People remember different things,
put things together in different w a y s . . . . Our definition is an
act of intervention that changes the situation, which thus
requires redefining, [pp. 36-38] 7

We agree with this idea of recursiveness between diagnosis,

therapy, and the change in the client's story as therapy pro­
ceeds. In the past ten years, "depathologizing" has become for
us the most important aspect of the assessment and therapeutic
process. This is effected through the language we use with the
client and through our attitudes and behaviour, as well as
through the creation of a context in which a positive view pre­
vails, a view of the possibilities for development and for over­
coming difficulties. 8

T h e last sentence of this quotation reminds us of the conclusion of the

7

article o n h y p o t h e s i z i n g (Selvini Palazzoli et aL, 1980) i n w h i c h it is postulated

that perhaps hypotheses m a y act as interventions.
In serious cases, of course, the therapist does not conceal from the client the
8

severity of the p r o b l e m nor the possibility that it m a y take a l o n g time to resolve

it. W h e n other specialists have already m a d e a w o r r i s o m e diagnosis (e.g.
schizophrenia, severe personality disorders), w e consider not o n l y the severity
of it, but also the possibility a n d probability of a positive evolution w i t h time.
 WORKING SYSTEMICALLY 53

GOALS OF THERAPY
The goals of therapy reflect the therapist's experiences, as well
as the biases and the theories that guide him. However, when
establishing goals for any particular therapy, the therapist
should first of all consider the client's goals. A client may sim­
ply wish to overcome a crisis and be rid of his symptoms.
Another client may be seeking answers to existential doubts
that have plagued him for some time. Yet another may have the
sensation that the symptom is just the "tip of an iceberg" of
something that is the matter but whose nature is unknown to
him. O r perhaps this sensation may appear when, after the
presenting problem has disappeared, a state of anxiety and
insecurity remains or even becomes more pervasive. Another
possibility is that a client may wish to change a relational situa­
tion in the family or at work, seeking in therapy indications of
what to do to change other persons. Still another possibility is
that a client may be requesting therapy, on the face of it, for
himself, but actually to placate the fears of some family mem­
ber who is worried about the client's presumed problem. It is
important that the therapist pay close attention to the client
and carefully assess the latter's goals as well as changes in these
goals during the course of therapy.
It seems to be generally accepted that the client's prime goal
is to be rid of his suffering or state of distress. A s Freud ob­
served, each of us lives in the best way possible, by constantly
seeking to avoid anxiety. A s therapy progresses, the goals may
also evolve, as happens in those cases in which after the symp­
toms have disappeared, the client, nonetheless, feels the need
to continue therapy.
The changes in the client's goals are considered together
with the goals of the therapist. A brief strategic therapist or a
behavioural therapist will have the single goal of helping the
client to establish by himself the goals to be realized in therapy,
and subsequently to help the client eliminate the target prob­
lems in as short a period as possible. A brief psychodynamic
therapist will have the goal of helping the client resolve
particular conflicts (focal psychotherapy: Balint, Ornstein, &
Balint, 1972; Malan, 1976) and problems that emerge during the
54 THEORY

course of therapy which are considered to be the basis of the

client's suffering. In these cases, the goal is the resolution of the
crisis and of the presenting problems, giving priority to the
analysis of the current reality rather than the past.
The goals are different if the therapist (due to his theories
and biases) feels that resolving the presenting problems is not
the main issue but instead considers the presenting problems to
be an epiphenomenon of something else to be explored (and
changed). Such a professional will try to create with the client a
therapeutic context of conjoint exploration and searching, i n
which the focus is on the whole personality of the client. U s u ­
ally, i n these cases, therapy is of longer duration. Symptoms
lose their importance as such and are considered to be the
result of internal and relational conflicts. What becomes most
important is the relationship that the client has with himself,
the relationship he has with his own internal world, and, above
all, the relationship that the client establishes with the thera­
pist. The client's passivity, dependency, attempts at seduction,
attempts to control the relationship, as well as his story, all
come to take precedence over the presenting symptoms.
In our way of working, the goal is to create a relational
context of "deutero-learning", i.e. learning to learn (Bateson,
1972), in which the client can find his own solutions and his
way out of the problems and suffering. To accomplish this,
client and therapist explore the context in which the client lives
and i n which his problems appeared. Particular attention is
paid to certain aspects; (1) the context of the problems, i.e.
family, work, or peer group relationships, (2) the life phase in
which they appeared, (3) the situations in which they have
appeared. We try to get to know the system that has organized
around the presenting problem (Anderson et al., 1986), i.e. the
events, meanings, and actions that initially organized around
it, as well as the client's relationships with significant systems
(e.g. himself, family, peer group, experts, including the thera­
pist) which contribute to the development and persistence of
the problems.
We pay particular attention to family relationships, not just
with members of the nuclear family, but also with the extended
 W O R K I N G S Y S T E M I C A L L Y 55

family. We could say that many of our individual therapies can

also be considered as "indirect family therapies". We pay most
attention, however, to the client's internal conversation, to his
premises, biases, and emotions, as well as to the relationship
between his inner world and external world and to the effect
that all of this has on the thoughts and emotions of the thera­
pist, who is inevitably influenced by and, in turn, recursively
influences the client.
In our first encounter with a client, we dwell upon the expec­
tations, hopes, and possible urgent needs of the client. These
may be expressed just as a pressing need to be freed of a specific
problem (e.g. a state of anxiety, a phobia, an intolerable obses­
sive ritual, or panic attacks) and to return to the situation of
relative well-being that existed before the appearance of the
symptoms. In such a situation, we find it useful to avoid going
deeply into the client's story and internal world, and instead we
mostly deal with the symptoms. We use all sorts of suitable
techniques from other models of therapy (strategic, behav­
ioural, Ericksonian models) to help the client to get rid of these
symptoms (see Chapter 4 for examples of strategic-systemic
therapies). Failure to recognize the client's urgency (or, more
generally, failure to recognize the client's expectations) may
compromise the client's engagement in therapy, and whenever
therapy is initiated, it may lead to deterioration of the thera­
peutic relationship.
We heard many stories by our clients of having previously
abandoned therapy due to their therapist's tendency to give an
inordinate amount of attention to the client's past story or to
the therapeutic relationship, while ignoring the urgency of the
client's symptoms. In addition to these clients who broke off
previous therapy because of misunderstandings with their
therapists, we have seen other clients who had previously
abandoned therapy because of their dissatisfaction with the
results. Reasons for breaking off therapy include dislike of the
therapist's technique (e.g. excessive use of silence, not respond­
ing to the client's requests or just reformulating them, being too
vague), the proposal of a long-term therapy contrary to the
client's expectation of a briefer one, and lack of empathy on the
56 THEORY

part of the therapist. These drop-out cases ought to make us

reflect on possible errors and rigidity on part of the therapist.
They indicate the importance of listening and of adapting to the
client's way of acting and communicating.
Some cases of drop-out occur because the therapist has of­
fered and begun therapy without having sufficiently inquired
into the reason's for the client's request for help. Lyman Wynne
(Wynne, McDaniel, & Weber, 1986) writes that a client may seek
out a therapist without having a definite intention of entering
therapy but, rather, wishing to understand some aspect of his
life or else to have professional advice about some matter. This
kind of request might be better satisfied by a consultation rather
than by therapy (Boscolo & Bertrando, 1993, pp. 105-107).
Many follow-up studies done in the United States reveal
that, generally speaking, clients expect no more than five or six
sessions with the specialist they have sought out. In fact, on
average, psychotherapies in the United States involve only ten
sessions. Most clients expect that therapy will go on for no
longer than three months, and they state that the greatest posi­
tive impact normally happens between the sixth and the eighth
session (Budman & Gurman, 1988). This may reflect a general
tendency in the United States for therapy to become shorter
and shorter for financial and political reasons. If i n such a
context the therapist intends to do long-term therapy, clients
whose expectations differ from the therapist's might prema­
turely drop out. Although in Europe brief therapies are more
common than they were before, clients' expectations are still
different. Clients tend to expect a longer duration, with a
shorter interval between sessions. The following example from
our book, The Times of Time, deals with one of these cases.

A 25-year-old man came to our center complaining of de­

pression. At the end of the first exploratory meeting, the
therapist, Luigi Boscolo, advised the client to have individual
therapy at the rate of one session a week. The client agreed,
but after a couple of months his symptoms began to worsen.
At a certain point he exploded manifesting all his frustration,
"I feel worse and worse because one session a week isn't
enough for me!" He laid on his complaint even thicker by
 WORKING SYSTEMIC A L L Y 57

mentioning a young aunt and a friend who were having

therapy two or three times a week, although they seemed
less depressed than he was. The therapist objected that the
decision to have one session a week was based on his evalua­
tion of the case and that this was the ideal choice in the
circumstances—otherwise, he would have opted for more
sessions. He also noted that his timing was out of step with
his client's, so that they found themselves at an impasse. If
the therapist had agreed to the client's demands, he would
have gone against his own clinical judgment, as well as what
he perceived his client's needs to be.
In order to break the impasse and satisfy both their needs,
the therapist suggested that two other "sessions" be added to
the weekly session with the therapist. The client should go
into a room on his own at home, imagine he was talking to
the therapist and, for exactly 50 minutes, write down in a
notepad everything that came into his head, omitting and
censoring nothing. He should then bring his notes to the next
session. The following week he came along with a thick pile
of notes, which he gave to the therapist. The therapist imme­
diately gave them back and asked him to read aloud what he
had written down. The client read for the whole 50 minutes
with no interruption from the therapist. In the next session,
as one could expect, the client brought only a few pages, " M y
mind was empty, only these things occurred to me!"
The client's mood improved and not long after he
stopped the "phantom"—or better the "self-help"—sessions,
because "Nothing comes to my mind." He stopped talking
about needing more than one session a week because he had
started feeling better. The improvement possibly occurred
because he felt that his need to have more sessions had been
accepted. He had also stopped writing down and reading
aloud his accounts of his "sessions" at home, possibly be­
cause he realized that this prevented him from having a
dialogue with the therapist. Paradoxically, the more sessions
he had, the fewer sessions he had. [Boscolo & Bertrando,
1993, pp. 116-117]

Currently, the systemic individual therapy we like to do is

brief in terms of number of sessions but long in terms of the
58 THEORY

period of the overall therapy. Our preference for such a " b r i e f ­

l o n g " therapy derived from the following factors: our prefer­
ence for an exploratory therapy rather than a "technologic"
problem-solving intervention; our previous, long experience
with a model of family therapy based on monthly sessions; our
interest in the person as a whole and not only for the presenting
problems and their solutions; the interesting correlation be­
tween time and change that we discovered in our research on
time; and, finally, the influence of our cultural background as
Europeans, manifested in our being partly pragmatic but espe­
cially speculative.
We like to think and work in a wide frame of reference. This
can permit us, according to the situation, to work on solving
specific problems or to help the client overcome difficulties
with his inner and external worlds which impede him from
achieving a satisfactory level of autonomy and self-esteem. In
some cases, our aim will be to help the client eliminate a symp­
tom in a short amount of time, generally within five or six
sessions. However, more often the nature of the presenting
problems (e.g. chronic anorexia and bulimia, immature or
obsessive-compulsive personality, borderline personality dis­
orders, psychosis) is such that more time is needed as well as
more emphasis on the process of exploration of emotions,
meanings, and actions emerging during the session, instead of
specific techniques and strategies for changing specific behav­
iours.

TIME AND CHANGE

Time defines approaches, and by their approach to time, each

approach defines itself. . . . Though each approach to therapy
has its own notion of time, and often a non-articulated position
with regard to the role of time in the formation and resolution
of human dilemmas, no one theory adequately captures a com­
prehensive view of time in relation to therapeutic theory and
practice. (Gibney, 1994, p. 61)
 WORKING SYSTEMICALLY 59

A crucial relationship

The relationship between time and change is a subject we have

treated extensively i n our book, The Times of Time (Boscolo &
Bertrando, 1993). In that book, we maintained that the thera­
pist's idea of the time needed for successfully ending therapy
may have a very important pragmatic effect in promoting, ac­
celerating, or slowing down change. Therapists who prefer
brief therapies tend to create a therapeutic context that facili­
tates the conclusion of therapy i n a limited amount of time. O n
the other hand, therapists used to long-term therapy tend to
create the conditions for a protracted therapy; they usually
observe signs of the client entering the ending phase of therapy
a few years after the beginning, and sessions numbering i n the
hundreds.
Obviously, of the two variables—time and change—the lat­
ter depends much on the therapist's ideas on what can be con­
sidered change, ideas that vary greatly according to the
different theories. For example, some therapists aim to change
symptomatic behaviours, while others expect a change of the
client's epistemological premises, yet others wish to change the
unconscious conflicts, or the client's story, and so on.
Cade and O'Hanlon (1993) have described in a nutshell what
therapists of different schools see as well as what they do not
see. They write:

Behavior therapists "discover" behavioral problems; analysts

"discover" intrapsychic problems, their origins often in child­
hood; biologically oriented psychiatrists "discover" evidence
of neurological problems and chemical deficits; structural/
strategic therapists "discover" hierarchical ambiguities and
coalitions; contextual therapists "discover" the effects of
intergenerational injustice and exploitation; brief therapists
"discover" self-reinforcing patterns of thought and action.
Each can operate from the assumption that he or she has
discovered the fundamental cause of the problem (and, sadly,
can often disregard or even scorn other models and explana­
tions, a tendency from which our field has not, by any means,
been entirely free. [p. 50]
60 THEORY

Actually, as stated in Chapter 1, Luigi Boscolo had been

working for many years as an individual psychodynamic
therapist before he began working with families, in the 1970s,
with the MRI strategic-systemic model and then with the
systemic-cybernetic model of Batesonian inspiration. The ex­
perience acquired from treating families has had a profound
influence on us in changing our techniques and our philosophy
of therapy, regarding both the goals and the time required to
achieve them. Below are some ideas as well as experiences that
have had the most influence on us:

1. The therapist can take as his goal the solution of the present­
ing problems if these dominate the client's life and he ex­
presses the urgent need to be free of them, if there are no
signs of an underlying major personality or psychiatric dis­
order. In these cases, therapy can be brief, and interventions
focused on the solution of the presenting problems are the
main tools.
In cases in which the presenting problems seem to be
merely the tip of an iceberg and resolving them is not suffi­
cient to overcome the client's difficulties, then the indication
is for a kind of therapy that deals with the whole person, his
premises and story. Then, a longer time is required. Such
therapy is characterized by joint exploration of the client's
story and perspective for the immediate and distant future.
Currently, our individual therapies are, for the most part, of
this type.
2. One of our leading ideas is that symptoms arise in contexts
in which the client is not able to find meaning in his relation­
ship with himself and with the significant others. A n ex­
tremely confusing context of this sort can be seen in
psychoses. In other words, symptoms can be considered as
relational dilemmas, which, at times, can disappear all of a
sudden when therapy works on a particular relational
node. This kind of change, i.e. change by leaps and bounds,
has already been described in the literature, and it is one of
the principal characteristics of the systemic model that has
 WORKING SYSTEMIC ALLY 61

nurtured our therapeutic optimism (Boscolo & Bertrando,

1993; Selvini-Palazzoli et al., 1978a).
3. O u r optimism, strengthened by the results in family
therapy, and by the short time needed to achieve them, was
also related to our exposure to the idea that individual and
family systems have inside themselves the necessary infor­
mation about how to evolve. A person in difficulty is like a
clogged stream. One can remove the obstruction and then
rebuild the river bed (a process similar to psychodynamic
therapy, which requires a great deal of energy and time).
Another alternative is just to unclog the blockage, confident
that the river, in itself, has the "information" necessary to
flow down to the sea (a process similar to systemic therapy).
This rationale, however, is not valid for every case. For ex­
ample, clients with severe personality disorders or psycho­
ses may be so innerly "destructured" as to have need of
long-term, time-open therapy or support.
4. O u r study on time and change emphasizes the importance,
for the therapist, of an awareness of timing and rhythm
within the session and within the whole therapy. The coor­
dination of the therapist's individual time to the client's, the
therapeutic "dance" (Minuchin, 1974), is a difficult and deli­
cate process, such as in cases when the client (or the thera­
pist) has an obsessive-compulsive or manic personality. We
should also be aware of how the client coordinates his time
with that of the significant others in his life.
5. In most brief therapy models, the therapist's interest is in
the present and in the future, but we prefer to deal with the
client's entire arc of life. We pay particular attention to the
connections and constraints that, over time, have led the
client to the current story that he has constructed. Another
leading idea of ours, illustrated here in Chapter 3, pertains
to the therapist's connecting the three dimensions of time—
past, present, and futures—in a reflexive loop that contrasts
the lineal-causal deterministic view that the clients avail
themselves of to explain—to others and to themselves—
their story.
62 THEORY

Brief-long therapy

A t the end of the 1980s, we started to work on a model of

systemic individual therapy that could satisfy what we pre­
sumed to be the needs of most clients, as well as our need to
work consistently with the systemic model developed over the
preceding two decades. The most suitable format was, in our
opinion, a time-closed therapy limited to a maximum of twenty
sessions, with intervals between sessions of two to four weeks,
which thus could last at most about one-and-a-half years.
Such a therapy could be called both brief and long—brief in
terms of the number of sessions, i.e. the time of face-to-face
contact, and long in terms of the span of time during which
sessions are held (much longer than in most short-term therapy
models).
A t the end of the assessment session, the client is informed
by the therapist—in those cases in which therapy is indicated—
that therapy lasts from one to a maximum of twenty sessions
(including the assessment), held at intervals of between two
and four weeks. Moreover, the client is told that the majority of
clients usually end therapy earlier, before the twentieth ses­
sion. If, at the final session, the client still needs help, the thera­
pist will consider whether or not he could still be able to help
the client. If so, a new, different contract is stipulated, although
not necessarily extended to twenty new sessions. If the thera­ 9

pist feels unable to help the client, he can be referred to another

colleague. The therapist is not to blame the client for the "thera­
peutic failure", but rather to attribute it to himself, by saying
that no therapist can resolve all of the cases he takes on.
This kind of therapy is indeed "time-closed" to twenty ses­
sions, but it is "time-open", in that the client is free to choose to
end therapy whenever he feels he wants to. This links with the
already mentioned depathologizing and positive view, which
allows the client to be active, responsible, and competent in
making his own existential choices.

After the first five therapies ended successfully w i t h i n the twenty-session

9

limit, i n one case at the twentieth session the client n e e d e d further help. It was
then d e c i d e d to leave a s m a l l loophole i n the r i g i d time b o u n d a r y .
 WORKING SYSTEMICALLY 63

W h y do we limit the number of sessions? First of all, we have

had extensive experience in conducting brief family therapies. In
the 1970s, the number of sessions was limited to ten, and
in the majority of cases the most important changes occurred
somewhere between the sixth and ninth session. Moreover, we
have been influenced by our readings of the literature on
brief psychodynamic, cognitive, and other kinds of individual
therapy. Freud himself would do therapy limited in time. H i s
analyses frequently finished i n less than a year, and some of
them lasted considerably less. (His training analysis of Sandor
Ferenczi, for example, lasted only six weeks). Sometimes Freud
himself used techniques that nowadays would be attributed to
the strategic model. For example, after the client had gained
insight into his behaviour, Freud would exhort the client to
confront the phobic objects directly. Some post-World War II
psychoanalysts (e.g. Malan, Sifneos, Mann, and Davanloo: see
Malan, 1976), especially i n the United States and in the United
Kingdom, developed various types of brief psychodynamic
therapy i n order to respond to the needs of a great many of the
clients who applied to psychiatric agencies for help. These ther­
apies—called focal or thematic psychotherapies—were con­
sidered to be suitable for selected clients and problems,
while classical psychoanalysis was considered appropriate for
others.
Brief psychodynamic therapy is different from a long-term
one i n that the therapist is more active, i n the therapist's inter­
est i n specific subjects or conflicts that are to be faced, i n his
preference for analysing the relationships in the here-and-now
rather than transference analysis (the latter of tending to favour
regression), and i n the emphasis on the present rather than on
the past. Other models of brief therapy (ours included) show
similar technical aspects.
Gibney (1994) states:

. . . the bulk of the research . .. points to two interesting

points. Firstly, there is evidence to suggest that brief therapy
is as effective as long-term therapy, and secondly, that the
benefits gained from brief therapy can be demonstrated as
being endurable, [p. 63]
64 THEORY

A s far as long intervals between sessions are concerned, the

article " W h y a Long Interval between Session?" (Selvini
Palazzoli, 1980) describes why the original Milan team, first of
all in the field of family therapy, started to do therapy with
sessions scheduled once a month. This shift from one session a
week to one session a month occurred, for understandable rea­
sons, with those few families who came from Southern Italy
and, for obvious financial and logistic reasons, could not come
at shorter intervals than one month. Surprisingly, these fami­
lies did better in therapy than those who came once a week.
The team then decided to see all families once a month, and the
results were good and prompted the team to adopt the one­
month interval in all cases.
Selvini Palazzoli (1980) hypothesized that in the encounter
between therapist and family a change might be triggered in
one of the family members, which would reverberate through a
whirl of cybernetic circuits involving all family members. This
process, naturally, would require a certain amount of time for
the family system to reach an equilibrium. The interval of one
month was arbitrarily considered the time necessary for this
process to initiate and end. If the therapists met the family after
a shorter interval of time, the team speculated, they would
interfere negatively in the spontaneous change process initi­
ated in the previous session (this is a reason why some Ameri­
can colleagues had defined therapy a la Milanese as "hit-and-run
therapy").
For many years, the senior author continued conducting his
own few individual therapies on a once- or twice-a-week basis.
H e thought that, if sessions were to be scheduled farther apart,
engagement of the client and development of the therapeutic
relationship would become more difficult or impossible. It is
well known that individual clients tend to develop a strong
relationship with and dependence on the therapist. In family
therapy, instead, the family members connecting with the
therapist are already connected among themselves by strong
ties, and this makes it more tolerable and "useful" to accept
long intervals between sessions. Expressed in psychodynamic
terms, the hypothesis we made was that the dyadic relation­
 WORKING SYSTEMICALLY 65

ship in individual therapy was more intense than the polyadic

relationship in family therapy, in the sense that, in the latter,
transference was " d i l u t e d " among many members.
However, as time passed, the senior author became more
and more curious to see what would happen if he used long
intervals in individual therapy too. He found that, in most
cases, the effect was just the opposite of what he had feared.
The client's thoughts and feelings about the therapist turned
out to be more and more intense as time passed and the date of
the following session drew near.
We have found, over time, that in cases in which the prob­
lems were not resolved in the first few sessions, the client be­
came more and more involved. Brief therapists (in particular,
Mann) have noticed that in these cases, the client tends to for­
get how many sessions have already been held. It is important
for the therapist to remind the client of how many have been
held, so as to avoid arriving at the conclusion of therapy with­
out having resolved separation anxiety (see the case of Susanna
C. in Chapter 5).
M a n n has developed a model of brief therapy limited to
twelve sessions, which he calls "time-limited psychotherapy".
It is based on a psychodynamic-experiential model. He states
that in this type of therapy,

.. . mastery of separation anxiety becomes the model for the

mastery of other neurotic anxieties, albeit in a somewhat
derived manner. Failures in mastery of this basic anxiety
must influence both the future course in life of the individual
as well as the adaptive means he employs, more or less
successfully... . A l l short forms of psychotherapy, whether
their practitioners know it or not, revive the horror of
time.. .. One way of understanding the failure to give time
central significance .. . lies in the will to deny the horror of
time by the therapists themselves, [Mann, cited in Hoyt,
1990, p. 130]

Mann's reflections are in agreement with ours, formed from

our own experiences. We have observed that when the client
does not decide to conclude therapy before the fifteenth ses­
66 THEORY

sion, and he enters into the final phase, the main theme be­
comes the separation from the therapist, often characterized by
a great deal of separation anxiety. In this phase, the therapist's
skills and emotional resonance are crucial elements for resolv­
ing the dilemmas of separation.
A s far as training is concerned, we wonder whether this
model of brief-long therapy is easily transmissible. We believe
it necessary for a therapist who wants to use it profitably to
be already experienced, to have already used different time
frameworks in therapy, and, last but not least, to be flexible and
to be confident in himself.
Finally, although our techniques and theories are useful for
us to give meaning to what we do, they may not necessarily be
appropriate to a specific client's situation. Hoyt writes:

What is most important in selecting a length of treatment is

attention to the needs of the particular patient at the particu­
lar time .. . "Fixed duration" should not be a procrustean
bed, with some patients fitting nicely, whereas others are
needlessly stretched or cut short. .. . Therapists should also
know their own personal strengths and weaknesses, but
should not impose their preferences or predilections in the
name of "policy" or "style". [Hoyt, 1990, p. 125]

We are essentially in agreement with these reflections. H o w ­

ever, we feel that the form of therapy we present takes into
account the life situations and needs of the majority of our
clients, though not all of them. A s we have mentioned, the
client decides within the twenty-session format when to end
therapy. For those who need more time, we evaluate whether
we can help them further; if we cannot, we advise them to
continue with another therapist. We must emphasize here that
in a number of cases (i.e. borderline personality disorders, psy­
choses, cases with a history of serious sexual or physical abuse,
and post-traumatic disorders), we do a time-open therapy,
which can last much longer. A time-open therapy may also be
advisable in those cases that need support more than psycho­
therapy.
 W O R K I N G SYSTEMICALLY 67

THE THERAPIST

The therapist's Self

Theory is the lens through which we look at the reality around

us and within ourselves. It influences the way one considers
one's o w n Self i n therapy. For example, when the senior author
was working as a psychoanalyst (as described i n Chapter 1), his
own Self and emotions were one of the main objects of interest,
and they were continuously monitored through the analysis of
his countertransference. During a supervising session, too, the
therapist's Self was an object of analysis by the supervisor.
Later on, i n the 1970s, when he d i d strategic-systemic
therapy, his priorities changed. In tune with a first-order cyber­
netic view, his attention was actively focused on the family
system, rather than on himself and his emotions. In individual
therapy, too, his attention was concentrated on his clients'
problems and the intervention techniques for dealing with
them, rather than on the analysis of his Self.
Afterwards, when second-order cybernetics and constructiv­
ist thinking—and then self-reflexivity—came to the forefront,
his attention was brought back to the individual and the indi­
vidual's biases, premises, and emotions. His interest then
turned towards the individual's relationship with his external
world, and especially with himself and his inner world. This
can be said of both the client's and the therapist's selves.
For this topic, too, we found inspiration i n Bateson (1951,
1972, 1979). H i s conviction, repeatedly underlined, was that the
most important part of the mind was the unconscious and that
consciousness was little more than an epiphenomenon (see
Chapter 1).
Bateson, as an anthropologist, dealt extensively with the i n ­
dividual's inner world (conscious and unconscious), with habit
formation, metaphors, artistic production, and pathological
states, especially schizophrenia. What we find particularly rel­
evant i n his writings are his views on the unconscious, which
are different from those of Freud. Bateson's unconscious, rather
than being made up of drives (instinctual forces), is made up
of habits and individual premises, acquired through a process
68 THEORY

of deutero-learning. The therapist's knowledge of his Self thus

becomes the knowledge of his premises, even if full knowledge
is unattainable because nobody can ever become fully aware of
them.

In truth, our life is such that its unconscious components are

continuously present in all their multiple forms. It follows
that in our relationships we continuously exchange messages
about these unconscious materials, and it becomes important
also to exchange metamessages by which we tell each other
what order and species of unconsciousness (or conscious­
ness) attaches to our messages. [Bateson, 1972, p. 137]

While Bateson respected science, he was also attracted by

expressions of the unconscious, such as art, rites, and religion.
The unconscious and its metaphoric language were always em­
phasized in his writings.

In the cliche system of Anglo-Saxons, it is commonly as­

sumed that it would be somehow better if what is uncon­
scious were made conscious. Freud, even, is said to have
said, "Where id was, there ego shall be", as though such an
increase in conscious knowledge and control would be both
possible and, of course, an improvement. This view is the
product of an almost totally distorted epistemology and a
totally distorted view of what sort of thing a man, or any
other organism, is. [Bateson, 1972, p. 136]

A therapist who wishes not to be naive in his work should

acquire a greater awareness of his own premises, i.e. the basic
assumptions that guide him in his actions: how much of
his doing is dictated by his own social and cultural biases and
the client's premises (individual, family, social, and cultural
assumptions); and in what way the therapeutic relationship
is determined by this relationship between different epistem­
ologies (systems of premises). If the therapist is aware of all of
this, it allows him to maintain a co-evolutionary perspective,
thus avoiding reification of relationships and considering them
within their contexts, constantly evolving under the pressure of
social and personal changes.
 WORKING SYSTEMIC ALLY 69

In this evolving process, the therapist is required to coordi­

nate his own time with that of the client, allowing space for
new perspectives and avoiding getting stuck in one vision of
the client's story. For this to happen, it is important for the
therapist to develop the therapeutic alliance and empathy, i.e.
the capacity and sensibility to put himself i n the client's place.
To paraphrase what Borges (1952) said about Shakespeare, a
good therapist must strive to become "equal to all human be­
ings".
H o w is it possible to acquire awareness of one's Self while
practising therapy? Over the years, we have found one answer
in the dialectics of the teamwork. In such work, we create a
three-part system: client, therapist, and observers. The task of
the observers is to supervise the therapist and to give an exter­
nal point of view, so that the therapist may become more aware
of his biases, premises, and emotions while participating in the
therapeutic system. This kind of supervision can be direct, with
the team observing behind a one-way mirror. Alternatively, it
can be indirect, with the supervisor(s) commenting on video­
taped material or the therapist's verbal presentation of the
case. O u r trainees often present individual or family therapy
cases from their own practices to their training group, which
acts as a supervisory team. Some of these cases are very com­
plex due to the connections that have been created over time
with various professionals and agencies. The development of
the ideas produced by the group generates a "pattern that con­
nects" (Bateson, 1972). This can help the person who presents
the case to break out of the dilemmas and rigidity that have
limited his understanding and technique.
One of the functions of the team is generating hypotheses.
These include hypotheses about the client as well as about the
therapist. They are also about the therapist's thoughts and
emotions, as well as about the relationship between therapist
and client. This practice is reminiscent of the analysis of the
countertransference in psychoanalytic supervision, with the
difference, however, that the team's feedback is immediate,
taking place i n the here-and-now of the session. The interaction
between therapist and client is examined by one or more per­
70 THEORY

sons who provide another level of reflexivity, which is then

integrated with the reflexivity of the therapist, contaminated
by his biases.
The therapist is always in danger of getting "sucked into"
the relationship and thus losing the distance that is necessary
for thinking in terms of differences and acquiring flexibility. In
their book Pragmatics of Human Communication (1967), Watzla­
wick and his colleagues maintained that the therapist's "period
of grace" for facilitating change was not unlimited: in the dia­
logue between therapist and client there comes a time when no
new information is introduced, i.e. no "differences which make
a difference" are created. Thus therapy enters an impasse. The
intervention of a third party, be it consultant or supervisor, can
create differences or new viewpoints that can unblock the situ­
ation. Since, in the strategic model, therapy is very brief and
focused on the presenting problems, generally the supervisor
deals with the choice of the most suitable techniques for freeing
the client of the symptom. Instead, operating within a systemic
model, where we pay attention to the whole person, supervi­
sion deals with the conjoint exploration of the client's and the
on-going therapeutic system's story.
The exchange of ideas and emotions behind the one-way
mirror leads the team to take into consideration a multiplicity
of points of view. Above all, it taught us, when we work alone,
to leave the immediacy of the relationship with the client and
take refuge, every now and then, behind an imaginary one-way
mirror and analyse the therapeutic relationship. In a sense, one
could say that our systemic training favours a process of inter­
nalization and introjection of the team and its "voices". This
becomes a sort of counterpoint in the mind of the therapist.
Through teamwork, every member of the team learns, in
time, to position himself at different observing points within
the significant system in which the client and the therapist are
embedded. A t any one moment, he puts himself as observer of
the presumed inner world of the client, the client's external
relationships, the therapist's own inner world, the therapeutic
relationship, and the relationship between the client's and
his own ideas, in relationship to cultural models. This way of
working, which was developed through research, training, and
 WORKING SYSTEMICALLY 71

family therapy, influences us even when we are working alone

with an individual client.
It is known that, in other therapeutic models (first of all,
psychoanalysis), having undergone a personal therapy is the
sine qua non condition for becoming a therapist. Although our
model does not require this, nevertheless it provides a team
experience that may have a "therapeutic" effect on the persons
of the trainees.

In the beginning, trainees were taught to develop technical

abilities. Gradually, through the use of teamwork, training
began to take on more of a personal formation characteristic.
In systemic training, it is also possible for the trainee to work
on himself/herself, but this is subject to free choice. (There is
no coercion, and the trainee is not even recommended to
undergo personal formation.) At any rate, this option is al­
ways based on the here-and-now of the training group.
These group activities . , . favour the emergence of a "col­
lective mind" (in Bateson's sense of the term) which does
both theoretical and clinical work, connecting the two in a
circular fashion. (Boscolo, Cecchin, & Bertrando, 1995, pp.
757-758)

During the training course, both actually working with a real

client or doing role-playing, the trainee will have the opportu­
nity to position himself within a large system. Thus, at different
times, he will hold the position at different system levels: at the
level of the (simulated) client, of the therapist, of a member of
the therapeutic team, and of a member of an observing group
who have the task of observing the therapeutic team who ob­
serve the therapist who observes the client. The "reality" expe­
rienced from these different points of observation, situated at
different levels of the whole system, changes not only in rela­
tion to the position occupied, but also for the task assigned to
each member. The attention of the client is on his own story and
on the therapist's expectations. The attention of the therapist is
on the client's descriptions and emotions and on his own
thoughts and emotions towards the client. The attention of the
other members of the therapeutic team is on the therapeutic
process in evolution and, specifically, on the therapist/client
relationship. Finally, the attention of the observing group is on
72 THEORY

everything mentioned above as well as on the process of

supervision given by the therapeutic team to the therapist. This
process, repeated over and over again i n training, favours the
acquisition of a linear and circular causal view of reality—in
Bateson's terms, a change in the personal epistemology of the
trainees—which thus may affect the view they themselves have
of their inner and outer family and the outside world. Periodi­
cally, at the end of the training, we have conducted a survey
among our trainees to find out whether this learning process
had indeed had an effect on their personal lives, as well as on
their professional lives. A very significant number of trainees
reported that the teamwork had indeed had a "therapeutic"
effect on them.
When we work alone with a client, one-to-one, we may try to
look at the situation through the eyes of our "internalized
therapeutic team"—what might they observe, what would they
think about what is happening in the here-and-now? This way
of thinking frees us momentarily of the cognitive and emo­
tional ties with the client, allowing us to develop alternative
points of view to our own. This could be considered an inter­
nalized external view, or, more simply, instead of inquiring our
internalized team, we can visualize an external team behind a
one-way mirror, watching and then discussing with us. One
could say that the systemic view makes the encounter of two
persons, i.e. therapist and client, a densely populated one! It is
made up of the whole community that forms the therapist's
Self: the significant figures from his personal and professional
life as well as his real colleagues (the referring person and other
professionals involved with the presenting problem). It is also
populated by the persons in the client's external and inner
worlds and by the "voices" of the client's and the therapist's
culture.
In this process, the therapist should aim at coordinating his
times, meanings, and actions into harmony with the client (a
"therapeutic dance") as well as giving priority to listening to
the client. The observation of the client's feedback, especially
the analogic one, guides the therapist in thus constructing a
therapeutic alliance. Harlene Anderson shows how important
this is to the client.
 W O R K I N G SYSTEMICALLY 73

[A Swedish patient] told that he had come to the conclusion

that there were two kinds of therapists: therapists who were
predictable and therapists who wanted to be entertained.
Talking about predictable therapists, he told how therapists
who already know the client's story and what the problem is
usually stick to their picture .. . and miss what the story is to
the client. He said that he knows what they are going to ask
him and what kinds of answers they want. He said that's
boring, that's what kind of hurts, it makes you feel very
heavy and sad inside. He told it was sad that therapist don't
have more fantasy and don't think more critically about
what's happening around them. He talked about therapists
who find the drama of the clients' story entertaining. They
want the details and ask questions that bring out the drama.
A n d they miss what is meaningful to the person. Or, in his
words, "what it means to be alone in a situation, because
alone is what you really are." [Anderson, in Holmes, 1994, p.
159]

We often ask the client if what we are asking makes sense to

him. Asking this question at important junctures in the dia­
logue allows the client to indicate whether the line that the
therapist is pursuing is important to him. The senior author
once asked a client the following question during a seminar in
Sydney: " D o you think that my questions give you the impres­
sion that I understand you in some way?" Ron Perry (1993)
makes this comment:

A good question in systemic work comes from a developing

understanding of the system. It expresses empathy in a
number of ways. As Boscolo's question implies, it indicates
that the therapist is in tune with the concerns of this system
when what s/he is asking is of interest to them. . . . To ask
such a question, it will be necessary to be in touch with the
system and its inner life. . . . The good systemic question is
guided by careful empathy, and the family knows it is under­
stood to some extent when such relevant intriguing ques­
tions are asked, [p. 70]

A s the therapist continually interacts with clients, fellow

therapists, and theories, not only does his knowledge increase,
74 THEORY

but he is also enriched as a person. Thus, as time passes, the

therapist's Self will contain the significant "voices" of those
persons with whom he has had contact—his family members,
teachers, clients—a process in constant evolution.

Power in the therapeutic relationship

Lately, in the systemic-relational field, there has been a debate

about the problem of power in family and therapeutic relation­
ships; this debate is discussed in greater detail in Chapter 3. We
limit ourselves here to a brief mention of various models'
orientations on power in therapy, orientations that vary con­
siderably in the different models of therapy. One common view
of the power of the therapist (see Jervis, 1975) states that the
therapist is by necessity in a position of power with regard to
the client, and this power is conferred by the context. Even
when he puts himself in the position of the listener and allows
the client the maximum freedom of expression, he is always the
one who sanctions it and is therefore the one in power. O n the
other hand, it is evident that the therapist receives permission
from the client to exercise this power: this position is different
from that of a hospital psychiatrist, who must often exercise a
coercive power over a non-consenting patient. Different mod­
els have the therapist explicitly exercise different degrees of
power.
In behavioural therapy, including the psychoeducational
variants, the therapist is most directive (Falloon, 1991). He has
the authority to suggest or directly impose certain behaviours
on the client, who generally accepts. However, not even in
these models does the therapist claim to be omniscient, and the
client has freedom of action. But the context in which this free­
dom can be exercised is explicitly controlled by the therapist.
The strategic model, especially as conceived by Jay Haley, is
traditionally among the most attentive to power relationships.
According to Haley (1963), the therapist has the responsibility
to exercise benevolent power, which may lead the client to
accept the one-dawn position necessary for the dissolution of
problems. Compared to behavioural therapy, this position is
 WORKING SYSTEMICALLY 75

different i n that power is exercised not overtly but rather

through strategies ("pseudocomplementary position"). Thus,
by using indirect means that do not challenge the client's one-up
position, the therapist induces the client to accept another per­
son's power.
The structural model (Minuchin, 1974), which is very atten­
tive to the problem of hierarchies and power, attributes to the
therapist less power, but this power is exercised in a much
clearer manner than i n the strategic model. The therapist has an
idea of the desirable structure for the clients to attain, and
during the therapy session he overtly exercises the amount of
power necessary to reach this aim.
In the psychoanalytic treatment, the analyst apparently has
little power; he does not try to direct the client's behaviour but,
rather, limits himself to interpreting the client's behaviours,
thoughts, fantasies, and dreams. However, his apparent pas­
sive position assures a power that is difficult to challenge since
it is never asserted openly (see Haley, 1963).
In our work, the therapist is moderately directive. A t times,
he may simply listen to the client express his emotions and
thoughts. A t other times, he may decide to follow a hypothesis
and direct the conversation through his choice of questions,
topics, and turns of speech. We try to cooperate with the client,
creating a context of deutero-learning that may allow h i m to
abandon suffering and rigidity and find new choices and solu­
tions. Since knowledge and power are intimately linked
(Foucault, 1966), we use the practical and theoretical knowl­
edge we developed (see Chapter 1) to ask questions rather than
draw conclusions. Questions put the client in the position of
giving his meanings to them.
The therapeutic models that leave the therapist in the posi­
tion of least power are Rogers' client-centred psychotherapy,
and especially the "not-knowing position" of the therapist
characteristic of conversational therapy (Anderson & Goolish­
ian, 1992; Holmes, 1994). Since, again, knowledge and power
are intimately linked (Foucault), Anderson and Goolishian's
"not-knowing position" holds that the therapist has just to keep
open the conversation and avoid exercising his own knowl­
76 THEORY

edge, to escape the position of expert, i.e. a position of power,

thus leaving the client free to construct his own story.
We are not i n agreement with this extremist position. First of
all, as we pointed out in Chapter 1, there is the unconscious
knowledge of the therapist—the unspoken—that cannot but
contribute to the story that the client constructs, together with a
conscious knowledge coming from theories and experiences,
which contributes to the formulation of hypotheses that are an
important tool i n our work. According to a certain view on
constructivist thinking, the therapist should abandon the role
of expert, and therefore power, since constructivism does not
acknowledge the existence of absolute truths. This view can be
confronted by an antithetical view: one could say that the con­
structivist view does not acknowledge the existence of absolute
truths, but it does accept the existence of truths (relative truths,
constructed truths) that derive from consensus. The position of
expertise comes from the shared consensus of a community.
The very fact that some persons accept that some others may
take on the role of "therapist" (and be paid to do so) has a
pragmatic effect indeed. For a therapist, to deny the role of
being an expert means denying the very possibility of doing
therapy rather than establishing a different way of doing ther­
apy (Efran & Clarfield, 1992).

Empathy, positive view,

and the therapeutic relationship

There is general agreement that, no matter what model a thera­

pist adheres to, empathy is an important, if not essential, aspect
of therapy. However, a few approaches (e.g. strategic and be­
havioural therapy) have either neglected it or given little i m ­
portance to it. For example, Jay Haley considers the therapist's
control of the relationship, rather than empathy, to be the pri­
mary feature i n therapy.
A s often occurs with ideas that are taken for granted, empa­
thy is not easy to define. In a book devoted to this subject,
Goldstein and Michaels (1985) list sixteen different definitions
before mentioning Macarov's simple and linear one:
 WORKING SYSTEMICALLY 77

1. Taking the role of the other, viewing the world as he or she

sees it, and experiencing all his or her feelings.
2. Being adept at reading non-verbal communication and
interpreting the feeling underlying it.
3. Giving a feeling of caring, or sincerely trying to under­
stand in a non-judgemental or helping way. [Macarov, 1978,
p. 88]

These three points are in agreement with our way of thinking,

except that i n point 2 we would substitute "questioning" for the
word "interpreting". Only i n the last 15 years has our approach
been i n agreement with Macarov's position. Previously, we
were inspired by a strategic model based on control and on the
instructive rather than empathic aspect of the therapeutic rela­
tionship. We must give credit to psychoanalysis for having
analysed and gained deep insight into the concept of empa­
thy. Several psychoanalysts—especially, among others, Kohut
(1971, 1977) and Schafer (1983)—have paid particular attention
to empathy, which was considered to be a fundamental aspect
in the healing process of the client.
Besides its emotional component, empathy has also a consid­
erable cognitive one. Roy Schafer (1983) underlined that ther­
apy creates an emotional situation i n which both client and
therapist present what he calls a "second Self", i.e. a Self that
exists only i n that relationship. This could be an explanation for
Fliess's (1942) observation that psychoanalysts are often very
much more sensitive and understanding with their clients i n
their clinical work than they are i n everyday life. Fliess, i n
explaining this, used the term "the analyst's work E g o " .
Systemic theory puts less emphasis on the difference be­
tween the therapist when doing therapy and when taking part
in everyday life. What is accentuated by the systemic model is
the context. For us, the context of therapy is a just particular life
context, one i n which the therapist tends to assume a stance of
understanding and curiosity. The therapist, i n empathically
understanding the client, creates an interior model of the client,
and it is to this model that he responds. In other words, even
empathic understanding is influenced by the theories and
78 THEORY

premises that the therapist holds, which are decisive i n guiding

and delimiting his field of observation. Nevertheless, even
though the therapist constructs a "model client", he is still able
to understand (and see positively) the client's drama and
wounds without taking on a judgmental attitude.
A n interesting conception of empathy is presented by
Harlene Anderson (in Holmes, 1994):

When I work with people I feel connected to them. I like

them, I enjoy t h e m . . . . I often talk about this as a " C " rela­
tionship—one that involves connecting, collaborating and
constructing.... I don't think of empathy as an inner experi­
ence of the therapist. I think of empathy as being in the
relationship. I think, if you are being respectful to another
person, listening to them, trying to hear what they want you
to hear, trying to make logic of what the other speaks about—
then you are in an empathic interaction, [p. 158]
10

In our analysis of the concept of empathy in the therapeutic

relationship, we would mention Bateson's contributions.
Bateson, using the theoretical tools of general systems theory,
cybernetics, and communication theory, analysed the individu­
al's relationship with himself, with other humans, and with the
surrounding world. This is a focal point of his model, although
it has been overlooked by many therapists—and especially
family therapists—who have been inspired by his thoughts.
Many of them simply substituted the psyche and the individual
with, respectively, the system and the family. Instead, in
Bateson's original idea, this dichotomy was overcome by the
idea that communication connects elements of the individual's
inner world with elements of the external world. The inner
world is seen i n terms of intrapersonal communication, and the
external world in terms of interpersonal communication. Par­
ticularly interesting are the descriptions he gives of intra­
personal communication (i.e. self-observation), of communica­
tion between two persons, and of the communication about

Some therapists, especially those who have treated schizophrenics (see

10

Searles, 1965), may object to this idyllic conception of the therapeutic relation­
ship in that one does not always feel so comfortable with any client, nor does
one always have such positive sentiments.
 WORKING SYSTEMICALLY 79

communication that can take place between persons (i.e. meta­

communication). Self-observation, based on intrapersonal
communication, makes self-therapy practically impossible, due
to the lack of an external point of view, such as the one that
could be offered by a therapist, in the same way as a trans­
cultural experience permits a deeper understanding of one's
own culture.
Communication between two persons, as occurs also in indi­
vidual therapy, depends on their common premises and on
what emerges in the dialogue:

. . . when we deal with two-persons systems, a new sort of

integration occurs—If I know that the other person perceives
me and he knows that I perceive him, this mutual awareness
becomes a part detenrrinant of all our actions and interac­
tions. The moment such awareness is established, he and I
constitute a determinative group, and the characteristics of
ongoing process in this larger entity control both individuals
in some degree. Here again, the shared cultural premises
will become effective. [Bateson, 1951, p. 208]

Thus, dialogue permits metacommunication (an essential

factor in any therapeutic process), which, according to Bateson,
depends on how and to what degree each participant i n the
dialogue succeeds in being aware of the perception of the other.

. . . it follows that a variety of characteristics attributed to the

other individual have become relevant in shaping and moti­
vating the behavior of the signaler. The signals are being
tailored to fit the signaler's ideas about the receiver. From
this point onward the evolution of a number of human habits
and characteristics—introjections, identifications, projec­
tions, and empathy—understandably follows, [ibid. p. 210] 11

This systemic view of the dyadic relationship is still at the

core of our way of conceptualizing and doing therapy. In such
a view, one can see basic aspects of the human (and therapeu­
tic) relationship, which were subsequently to be described and

11
In this statement (written by Bateson in 1951), Maturana's idea, that it is the
receiver who gives sense to the message, is already present in embryonic form
(Maturana & Varela, 1980).
80 THEORY

explained differently i n the works of the constructivist and

constructionist authors.
While on the subject of the therapeutic relationship and the
therapist's positive emotions, we would like to mention the
concept of "happiness", introduced by the Italian psychoana­
lyst Giampaolo Lai. H e writes:

Most of all, I am interested] in things going well, in having a

pleasant conversation. Evidently, according to my subjective
criteria, since I cannot know what is, for my conversation
partner of the moment, a good conversation, a happy
conversation.... A n d from my point of view, the situation of
being together which interests me, that is alright for me, is
that in which I am most happy, or, as one has to be content
with what is possible, the least unhappy that is possible. A n d
as for my conversation partner, while he is with me while I
am trying to feel comfortable with him, if he also tries to feel
comfortable with me, or the least uncomfortable possible,
maybe that would be fine with him. That would please me
very much. [Lai, 1985, pp. 10-11]

This idea about the therapist's "happiness" is an important

one, since a " h a p p y " therapist is more likely to be able to help a
client than would a sad or frustrated therapist. While doing
therapy, we frequently ask ourselves, "What could I do to feel
more comfortable and to stimulate my curiosity and my crea­
tivity?"
If the concept of empathy was analysed in depth and was
central in the psychoanalytic treatment, the concept of "posi­
tive view" and the closely connected idea of positive connota­
tion were central i n systemic family therapy. Already i n the
1970s, i n the Mental Research Institute's strategic model, the
positive view referred not just to the nature of the presenting
problems, which were considered a manifestation of living
together and not of mental illness, but also to the use of thera­
peutic interventions such as positive reframing of symptomatic
behaviours. This led to focusing attention more on the client's
resources than on his deficiencies.
In the early 1970s, the Milan team added the concept of
positive connotation of behaviours of all family members, both
 WORKING SYSTEMIC ALLY 81

symptomatic and non-symptomatic. In other words, the thera­

pist would connect and connote positively the behaviours of all
family members, thus giving a relational meaning to the symp­
tomatic behaviour, accepting it, and, at the same time, accept­
ing the reactions of the other family members to it. Thus, a
relational double-bind was created—on the one hand, the fam­
ily members' behaviour was connoted positively and not told
to change (symptom prescription), on the other hand, the
therapeutic context by itself is a context of changes—thus a
therapeutic paradox was created. The paradox was resolved by
a counterparadox, through the introduction of time, of a tem­
poral sequence, such as, "For the time being, continue this way
. . ." (see Boscolo & Bertrando, 1993).
The positive connotation of all behaviours had the effect of
giving a sense to family relationships and particularly to the
presenting symptoms, which were seen as the expression of an
existential problem rather than mental illness. The relational
meaning given to the symptoms, and the acceptance, for the
time being, of these symptoms and of the reactions to them,
made it more likely for all family members to feel accepted,
favouring their engagement in the therapy. Since in most cases
problems are an expression of separation-individuation from
the significant others (and this is meant not just for the client),
the positive acceptance of what the client(s) brings to us, with
the implication "for the moment . . .", is one of the common
features of our style of therapy up to this day. In our experi­
ence, this therapeutic stance accepts both the attachment needs
and the separation process.
In addition to empathy, positive view, and the temporary
acceptance, "for the time being", of behaviours and solutions
clients brought to us, another element that influenced our prac­
tice of therapy came from an early interest in language. One of
the first decisions, in the struggle to enter into a systemic way
of thinking, was to change the language used in team discus­
sions. Referring to clients, the verb "to show" was used, rather
than the verb "to be". Thus, for example, a client would not be
described by the statement "he is aggressive" but rather by "he
is showing aggression". This linguistic device eliminated a verb
denoting an inherent quality and implied a communicative
82 THEORY

action recorded by an observer ("is showing" something to

whom? why?, etc.). The elimination of the verb "to be" helped
us to avoid looking at problematic or symptomatic behaviours
from a moralistic and lineal-causal point of view (Selvini
Palazzoli et al., 1978a).
Attention to language characterized our later work even
more. In the middle of the 1980s, we became more and more
interested in depathologizing language, i.e. avoiding the use, as
much as possible, of clinical words, in favour of a language that
could free the client from the role of " o d d b a l l " or "deviant",
thus facilitating the emergence of descriptions and stories that
may open up " n o r m a l " courses of development. This is similar
to Anderson and Goolishian's idea, describing the therapeutic
action as "dis-solving" the pathologizing system, i.e. the prob­
lem-determined system, which includes the patient, the family,
and the experts who make diagnoses. Conversely, technical
language, based on clinical words and concepts, implies the
possibility of the client having an illness of the nervous system,
which could have the effect of relieving the client of his per­
sonal responsibilities and favouring the so-called secondary
advantages of the illness, besides representing the danger of a
self-fulfilling prophecy.
A positive view and a depathologizing dialogue are merely
two particular cases of a more general attitude of acceptance of
the client, of the client's world and problems, as well as of his
strengths and future possibilities. We feel that among the main
sources of anxiety, insecurity, and their symptomatic expres­
sions are those rooted in past and present relationships, i n
which expressions of disqualification, disconfirmation, and ne­
gation by significant others have led to a partial or total
delegitimization of the individual. If the therapist is capable of
empathy, i.e. he behaves like a person who unconditionally
accepts the client, without demanding that the latter behave
12

Obviously, "unconditional acceptance of the client" does not mean the

12

acceptance of all of his behaviors, but accepting him as a person. At times, the
therapist may in fact have to step in if the client's behavior is dangerous for him
or for others. In extreme situations, such as in abusive and violent behaviour,
the therapist may be compelled to interrupt treatment and request social con­
trol.
 WORKING SYSTEMIC ALLY 83

like a "good client", then this message i n itself may have sig­
nificant therapeutic effects.

ETHICAL ISSUES

Lately, there has been an increasing interest i n ethical issues i n

therapy. Credit should be given especially to the feminist
movement, which put at the centre of its interest the problems
of ethics and values (Doherty & Boss, 1991; Hare-Mustin, 1986).
In the late 1980s, several health workers at the forefront of
dealing with persons suffering from the effects of physical and
sexual abuse, as well as some in the feminist front, criticized
what they called the "justificationism" of systemic family
therapists, whose explanations, based on a circular-causal epis­
temology, tended to put the contributions of the aggressor and
that of the victim on the same level. During the course of family
therapy, the family members, including the aggressor, could
come to believe that they were justified in their behaviour be­
cause of the behaviour of the others and feel legitimized by the
therapist. These critics contended that, after the disclosure of
the abuse, the therapist, instead of trying to change the "family
games", should have interrupted therapy and initiated pro­
ceedings for social control. Heavy criticism was addressed to
Batesonian thought, which had rendered the concept of power
marginal and had simplistically considered power to be just an
epistemological error. Bateson was criticized as having influ­
enced systemic therapists to being insensitive to the sometimes
devastating effects of power on the victims. According to such
critics, the relationship of power (and of violence) is an asym­
metric relationship of inequality between aggressor and victim,
which may be i n need of an intervention of social control so as
to cause the abuse to stop. The critics said that this kind of
relationship is better described by linear causality.
Paul Dell (1989), i n an important article, recognized the v a ­
lidity of these criticisms of systemic thinking's concept of
power and of the prevalent tendency of systemic therapists to
favour—among the three levels of knowledge—description and
explanation over experience (e.g. the traumatic experience of an
84 THEORY

abused family member). Nichols (1987), referring to the famous

example by Watzlawick et al. (1967) of the nagging wife and
the withdrawing husband, writes:

Family therapists have learned to see nagging and with­

drawal as circular, but they must also learn to see them as
human. Thoughtful clinicians need to see through the nag­
ging to the pain behind it, and to understand the anxiety that
motivates withdrawal. In other words, to the attitude of the
systems thinker we must add the attitude of a compassionate
helper, [p. 20]

A m o n g the many ethical questions under discussion, one of

the most important concerns the therapist's openness or closure
(clarity or reticence) towards the client; another is the possibil­
ity of manipulation of the client by the therapist. In this regard,
therapists inspired by the conversational model urge almost
complete openness, a position reminiscent of humanist ap­
proach therapists (Carl Rogers, Rollo May). They also advocate
a genuine respect towards the client, avoiding any possible
manipulation. Harlene Anderson sums up the ethical basis of
the model she adheres to as follows:

For me, an ethical position has to do with a way one positions

oneself with the other, to permit the other without invalidat­
ing them or their story. Genuinely respecting people, allow­
ing people to experience dignity in their relationship with
you and in their lives, to have responsibility for their own
lives—that is an ethical base. To be open and public, rather
than close and private, in my thoughts as a therapist, to allow
my views, my ethics to be questioned by the other, to reflect
continuously on my own values and morals—that is an ethi­
cal base. [Anderson, cited in Holmes, 1994, p. 156]

In our model, the issue of openness is viewed, to a certain

extent, differently. We prefer to be somewhat reticent or closed
rather than open and public. Sometimes when a client is hesi­
tant to open up and reveal some particular event or thought,
the therapist can invite the client to think about it and decide
later what he wants to say. Thus, the client's privacy and deci­
sions will be respected, and the possibility of there being non­
 WORKING SYSTEMIC ALLY 85

shared areas between therapist and client will be admitted (this

is, i n any case, the normal situation i n the majority of human
affairs). 13

In contrast, we are completely in agreement with Harlene

Anderson's view that, i n therapy, it is important to have a
genuine respect for individuals, their dignity, and their as­
sumption of responsibility for their own lives. O u r manner of
being faithful to these principles consists of creating a thera­
peutic context i n which there is a high degree of attention,
empathy, and respect on the part of the therapist. A dialogue
should take place that focuses less on answers than on ques­
tions to which the client can attach his own meanings. In addi­
tion, in agreement with V o n Foerster's ideas on ethics, we try to
act so as to maximize the possible choices. Consistent with that
principle, we try to maintain the necessary distance from our
theories and any other idea that may suffocate our freedom
and creativity, as well as that of the client.
The therapist's deliberate manipulation of the client is an­
other important ethical problem. We think it ethical to avoid
manipulating persons towards one specific outcome, i.e. pur­
posely conditioning the results of the therapy by telling people
how to live their own lives. In holding such a position, we feel
close to many colleagues working in a constructivist, construc­
tionist, or narrative framework.
Watzlawick (Nardone & Watzlawick, 1994), instead, holds
that it is ethical to free the client, in the best way possible, of the
problems that afflict h i m and of which he explicitly asks to be
freed, even though this inevitably implies a certain degree of
manipulation. According to Watzlawick, i n general it is impos­
sible not to manipulate i n a relationship, and the therapeutic
relationship is no exception.
This is also the position of all strategic therapists, who often
challenge our implicit assumptions on ethics. For example,
Haley (1976) says that the ethical issue i n therapy is about the

13
We have frequently noticed that relationships (especially familial ones) can
have disastrous effects on individuals when they are conditioned by rigid
premises focused on the choice of being either totally open (thus good) or
reserved (thus bad).
86 THEORY

polarity between concealment on the one hand, and intimacy

and sharing on the other. "Individuation and total sharing of
information are incompatible. The act of concealment between
therapist and client defines a boundary between them and so
individuates them" (p. 198). Haley continues by explaining
how hard it is, in therapy, to be completely aware of everything
one is doing:

Through videotapes it has become increasingly clear how

complex the interchange is between a therapist and his cli­
ent. Every minute hundreds of thousands of bits of informa­
tion are exchanged in words and with body movement and
vocal intonation. Both client and therapist may be conscious
only of small amounts of so complex an interchange, [p. 200]

Since the therapist is only partially aware of the origins and

goals of his every act (we discussed "the unspoken" of therapy
in Chapter 1), it is impossible for him to reveal himself totally.
Thus, it is inevitable that there will be some degree of uncon­
scious manipulation as well as some degree of solidarity, se­
duction, control, etc.
With his characteristic clarity, Haley also deals with the ethi­
cal issue of behavioural prescriptions. Here is what he has to
say about the prescription of the symptom:

Therapeutic manoeuvres involved in encouraging sympto­

matic behavior are not simple lies, but rather benevolent lies.
The question is not so much a question of whether the thera­
pist is telling a lie, but whether he is behaving unethically.
Even if he is deceiving the patient for his own good, is it
ethical to deceive a patient? . . . One must also be concerned
about the long-term effect of a person experiencing an expert
as an untrustworthy person, which may be more harmful
than the continuation of the symptom. A more basic issue is
raised by this approach. Is encouraging the symptom deceiv­
ing the client? [p. 200]

To conclude our discussion about the therapist's openness

and closure, Viaro and Leonardi (1990), in their interpretation
of Milan systemic therapy according to conversational theory,
have identified two of the implicit principles followed by thera­
pists during the circular interview: the principle of normality and
 WORKING SYSTEMIC ALLY 87

the principle of reticence. According to the principle of normality,

everything that is said i n the session is said by a person who has
a normal ability to articulate what he wants to say, to under­
stand what the others say, to make choices, etc. During the
course of the session, the therapist does not abandon this as­
sumption, not even when a person talks in an incomprehen­
sible manner. In the latter case, the therapist states that the
individual is speaking i n an incomprehensible manner to com­
municate something or other. Mental illness is not used as an
explanation. The principle of reticence, on the other hand, al­
lows for the various participants in the conversation not to
reveal all of what they are thinking. One neither expects nor
requests reciprocal total frankness. The therapist, too, remains
reticent about his hypotheses and asks questions that are only
indirectly connected to these hypotheses (more is said about
this i n Chapter 3).

THE PHILOSOPHY OF THERAPY

Roy Schafer (1976) re-proposed a distinction that Northrop

Frye (1957) had presented i n literary criticism. H e distin­
guished four possible views of the world and life that can also
be applied to persons who go into therapy and to the effect that
therapy has (or could have) on them: these are the comic, roman­
tic, tragic, and ironic views. We find this distinction interesting
and useful for putting our therapeutic model i n a wider frame­
work and distinguishing it from other models.
The comic view makes a clear distinction between "the
14

good guys" and "the bad guys" in a world in which the good
guys can reach their goals once the (external) obstacles, which
are i n the way of one's goals, have been removed. Since, in this
view, everybody identifies with the good hero/heroine, it is an
optimistic view i n which every person has the possibility of
attaining complete happiness. Nietzsche quoted Socrates, say­
ing that "Virtue is knowledge, sins arise from ignorance, the
virtuous man is the happy m a n " (Nietzsche, 1871, p. 69).

The term "comic" here has nothing to do with humour. It refers to the
14

comedy-tragedy distinction: a play for the theater that is not a tragedy, i.e. has a
"happy" ending, is considered a comedy.
88 THEORY

In the romantic view, life is a continuous search for union

with perfection. One reaches it only after many ups and downs,
but the hero/heroine can always overcome the obstacles. In
Schafer's analysis, both the comic view and the romantic view
share two characteristics. They both idealize the end goals
and the heroic figures, which are always described in absolute
terms. (Everything is either all positive or all negative.) They
both have a cyclic conception of time. N o matter how enormous
the obstacles and how dangerous the adventures, the heroes/
heroines can always emerge uncontaminated and restore
everything to its original purity. They can cancel out everything
that has happened and begin again with a clean slate.
In contrast, in the tragic view, the unavoidable contradic­
tions and double-dealings of life are evident. In victory, the
seeds of defeat are already present; in happiness, unhappiness
already exists in embryonic form. Often the categorical com­
mands that we must obey are intrinsically contradictory, and
they lead to serious inner wounds. In the tragic view, time is
linear and irreversible, and once one makes a choice, it is irrevo­
cable. The tragic view implies a painful acceptance of incom­
patible contradictions in life. Nietzsche said that " A l l that exists
is just and unjust, and equally justified in both (Nietzsche, 1871,
p. 51).
The ironic view implies the same acceptance of contradic­
tions, ambiguities, and paradoxes of life. However, this accept­
ance is not permeated with the same pathos that is present in
the tragic view, which assumes a full participation and emo­
tional intensity, while the ironic view assumes detachment. The
ironic view implies a distancing from a critical support of a
point of view and the recognition that every point of view is
relative and susceptible to being reversed to its antithesis. Even
though it can be humorous, the ironic view is "something very
serious" (Schafer, 1976, p. 51). It means being ever ready to
change one's certainties into maybes. 15

For Schafer, the ironic view is the other face of the tragic point of view. Or,
15

as Nietzsche puts it in his Birth ofTragedy, "You should learn to laugh, my young
friends, if you are determined to remain pessimists!"
 WORKING SYSTEMICALLY 89

Schafer, i n his role as a psychoanalyst, connects the four

views to the analytic process:

The comic vision, with its emphasis on optimism, progress,

and amelioration of difficulties, and the romantic vision,
with its emphasis on the adventurous quest, are related espe­
cially to the curative, liberating, and alloplastic emphasis in
the analytic process. The tragic vision, stressing deep in­
volvement, inescapable and costly conflict, terror, demonic
forces, waste, and uncertainty, and the ironic vision, stress­
ing detached alertness to ambiguity and paradox and the
arbitrariness of absolutes, are related especially to the inves­
tigative, contemplative, and evaluative aspects of the ana­
lytic process. [1976, pp. 55-56]

Not only the analytic process, but any therapeutic process

can be read in terms of all four of these views. We feel that there
are also certain therapies that are characterized, to a large ex­
tent, by a particular one of these four views.
The " c o m i c " view characterizes many versions of brief ther­
apy, focused on the symptom and based on problem-solving.
A l l of those therapies assume that the elimination of the u n ­
desired symptom, behaviour, or designation of meaning can
(fully) restore at least a potential state of well-being. These
include the M R I model and other strategic and Ericksonian
therapies, and, i n general, all of the therapies characterized by a
basic optimism, which is traditionally deeply rooted i n the
American society's view.
A romantic view is typical of Jungian therapy and Bowen
(1978) family systems therapy. In both, therapy is seen as a
continual search and striving for an ideal (individuation and
self-realization) which is seen as distant and to be at least aimed
for, even if not actually reachable.
Schafer attributes a deep awareness of the tragic view to
Freudian psychoanalysis (born i n a society and in a generation
in which the nineteenth-century certainties were being shaken).
In this model, both the analyst and the person i n analysis are
ever more aware of the impossibility of avoiding the contradic­
tions and neurosis inherent i n life.
90 THEORY

The ironic view is characteristic not only of psychoanalysis,

as Schafer states, but also of Whitaker's experiential therapy
(which some call the "therapy of the absurd") (cited in Giat
Roberto, 1991). In this model, insanity is accepted as a modus
vivendi that has its own dignity. We would also put our model
among those that pertain to the ironic view, for the following
reasons. It accepts many views of the world, even contradictory
ones, but this is not felt to be a drawback or a terrible limitation.
It also encourages the client and the therapist to accept contra­
dictions as different world views or as different life styles,
which are all possible even if incompatible. This does not bar us
from also conducting comic-view therapies (when we simply
deal with the symptoms) or carrying out tragic-view therapies
(when we work with intractable problems of loyalty and pain,
as in cases of incest, violence, or psychosis).
CHAPTER 3

Therapeutic process

I
n the present chapter we address all those aspects pertain­
ing to the process of individual systemic therapy. The dif­
ferent principles employed since the 1970s in conducting
the session (hypothesis, circularity, and circular questions) are
fully dealt with first. We then turn our attention to the stages of
therapy (from the initial evaluation to the final session) and
conclude by discussing in depth the recent, stimulating contri­
butions concerning some linguistic aspects (semantic, rhetori­
cal, and hermeneutic) of therapeutic dialogue.

DIALOGUE

As indicated in Chapter 1, the development in the past few

years of narrative and social constructivism has witnessed the
increasingly widespread use of the term "conversation" to de­
fine the complex of linguistic exchanges between therapist and
client. Most of the authors who identify themselves with these
ideas attribute the effects of therapy to the conversation itself,

91
92 THEORY

with no special reference to the therapist's hypotheses, typol­

ogy, or theories. We have already expressed our interest and
appreciation for these ideas—but also our criticisms. Hence, we
keep to the well-known and experimented term of therapeutic
"dialogue" and illustrate here some of its aspects.
1

Principles employed in conducting the session

A s previously mentioned, since 1975 hypothesizing, circular­

ity, neutrality, as well as circular questions, have assumed a
central role in the conducting of the session (Selvini Palazzoli et
aL, 1980). However, as discussed later, the principle of neutral­
ity has undergone further developments directly attributable
to the advent of constructivism and second-order cybernetics.
Individual therapy sessions are equally dependent on these
principles, with the necessary adjustments that naturally
emerge from the differences in the context with respect to fam­
ily therapy.
In conducting the session, it is the hypothesis that connects
what is heard and observed: "The hypothesis is, per se, neither
true nor false, it is simply either more or less useful" (Selvini
Palazzoli et al., 1980, p. 215). It is important that the hypothesis
should not be reified, but just be conjecture. Lately, some
groups that originally identified themselves with the Milan
model and now adopt the narrative-constructivist approach
(e.g. Andersen, 1992; Anderson & Goolishian, 1992; Hoffman,
1992) have argued against maintaining this principle: in their
view, foregoing the hypothesis would avoid contaminating the
story of the client with ideas, typologies, and information intro­
duced by the therapist. 2

We, on the other hand, believe that the hypothesis performs

a useful function in connecting the information, meaning, and

For the sake of completeness, it should also be noted that some authors
1

have recently begun adopting the term therapeutic "discourse" (Goldner,

1993) .
Anderson and Goolishian (1992, p. 130) have substituted for hypothesis the
2

term "pre-knowing", while Andersen (1995) has opted for the term "pre-cogni­
tion", originally coined by the philosopher Martin Heidegger.
 THERAPEUTIC PROCESS 93

actions that emerge in the dialogue within the co-ordinates of

space, time, and other reference points described in the previ­
ous chapteer. When confronted with the question: " T o whom
does the hypothesis belong? To the therapist or the client or
both?", we have already replied as follows:

Hypotheses emerge from repeated interactions between

therapist and client. In this sense, being a "real Batesonian"
means attributing hypotheses neither to the therapist nor to
the clients, but to both. . . . Where or what is the hypothesis?
In the therapist's mind or somewhere else? In the seventies, it
was regarded as in the therapist's mind, but now we would
locate it in the total interactive context. [Boscolo & Bertrando,
1993, pp. 85-86]

To maintain a critical stance when assessing hypotheses is

vital, but the term of reference is their plausibility and cogency,
not their veracity. The resulting, and equally important, proc­
ess of ongoing re-evaluation and modification is equally essen­
tial to enrich the discussion with greater detail and further
alternative viewpoints; this approach also protects the thera­
pist from falling into the trap of reification, i.e. of crystallizing
the principle into a "true hypothesis" and thus introduce a
rigidity that would close all dialogue.
To evaluate the plausibility of a hypothesis, the therapist
makes use of the principle of circularity—in other words, the
client's verbal and non-verbal feedback. The original definition
of this concept is worth reiterating: " B y circularity, we mean
the therapist's ability to conduct investigations on the feedback
. . . to the information solicited in terms of the relations and,
therefore, in terms of differences and change" (Selvini
Palazzoli et al., 1980, p. 219).
From the standpoint of conversational analysis (Viaro &
Leonardi, 1990), circularity is expressed through the therapist's
self-correction on the basis of the answers (verbal and analogic)
to the questions posed, and through the self-correction induced
in the client emerging from the therapist's further questions
and reframings.
94 THEORY

It is the third principle, that of neutrality, which has been the

object of greatest criticism. By adopting a neutral stance, the
therapist should be protected from assuming a biased attitude
with respect to the clients or the people with whom they are
connected, from taking specific moral or social attitudes rather
than others, and from influencing the client towards a particu­
lar path. This is clearly an arduous task. By definition, just as it
is impossible to not communicate, in terms of the first axiom of
human communication (Watzlawick et al., 1967), so it is impos­
sible to be neutral at the time of the action. A t any given mo­
ment, for example, the therapist can take sides either to
preserve spontaneity or to overcome the danger of remaining
blocked, pondering the extent of his or her neutrality with re­
spect to the task at hand. The latter question can only be judged
with hindsight. At times, in therapy involving team work, it is
the team who point out situations where a neutral stance has
not been maintained. In other instances, it is the therapist who,
while reviewing the work effected, notices such weaknesses
and thus can monitor their effects. From the above, we can
deduce that a synchronic approach produces a non-neutral
stance, while a diachronic one helps to preserve it.
There are, of course, circumstances in which neutrality
should be put aside: a case in point might be the realization that
physical, sexual, or psychological abuse is taking place. Even
classical psychoanalytical theory, which devotes to neutrality
an important role, recognizes this aspect:

Although not always adhered to, the whole series of recom­

mendations relating to neutrality does not as a rule meet
with opposition from psycho-analysts. Even the most ortho­
dox, however, may be led in particular cases—especially
cases involving anxiety in children, the psychoses and cer­
tain perversions—to waive the rule of complete neutrality on
the grounds of its being neither desirable nor practicable.
[Laplanche & Pontalis, 1967, p. 272]

Some authors (including Campbell, Draper, & Crutchley,

1991, and T o m m , 1984) have put forward an alternative view of
neutrality. They suggest that the neutral stance should be ap­
 THERAPEUTIC PROCESS 95

plied not only towards the people and ideas present in a given
system, but also with respect to the ideas of change preferred
by the therapist. In fact, the tendency may emerge in a therapist
to exhibit a bias in favour of change, or even of a specific kind of
change. The correct attitude for a therapist should be to remain
neutral even towards the very concept of change: " T h e thera­
pist thus avoids clearly siding for or against any given result i n
terms of behaviour" (Tomm, 1984, p. 263).
We would suggest that though the above approach was
formed within the context of family therapy, it is fully applic­
able to individual therapy as well. It is worth stressing at this
point that, i n our opinion, a neutral stance should not be a
strategic choice, but an attitude truly and sincerely acquired by
the therapist—not simulated.
Criticisms directed at the concept of neutrality have come
from two fronts: (1) those, particularly the feminist movements,
who perceived it as being the product of a conservative and
apolitical attitude on the part of systemic therapists, and (2),
above all, through the rising tide of constructivism and second­
order cybernetics. The advent of the latter front i n the m i d ­
1980s removed the distinction between observer and observed
and thus rendered the concept of neutrality unsustainable: the
theories and prejudices of the observer necessarily contaminate
any attempt at describing. Cecchin (1987), in his revision of the
concept of neutrality, introduced the alternative—and very suc­
cessful—concept of "curiosity":

The term "neutrality" was originally used to express the idea

of actively avoiding the acceptance of anyone position as
more correct than another. In this way, neutrality has been
used to help orient the therapist toward a systemic episte­
mology. . . .
In order to avoid the trap of oversimplifying the idea of
neutrality, I propose that we describe neutrality as the crea­
tion of a state of curiosity in the mind of a therapist. Curiosity
leads to exploration and invention of alternative views and
moves, and different moves and views breed curiosity. In
this recursive fashion, neutrality and curiosity contextualize
96 THEORY

one another in a corrmutment to evolving differences, with

a concomitant non-attachment to any particular position.
[Cecchin, 1987, pp. 405-406]

Reference points for the therapist's hypotheses

During workshops and seminars, colleagues often ask us on

what elements we build our hypotheses and interventions.
Naturally, we draw on the theory being applied and select
from that fund of personal and clinical experience that we have
acquired those elements that somehow appear fitting at a given
point in time. That however, is not all. Described below are
some of those reference points which, to our mind, represent
the co-ordinates we employ to connect and make sense of the
elements (either from theory or direct experience) mentioned
above.

1. Time. Together with space, time represents one of the

first distinctions the therapist carries out when organizing per­
sonal experience, as well as the client's and that derived from
the therapeutic process itself. It can be stated that spatio­
temporal parameters cannot be removed from a description.
We have dedicated a great deal of research work to exploring
the importance of time in human relationships (Boscolo &
Bertrando, 1993). We have looked at the "times of time", those
types of time that relate to the individual, to the family, to the
social, and to the cultural spheres; we have also explored their
mutual correlations and interlaced evolution in both " n o r m a l "
and "pathological" development. We have thoroughly de­
scribed how harmonic development requires the co-ordination
of internal and external time, of individual time with that of
those who represent the most important relationships and with
social time—as one, for example, could find at work or at home.
Loss of co-ordination, i.e. of harmony, between the time cat­
egories leads to suffering and "pathology". Innumerable exam­
ples exist: the lack of co-ordination in cellular time between
pairs and groups of cancerous and healthy cells; the slowing
down or breakdown in the tempo of individual development in
 THERAPEUTIC PROCESS 97

an anorexic girl, or a psychotic who has lost co-ordination with

the time of other significants such as family members or peers; 3

and, finally, the difficulty of co-ordinating social and work

time. In Modern Times, Charlie Chaplin demonstrated, in his
own inimitable fashion, how the fast and mechanical tempo of
work on a production line can lead to the loss of co-ordination
between the worker's and the machine's time—with cata­
strophic effects. In family therapy, one is occasionally faced
with situations where loss of co-ordination arises from a myth,
rooted in the historical past of a family group, to which only
some members adapt while others opt for society's time. A n
exemplification of this is the case of Luciano M . , a prisoner in
the myth of the lost and unattainable father (see Chapter 5 ) .
In our investigations, an effort is made to understand
whether the client's temporal horizon faces backwards into the
past (e.g. in depression), is locked exclusively into present time,
or is open to both past and future. In some instances, the cli­
ent's time might be split, as in psychoses; or chiefly locked on
4

past traumatic experiences, as in post-traumatic neuroses and

following the loss of significant others (mourning not ad­
equately worked through); or co-ordinated with the time of
members of the family of origin, rather than the present one.
These situations are often connected to problems of identifica­
tion, separation, and attainment of a well-defined identity. The
time of these clients loses co-ordination with the evolutionary
time of the rest of the family and the peer group, with predict­
able negative effects.
Synchronic and diachronic time are two important reference
points for the therapist. In the conjoint exploration of the client's
life, the therapist may suddenly stop to ponder over a particular
moment (synchronic time) placed, for example, in relation to

3
Chronic disorders are one example of how individual time may appear to
slow or even break down: a young psychotic, for instance, who shuts himself
up at home, leaves school, or gives up his job, who denies himself external
relationships and becomes a recluse. In some extreme cases, a regressive proc­
ess presenting behaviour patterns typical of a preceding age appear to be
engendered.
4
See the case of Nancy B. in our book, The Times of Time (Boscolo & Bertrando,
1993, Chapter 1).
98 THEORY

the family's history or the evolution of the therapeutic relation­

ship, and vice versa. In other words, the therapist, in coopera­
tion with the client, may go forward or backward in time while
investigating the client's history or when analysing the thera­
peutic relationship, then " z o o m i n g " in on specific past, present,
or future events and meanings, seen from different vantage
points, thus contributing to the reconstruction of new stories. In
Part II, which is devoted to clinical cases, we furnish a range of
examples of this process.

2. Space. Proximity and distance are two spatial metaphors

that come to our attention during therapy work. We can first of
all distinguish an internal, personal space that varies widely in
our imagination and in our fantasies, but which may be re­
strained in, for example, rigid individuals with obsessive—
compulsive disorders or in states of chronic anxiety.
In addition, there are relational spaces within which indi­
viduals move: these too may vary greatly. Some individuals
tend to remain closed within the environment of the family of
origin (as often occurs with psychotics), or of the current family
(e.g. symbiotic couples), or of one of the peer groups (e.g. drug
addicts who attach themselves to a group of peers with whom
they share habits and rituals). Many clients oscillate between
the space of their family of origin and their new family, or
avoid entering the space of one family member (as when a
parent and a child continually ignore each other). The space of
the therapeutic relationship may also vary: a client may sig­
nal the therapist to keep his distance or to get closer. Other
individuals, instead, live in a much wider relationship web,
constantly in touch with families, friends, and colleagues. Sig­
nificant cases are those of Teresa S. (Chapter 4), Olga M . (Chap­
ter 5), and Bruno K. (Chapter 5).
In the course of therapy, the spatio-temporal co-ordinates
are used to explore the internal spaces and the relationships
with the client's significant systems: family of origin, extended
family, work contemporaries, and so forth. There is, in fact, a
special relation between attachment and the spatial dimen­
sions. A person may know many others but have only superfi­
cial ties with each (Riesman's "lonely crowd"); a client may, for
 THERAPEUTIC PROCESS 99

example, complain of feelings of loneliness despite having a

large circle of acquaintances: the others establish ties with each
other but not with the client. In extreme cases (e.g. the autistic
child), the individual remains totally alone; space is restricted
to such an extent as to become confined to one's own internal
space. We can glimpse in the dynamics of certain categories of
juvenile suicides a degree of constriction in the living space that
makes that individual feel trapped in a corner from which there
is no way out.
We take an interest in the client's relation with his or her
surrounding space, particularly with respect to the elements of
proximity or distance—in other words their emotional ties or
attachments to people and things. We frequently pose ques­
tions regarding the degree of proximity or distance of the cli­
ents' emotional ties to significant individuals with w h o m they
interact. Moreover, in keeping with a diachronic perspective,
we also explore the variations in the time of the emotional
involvements. What should be absolutely clear is that relational
space may oscillate widely with the onset of symptoms: a pho­
bic relationship with a particular individual or environment
can reduce dramatically the subject's available space, just as the
common fear of growing up and becoming independent re­
duces the chances of expanding oneself in space and time. 5

There are those who behave like a bear who has just been set
free from a zoo: they move as though they were still behind
bars, unable to escape from the confines of the family of origin
despite being given every opportunity and practical possibility
of becoming independent. Helping our clients overcome their
anxieties and fears is a means of freeing them from those con­
strictions that hamper them in taking possession of their own
space and from flowing freely with time. If, as many believe,
"health" is to be associated with flexibility, then we can say that
one of the goals of therapy is to help free clients from those

5
The above brings to mind Erich Fromm's book, Escapefrom Freedom (1948),
which describes how fear of freedom can lead a person to seek dependency on
an authority (e.g. the leader of a cult group or even a therapist), or a nation
towards dictatorship.
100 THEORY

spatio-temporal limitations that constrict their lives and pre­

vent the development of their potential.

3. Attachment. Individuals are social beings who need the

Other. Furthermore, this is an essential condition for many
other species. Harlow's (1961) observations, for example, on the
rearing of new-born monkeys with a puppet representing the
mother have demonstrated that an incomplete emotional bond
had devastating effects on the future behaviour of the young
monkey. Emotional bonds are a fundamental pillar in the lives
of each one of us. We all live through emotional ties, which may
be either strict or distant, with respect to those who are signifi­
cant to us; this is particularly true with respect to one's own
family of origin, the acquired family, as well as friends and
objects i n our world. Bowlby's attachment theory (1972, 1973,
1980) has highlighted how vital it is to experience at an early
age what the establishment or loss of emotional ties implies i n
human relationships. The various types of bonds between
mother and child (e.g. see secure, insecure, insecure-avoidant,
insecure-ambivalent, insecure-disorganized attachments de­
scribed by Holmes, 1992) have had important effects i n the
development of future emotional ties; the therapist's awareness
and understanding of these is especially useful—particularly i n
therapy with psychotics (Doane & Diamond, 1994).
It is also significant that the epigenetic model of human rela­
tionships proposed by Wynne (1984) places those mutual at­
tachments as essential for the existence of even the possibility
of establishing family relationships and evolving towards inti­
macy. According to Wynne, the absence of a sound and basic
attachment leads to severe difficulties in the epigenetically
higher levels of human relationships, i.e. communication (the
cognitive and emotional sharing of experiences), joint problem­
solving, and mutuality.
Apart from emotional and affective patterns of proximity
and distance that characterize the client's relationship with
himself and with the external (human and non-human) refer­
ence systems, the therapist must be especially attentive to those
that may connect him to the client.
 THERAPEUTIC PROCESS 101

4. Belonging, A specific form of attachment, definable as

belonging, develops through time in step with the evolution of
the individual and the relationships he has with significant
people or peer groups: the mother, the family, the school,
friends, and the nation. The feeling of belonging emerges
within the family, which, in this way, has a crucial role i n the
development of this characteristic. A given family may ease the
development of a balanced sense of belonging in its members,
while another family might instigate doubts or even dangerous
relational dilemmas, such as: " A m I accepted in the family or
not? D i d my mother want to have me or not? W h o m do they
love more, my sister or me? Are they sincerely happy with me
or not?", and so on. These dilemmas can erupt in states of
severe anxiety, insecurity, and low self-esteem. In this frame­
work, the psychotic is the very person who is never sure of
belonging and, with this insecurity, may develop an overriding
need to control the distance of the other, to the point of never
leaving his or her autistic castle. In this way the psychotic erects
an unbridgeable barrier against others, or tries to establish a
complete and totally involved relationship of the symbiotic
type—usually with another family member.
The sense of belonging formed in the family later becomes a
belonging to a peer group, to the school, to one's heritage or
country. The effort to defend one's belonging to an ethnic
group may spark serious local or general conflicts, such as wars
(the civil war following the break-up of Yugoslavia is a case in
point). Less serious problems, which, however, may have clini­
cal relevance, develop in cases of first-generation immigrants
who are forced to live in two often dissimilar cultures; this
seriously tests their loyalty towards their parents as well as
their new country. A well-known conflict of belonging rears its
head at the beginning of a marriage, directing itself towards
one's own or the spouse's family of origin. The difficulty in
managing this conflict has the effect of filling the schedules of
individual, marital, or family therapists with clients who to
some extent are trying to balance the needs of belonging to the
family of origin, to the new family, and to themselves. In this
sense, cultural reference models are of fundamental impor­
102 THEORY

tance in the creation (and in the resolution) of these conflicts.

After the Second World War, the patriarchal model of the fam­
ily began to fracture with the emergence of the feminist revolu­
tion, the use of contraceptives, the entry of women into the job
market, and through a series of sociologically relevant factors.
This changed environment was conducive to an increase in the
number of single and independent individuals—above all,
women who realized that there was nothing wrong in belong­
ing to themselves as well as to the family. The current cultural
panorama offers a far wider range of models of how to live
together; some individuals have experienced this change in a
positive and liberating way, while for others this choice of free­
d o m has, paradoxically, engendered a paralysing effect that
manifests itself through anxiety, feelings of guilt, and an inabil­
ity to resolve dilemmas of belonging. This multi-dimensional
framework (from the individual to the couple, to the family,
and to the culture) is a reference framework that the therapist
employs in his attempts to "understand" the behaviour, emo­
tions, problems, and choices of the client. Since the capacity to
be attentive is punctiform, the therapist's attention will be fo­
cused in turn on each of the different points in the client's
macrosystem.

5. Power. In the 1980s the feminist movement gained ever­

increasing importance and influence within family therapy,
giving rise in the United States to a type of therapy called
"feminist therapy". This movement had an important and posi­
tive effect in reawakening our awareness of problems of in­
equality due to gender differences and to social conflicts such
as processes of discrimination against all types of minorities.
The systemic model of Batesonian inspiration has been the
most severely criticized, both from feminist movements and
from those who work with problems of physical and sexual
abuse of women and children. The systemic explanation em­
ployed in family therapy was, in fact, defined as justificationist,
inasmuch as the therapist connected the behaviour of the vic­
tim with that of the aggressor according to a circular causality
that placed them on the same level. It was the recognition of the
inequality—or, better, of different degrees of power—between
 THERAPEUTIC PROCESS 103

victim and aggressor that introduced a new perspective; the

hypothesis or the systemic explanation whereby victim and
aggressor co-create the violent relationship was severely ques­
tioned.
Bateson considered the idea of power to be an epistemologi­
cal error, and, i n keeping with a circular-causal vision, he be­
lieved that no individual could exercise power on another
unilaterally. In the arguments that raged on the problem of
power between systemic therapists and their critics, Paul Dell
(1986) introduced the distinction between systemic explana­
tion, which connects elements i n a system as though they were
on the same level, and the experience of physical and sexual
abuse, which implies an inequality between aggressor and vic­
tim and therefore a linear-causal view.
Elsa Jones provides a convincing criticism of the effects of an
acritical acceptance both of the Batesonian idea that it is not
possible to exercise power unilaterally and of Maturana's idea
concerning the impossibility of an instructive interaction,
which i n some way denies the possibility of exercising power
on another directly:

It would be absurd . . . to suggest that the victim is respon­

sible for the torturer's actions, or has equal responsibility and
power . . . or even—in the sort of reversal beloved of family
therapy strategists—that the torturer can be usefully de­
scribed as the victim of the victim. It is clear that they do not
have equal choice and influence. . . . The torturer has more
choice, influence and power in regard to what can be done to
the victim, and to remaining within or leaving the field of
relationship. [Jones, 1993, p. 144]

A s indicated by Dell (1989), the problem of power was swept

under the carpet by Batesonian therapists, then to return to
centre-stage. One author above all, Michel Foucault, imposed
himself—through the stress placed on power i n our under­
standing of human relationships. The French philosopher sug­
gests that knowledge and power are intimately connected; his
attitude towards power is central, i n the sense that it can be
exercised in a negative, constrictive, or coercive form, but also
in a creative and productive one. One instrument that Foucault
104 THEORY

provides is the analysis and deconstruction of the discourse,

which allows us to discern how certain ideas, actions, or narra­
tives may become dominant, to the detriment of others, which
become secondary or marginal. This is an important point since
it enables the therapist, in his internal dialogue, to become
aware of the influence he exercises in deciding " . . . which nar­
rative can become dominant and, secondly, to recognise that
both therapist and client are organised and necessarily influ­
enced by the dominant narrative of the social structures which
surround us a l l " (Jones, 1993, p. 139).
A greater sensitivity towards power gives the therapist the
chance to explore further his or her presence and effects in
the therapeutic relationship and in the relationships with the
client and the client's significant systems. Hypotheses on the
transmission from one generation to the next of the attitude of
various members of the family with respect to power can be
enlightening and can offer important information to both client
and therapist.
With respect to the relation between power and responsibil­
ity, Fruggeri (1992) states:

The problem for a therapist is neither to be powerful nor to

succumb to power. Rather, the therapist should take a re­
sponsibility for his or her power of construction within the
constraints of the relational/social domain. . . . As power is
not unilaterally determined, egalitarianism and the respect
for others are not unilaterally determined. They are the re­
sult of an interactive process, in which both the offering of
respect and the same acceptance/recognition of the offer are
necessary, [p, 47]

6. Gender. The last but not the least of the variables that,
chronologically, we have looked at is that regarding gender—
the masculine and feminine roles. In some respects, it is gener­
ated by the problem of power (see above), but it is most closely
associated with personal identity. It is not just a question of a
situation acquiring different connotations depending on the
gender of the observer; but, as evidenced by the feminist school
in particular, the evolution of the gender roles can either occur
harmoniously and lead to the development of a sound and
 T H E R A P E U T I C PROCESS 105

balanced identity, or cause irrevocable conflicts, with serious

effects on self-esteem, and bring about significant personal and
relational consequences.
Therapists must be aware of their own and the client's gen­
der prejudices since these have what at times is a crucial role in
the therapeutic process. Problems of "falling in love", competi­
tion, dependency, seduction, hostility, etc. may emerge, and
sooner or later these will have to be faced. The therapist can be
supported in this effort by both the supervisor and the thera­
peutic team; the usual presence of colleagues of both sexes
enables the therapist to observe and test out what happens in
therapy through the eyes of both men and women. We have
repeatedly observed that, in those cases where the therapist
invites one or more members of the therapeutic team to com­
municate, at the end of the session, their own viewpoint to the
client, it is usually the viewpoint of the colleague of the oppo­
site sex to that of the therapist that has the greater impact.

Circular questions

The concept of "circular questions" has frequently been con­

fused with the concept of circularity mentioned above. Circular
questions received their original definition because, at that
time—in the context of family therapy—each family member
was in turn asked questions by the therapist regarding the
behaviour of two or more other family members. In other
words, therapists tried to build a family map as a network of
interconnected relationships (between ideas and emotions as
well as between behaviours); the most effective way to create
such a map appeared to be through questioning that could
highlight differences. These questions were created to obtain
information rather than data: Bateson (1972), in fact, believed that
information is " a difference that makes a difference", i.e. a
relation, which in this way distinguished itself from a datum.
To further appreciate this process, we could say that the
information obtained through circular questioning is recipro­
cal: through questions, both clients and therapists constantly
change their understanding on the basis of the information
offered by the others. Circular questions bring news about dif­
106 THEORY

ferences, new connections between ideas, meaning, and behav­

iour. These new connections can contribute to changing the
epistemology—in other words, the personal premises, the u n ­
conscious assumptions (Bateson, 1972)—of the various family
members. Circular questions arrange themselves as an inter­
vention, perhaps the most important one for systemic thera­
pists.
Circular questions were initially proposed in the article
"Hypothesizing-Circularity-Neutrality" (Selvini Palazzoli et
al., 1980), which also described some types of circular questions
considered particularly useful in soliciting differences during
the therapy session: triadic questions, where one person was
asked to comment on the relationship between two other mem­
bers of the family (e.g. "What does Dad do when his son criti­
cizes him?"); questions on the differences in the behaviour of
two or more people, but without focus on the intrinsic qualities
of the persons themselves (e.g. "Who helps her out more when
she's sad, M u m or Dad?"); questions on changes in behaviour
before or after a given event (e.g. " H i s sister stopped eating
before or after grandma's death?"); questions on hypothetical
circumstances (e.g. "What would you kids do if your parents
separated?"); and, finally, gradings of family members with
respect to a given behaviour or interaction (e.g. " W h o cheers
M u m up more when she's down?").
Sheila McNamee (1992) goes further, suggesting that circu­
lar questions are the prototype of the constructionist therapeu­
tic technique since they help create a multiplicity of viewpoints:

One illustration of social constructionist therapy is the notion

of circular questioning introduced by the Milan team. Circu­
lar questioning is built on the idea of relational language.
. . . The multiple descriptions that emerge in the process of
circular questioning provide the sources for new connections
(relationships). [Data] gathered through this questioning
method quickly become information about connections
about people, ideas, relationships and time. Thus, informa­
tion about pattern and process (not products or outcomes)
emerges in this context.
Because circular questions do not engage individuals in
upholding their own version of the world (including the
 T H E R A P E U T I C PROCESS 107

privileged, professional, psychological version), they allow

for a departure from the stories or logic that people tend to
live and act daily. They provide an opening for alternative
descriptions that often encompass the multiple voices that
have previously been competing in the discourse, [pp. 195­
196]

Circular questions have been studied by many authors,

among them Hoffman (1981), Penn (1982, 1985), T o m m (1984,
1985, 1987a, 1987b, 1988) Deissler (1986), Fleuridas, Nelson,
and Rosenthal (1986), Borwick (1990), and Viaro and Leonardi
(1990). We take a brief look here at the results of some of these
studies.
Karl T o m m , one of the earliest and most important research­
ers on circular questions, divided them into different categories
according to their aims and their characteristics. We shall limit
ourselves to Tomm's first distinction. By taking into considera­
tion the intentional way i n which the therapist poses questions,
T o m m divided circular questions into two categories: informa­
tive or reflexive. Informative questions have as their main goal
the collection of information, while the second type of question
solicits change (the two goals are mutually exclusive, and the
questions are often mixed in character). The distinction be­
tween informative and reflexive questions is not so much i n the
formulation but i n their timing during the dialogue: the same
question might express an informative or a reflexive character,
depending on the moment at which it is posed (Tomm, 1985,
1988).
A m o n g the other authors, Viaro and Leonardi (1990)—one a
therapist, the other a linguist—have supplied an interesting
interpretation of circular questions (and of other aspects of the
therapeutic dialogue) in terms of conversational theory. A c ­
cording to this theory, the therapeutic session is a special type
of conversation and, as such, is subjected to all those general
rules upon which conversation is founded, and to a few more
that are applicable in the therapeutic environment. The inter­ 6

pretation offered by these two authors is given a certain em­

W e use here the term " c o n v e r s a t i o n " as e m p l o y e d b y V i a r o a n d L e o n a r d i

6

(1990), t h o u g h , to reiterate, w e prefer the term therapeutic " d i a l o g u e " .

108 THEORY

phasis i n this chapter, since we believe that they provide a

different and rather interesting perspective on therapeutic dia­
logue. A l l the authors quoted herein (including ourselves) con­
sider circular questions, and the other events i n the dialogue,
from the point of view of the therapist, supplying therefore a
description that highlights the therapist's intentions (this is
particularly true of Karl Tomm). Viaro and Leonardi, on the
other hand, offer a more direct reading of linguistic interaction.
Their approach is from "the outside": in this way, one can see
the effects of the linguistic acts (Austin, 1962) of therapist and
client i n a manner that is not influenced by the therapist's i n ­
tentions and prejudices.
A first distinction i n circular interview questions i n this con­
text is between questions with finite alternatives ("Who do y o u
feel closer to you, your M u m or your Dad?"), questions with
infinite alternatives ("What do you think your wife would do if
you two divorced?") and yes/no questions, which are self-ex­
planatory.
Some circular questions require statements from the inter­
locutor, i.e. accounts on concrete facts; others require attribu­
tions, i.e. the attribution to another of given states of mind or
stances. If questions of the first type (such as: "What does your
mother do when your father teases her?") deal with behav­
iours; those of the second type (such as: " I n your opinion, how
does your mother feel when your father teases her?") definitely
enter i n the arena of significance.
These distinctions are to a certain extent akin to those made
by the first author at the end of the 1970s, after abandoning the
black box theory. To those questions that used to be posed,
which were based on descriptions of behaviour—"What does
your husband do when your daughter refuses to eat?"—two
further types were added: "What does your husband feel when
your daughter refuses to eat?" and " H o w does your husband
explain the fact that your daughter refuses to eat?" In these
three types of questions one can identify three levels of human
communication: description, experience, and explanation. It
goes without saying that the use of such levels i n circular ques­
tions opens new horizons in the connection of events, emo­
 THERAPEUTIC PROCESS 109

tions, and meanings, thus enriching the clients' view of the

world and providing a means to escape that rigidity which
imprisoned them.
In any case, be they connected to facts or experience, circular
questions usually require precise and specific details, rather
than generic information alone. To the question: "Who's the
happiest person in your family?" one might receive the follow­
ing answer: " M y wife." To this answer the therapist poses
other questions such as: "In your opinion, why is your wife the
happiest? H o w does she show it? Can you give me some exam­
ples that show how she is the happiest?" and so on.
The reader will have realized that the first question is a ques­
tion/theme, since it introduces a base theme (happiness/un­
happiness), through the keyword " h a p p y " , and immediately
inserts the theme in a difference grading: happiness is a state
that one can experience to a greater or lesser degree than oth­
ers, it is also a state that depends on other people. The ques­
tions/themes are followed by specification questions that
allow the therapist to define the theme more and more, and
insert it into the arena of relationships.
Another type of question that we resort to frequently for its
effectiveness in acting upon the deterministic limitations of sto­
ries brought by clients relates to hypothetical questions on the
past, present, and future. The client who seeks our help often
has a lineal-causal (i.e. deterministic) view of time and of his or
her own story, in which negative and traumatic events or rela­
tionships from the past are considered to be the cause of the
problematic and unstable present, with the expectation that
these will also negatively influence the future. Clearly, if thera­
pists, too, had this deterministic view of the story, they could
not perform their function or be useful. We believe that past,
present, and future are mutually interconnected and, therefore,
that through the widening of the context of past stories, of
present reality, of future expectations, and by employing hypo­
thetical questions in particular, it is possible to break down
those deterministic limitations that make the client's story
more rigid, constrict thoughts and emotions, and limit freedom
(see Boscolo & Bertrando, 1993).
110 THEORY

Circular questions in individual therapy:

the "presentification of the third party"

Circular questions have been discussed at length, and, indeed,

they continue to represent one of the most important instru­
ments (if not the most important) in therapy and consultation. 7

Circular questions have found increasingly widespread utiliza­

tion and may perhaps be considered the Milan group's most
important contribution.
Obviously, the therapist has other tools apart from circular
questions: silence, sounds, or words expressing doubt or agree­
ment, affirmations, metaphors, anecdotes, simple questions
("What do you have to tell me today?" or " H o w do you feel at
this moment?"). These different types of expressions have been
used far more frequently in individual than in family sessions.
In the latter, the therapist is more active and chiefly engages
family members through various types of circular questions,
particularly triadic ones. These have the important effect of
putting each family member in the position of observer with
respect to behaviours, emotions, and thoughts originating from
others; by their interconnecting during the time of the session,
they help increase the complexity of individual and family mat­
ters.
Even in a dyadic relationship, such as exists in individual
therapy, one can use circular questions very profitably, particu­
larly when employing the "presentification of the third party"
technique. In family therapy, circular questions in general, and
triadic ones in particular, have, among other things, the effect
of placing each family in the position of observer of the
thoughts, emotions, and behaviours of others, thus creating a
community of observers. This may be reproduced in individual
therapy as well; significant third parties belonging to either the
external or internal ("voices") world are presented, thus creat­
ing a "community" that contributes to the development of dif­
ferent points of view. One of the effects of this method is to

Hypotheses and circular questions have both been employed very benefi­
7

cially in consultation on the organizational development of institutions and

firms.
 THERAPEUTIC PROCESS 111

challenge egocentricity: the client is placed in a reflective condi­

tion and makes hypotheses that take into account the thoughts
and emotions of others and not just his own.
The presentification of the third party is one of the most
interesting and effective of the techniques that we employ in
therapy. It avails itself of an important function of circular
8

questions in individual therapy: namely, that of evoking, for

the client, significant persons in therapy, thus expanding the
spatial, temporal, and relational horizon of the dialogue. This
may occur in different ways:

1. Through circular questions that introduce within the dia­

logue people who are significant to the client: "What opin­
ion would your mother or her friend express on what you
are saying now?", "What advice would your father give me
at this moment?", "If the person you like were now here to
comfort you, what might they say to you?". Circular ques­
tions may also include "internal voices": "We all have our
internal voices, but whose voice is it that tells you to behave
in a destructive manner?", "It would seem the positive
Voices' inside you are rather weak. Don't you agree?".

The presentification of the third party as an internal "voice"

or "force", or as an " i d e a " that acts on the client in either
a positive or a negative sense, is frequently employed by us
in therapy. This technique—which we utilize, for example,
in anorexia, in bulimia, in obsessive-compulsive neurotic
forms—is based on the creation of a relational system with
three elements: therapist, client, internal "voice" or "force".
The therapist tries to establish a therapeutic alliance with
the client and against any "voices", "forces", or "ideas"
considered responsible for the client's symptoms or suffer­
ing; this contributes to the separation between person and
"illness", thus favouring the process of depathologization.

"Different authors have observed that no two-way interview can be truly

confined to the two people present. Many physically absent persons enter the
game as, according to Sullivan's (1953) definition, the "imaginary other".
112 THEORY

Michael White (White & Epston, 1989) employs the same

principle, defining it as "externalization of the problem".
2. The client may occasionally be asked to speak directly to the
presentified other, represented by an empty chair: "Imagine
that your brother is sitting in that chair and that he does not
agree with what you have just said. H o w would you answer
him?" Less frequently, the therapist might suddenly organ­
ize a type of role-play: while the therapist takes on the part
of either the client or a significant family member, the client
interprets the part of the therapist or himself (see the cases
of Bruno K. and Susanna C. in Chapter 5). The role-play is
usually of brief duration and is followed by both therapist
and client expressing their experiences and ideas about
what has just occurred. This procedure enables the client to
try out and visualize an event or a significant relationship
from a different angle; this requires the therapist to be par­
ticularly sensitive and intuitive towards the client's expecta­
tions with respect to the other. 9

3. When we work with an observation team behind the one­

way mirror, the other may be represented by one (or more)
of the team members, who, at the end of the session and in
the presence of the therapist, communicates one or more
points of view, which, at times, may be different from that
of the therapist (see the case of Luciano M . in Chapter 5).

Whichever method the therapist uses to presentify the third

party, circular questions maintain their fundamental role: cre­
ating connections. In this case, however, the connections must
be built up by therapist and client in the absence, rather than
presence, of the other components of the client's significant
systems.
In this sense, circular questions are a means that the therapist
has of entering into the client's dialogue with other significant

The personification of the other is vaguely reminiscent of one of the tech­

y

niques employed in Gestalt therapy; the underlying concept here is that change
is triggered more effectively if one assumes that the client's past (or present)
significant other is sitting in an empty chair. In this way the client may speak to,
rather than about, that person directly (Hoyt, 1990, p. 128).
 THERAPEUTIC PROCESS 113

persons without directly introducing his or her own ideas.

These are introduced indirectly as questions, and the question
mark leaves the responsibility of attributing meanings to the
client; the absence of such a question mark would introduce an
interpretative and prescriptive dimension. It is through ques­
tions that multiple voices—the significant voices in the client's
life—enter the arena of therapy. Further circular questions on
these many voices creates a reflexive process (that which others
produce in the present through the reflecting team), which
leads to further differences that make a difference. A sense of
the community is thus introduced even in working with the
individual. 10

Although what we are about to say will probably not be

perceived with favour by those colleagues who believe that
therapists should always be open and spontaneous and never
reticent, we suggest that it is in fact good for the therapist to be
closed and reticent rather than open: the therapist must cer­
tainly empathize, participate, and listen, but he should not re­
veal his own ideas. In this fashion it is truly possible to create
11

for the client a context of deutero-learning: the client may learn

from the answers that he himself provides. A n d the answers the
clients provide allow the therapist to pose further questions,
while previously he tended just to have answers. If we accept
that, in the clinical cases we see, one of the fundamental prob­
lems is rigidity—in other words, the tendency to give the same
solutions to different problems—this would imply that in many
respects the client has no further questions to ask himself and
uses the same map, which furnishes predictable answers. The

10
Terry (1989) has developed a didactic method to improve the ability of
family therapy trainees to evaluate relational systems through individual inter­
views. The trainee is advised to pose, in sequence, questions that range from the
monadic to the dyadic and triadic, assuming in this way gradually the form of
actual circular questions. In this way, the trainee not only maintains a systemic
perspective but also accepts the client's individual perspective, thus easing and
favouring the establishment of a positive therapeutic relationship.
11
A n exception to this procedure is represented by occasional comments,
usually found more frequently at the end of the session, in which the therapist
communicates one of his hypotheses, which at times might be rather complex,
in a doubtful or affirmative tone.
114 THEORY

range of points of views elicited by the therapist's questions

may lead the client to develop new ideas and emotions, which
in their turn may further the development of new levels of
curiosity and new self-directed questions.
Through a series of circular questions we can lead the indi­
vidual to say (and therefore to explore and see) what another
might think of him, then of a third person, then of both the third
person and another towards the client, then the client towards
the other two, and so on. In this fashion, the relational circuits to
which the individual is connected are explored. These circuits
may be self-reflexive (the internal dialogue), or hetero-reflexive,
the real or virtual relationships between the person and his or
her context. Circular questions and the hypothesis during the
dialogue (concerning the subject's relationship with himself
and with the significant systems) have the important—but not
sole—effect of placing clients in a position to enter a hermen­
eutic circle, i n which to connect their own actions, emotions,
and meanings with that of the therapist. To some extent a con­
text is created, with the help of the therapist, i n which clients
analyse themselves and their significant systems. It is these
dynamics that create a situation of deutero-learning, which
leads the client to new choices and solutions. Goldner (1993)
evoked an analogous process to that established through circu­
lar questions when referring to "the discourse of the other".
What has been said above should not give the impression
that systemic therapy is a rigid play of questions and answers.
If questions and answers were the cornerstone of therapy at the
time of Paradox and Counterparadox (Selvini Palazzoli et al.,
1978a) and of Milan Systemic Family Therapy (Boscolo et al.,
1987), the session was later enriched by a range of different
elements. The concepts have become more complex, thanks to
the interest and contribution of authors, through the new per­
spectives that have been opened by research on language and
on the importance of narrative and of the concept, taken from
literary criticism, of deconstruction and reconstruction. A t the
present time terms such as therapeutic dialogue, conversation,
or discourse, with the different meanings given to them by
various authors (Anderson & Goolishian 1992; Hoffman, 1988;
 T H E R A P E U T I C PROCESS 115

Lai, 1985), hold the same common view of the therapeutic rela­
tionship: as an interactive dance in which the interlocutors take
turns to shape the discourse, as is discussed later in this chap­
ter.

Deconstruction and construction during the session

In order to describe the therapist's thoughts and actions during

the session, we were aided by a model found in literary crit­
icism and text analysis, in which the text is deconstructed
and reconstructed according to the reader's sensitivity, culture,
knowledge, and prejudices. The reason why we consider this
model appropriate is that it does effectively and adequately
describe the process occurring in the therapeutic dialogue,
which may in fact be seen as an ongoing deconstruction and
reconstruction of stories. We can identify a process of micro­
deconstruction-reconstruction that occurs within a limited
number of exchanges (turns to speak) between the therapist
and the client; we can also distinguish a macro-reconstruction
process that occasionally occurs (usually at the end of the ses­
sion) in the reconstruction of the various "pieces" that had
emerged from previous deconstructions.
With this model, the therapist's use of hypothesizing and
circular questioning can be described simply and clearly. In
the process of hypothesizing, the therapist connects those ele­
ments emerging from the dialogue and then formulates hypoth­
eses (construction), verifies the plausibility of the hypotheses
through circular questions, which provoke responses that high­
light further elements (deconstruction), which lead to further
hypothesizing, and so on. Naturally, as previously stated, the
session comprises other aspects apart from circular questions:
the therapist employs pauses, sounds, or words that express
doubt or assent, statements, metaphors, anecdotes, simple
questions, dyadic questions. Therapists frequently resort to m i ­
cro-reframing when it is their turn to speak; these partially
summarize what was said by the client in a way that takes into
account the therapist's ideas at that time. The therapist must
also carefully observe the effect on the client, i.e. the likelihood
116 THEORY

that the micro-reframing will be accepted. It may happen that

12

the client, too, does the same by reformulating what the thera­
pist has just said.
It should be underlined that the therapist tends to employ an
interrogative tone when offering micro-reconstructions; this
leaves the client with the possibility of expressing agreement or
disagreement or, better, a personal opinion and meaning. By
carefully observing the client's verbal and analogic reaction
(feedback) to the micro-reconstruction presented, the therapist
can establish whether the message has been "received" and
determine the possible significance attributed to it.
Sometimes the therapist ends the session with a lengthy
commentary, a macro-reframing that summarizes the informa­
tion emerging during the session, and connects these elements
in a way that is, hopefully, significant for the client and can
open new perspectives. Some clinical examples i n Part II (e.g.
the cases of Bruno K. and Susanna C. i n Chapter 5) present very
long final reconstructions that summarize the client's story by
connecting his or her past life with the present one and antici­
pating likely future developments. If the session is conducted
with the therapeutic team, the latter actively participates i n the
reconstruction of the story itself, which is then communicated
to the client by the therapist alone or together with one or more
members of the team.
It might be useful to remind the reader at this point that we
do not restrict ourselves to operating in the linguistic domain,
using words, metaphors, or stories; we also enter into the do­
main of action, using ritualized or behavioural prescriptions
(Selvini Palazzoli et al., 1978b). The latter were developed i n
the early 1970s and were frequently employed i n family
therapy; they are structured experiences that symbolize an i m ­

12
I n the 1980s, Viaro and Leonardi (1983,1990) evaluated the conduct of the
session by the members of the original Milan group from the conversational
point of view. It emerged that, while some tended to employ summaries and
retrainings more frequently (particularly Mara Selvini Palazzoli and Luigi
Boscolo), others (especially Gianfranco Cecchin) made almost exclusive use of
questions. The choice of different modalities in conducting the dialogue de­
pends, therefore, also on the personal style that the therapist develops through
time.
 T H E R A P E U T I C P R O C E S S 117

portant and significant aspect i n the life of clients. They have at

times proved themselves decisive, particularly in dissolving a
family myth at the source of the discomfort or suffering of one
or more of its members, or i n situations of feelings of unre­
solved loss. For a more in-depth description of this fascinating
subject, the reader should refer to Selvini Palazzoli et al. (1978a,
1978b) and to Boscolo and Bertrando (1993, Chapter 8).
In some instances we also resort to behavioural prescrip­
tions, particularly in cases where the resolution of the behav­
ioural problems presented has priority, or in cases where an
"immunity' towards words has been created—for example, in
7

obsessive-compulsive or psychotic disorders.

Further considerations on the therapeutic dialogue

We have found rather interesting the work carried out by Viaro
and Leonardi (1990) on systemic family therapy sessions ana­
lysed from the point of view of conversational theory. Accord­
ing to this theory, therapeutic conversation obeys the rules 13

found i n any conversation: the speaker, on the one hand, as­

sumes that the other participants in the conversation have
the speaker's own linguistic competence and, on the other,
supplies these participants with information regarding facts,
emotions, and attitudes. Apart from these general rules, the
therapeutic session is characterized by some specific ones: for
example, the rule concerning the directivity of the therapist. It is,
in fact, the therapist who has the possibility of choosing whose
turn it is to speak, on what, and for how long. The moment
therapy begins, the therapist acquires the right to decide what
14

to speak about—and, therefore, the themes of the conversa­

tion—and also to decide when to pass from one theme to an­
other—to interrupt the speaker, to suspend or conclude the
session, and so forth.

13
By "rule" we mean, coherently with conversational theory, a set of princi­
ples immanent to conversation, in some way similar to the "rules" of grammar.
14
It is understood that the "rules" of the therapy are not detailed explicitly
by the therapist at the beginning of the first session: they establish themselves
gradually, with the therapist conducting the conversation in a certain way and
that certain way being accepted by the client.
118 THEORY

To our minds, the directivity of the therapist may be clear

and open, but it is more often concealed or—resorting to a
paradox—one could term it "indirect": this depends on the
particular moment in the session, the behaviour of the client,
and, naturally, on the therapist's choice. This description (or
point of view) is only a partial one and represents a deeper
clarification of the relationship that stems from the behaviour
and purposefulness of the therapist. If, on the other hand, we
consider the opposite slant, we can describe the therapist's be­
haviour as a response to the client's behaviour. In this case,
15

directivity is a characteristic not just of the therapist, but of the

client as well. The three slants described represent three points
of observation: the therapist's, the client's, and a point of obser­
vation external to both. This represents one of the fundamental
principles of systemic thought: the importance of placing one­
self as observer at the different points of the significant system
in which one finds oneself or, as occurs i n individual therapy,
the view of the observer/therapist, the vision of the Other as
observer, and a point of view external to their relationship.
What is one to think i n those cases where clients choose not
to answer the questions a n d / o r pose questions to the therapists
in their turn? These clients commit what Viaro and Leonardi
(1990) define as an insubordination. In the way defined above,
these insubordinations occur frequently and may severely test
the ability of even the most experienced of therapists. If they
occur often, they tend to invalidate the therapist's role: one
only has to think of the continued insubordinations of psy­
chotic clients, which can easily overcome or paralyse an i n ­
experienced therapist. Milton Erikson, Jay Haley, Paul
Watzlawick, and other strategic therapists have taught us that
insubordination can be neutralized by the therapist, thus
avoiding the establishment of an " a r m wrestling" type of sym­
metric relationship, which could easily lead to an impasse.
Non-cooperative behaviour in clients can take many forms:
by not answering questions, by answering in a wilfully oblique

15
The example of the nagging wife and of the withdrawing husband, found
in the Pragmatics ofHuman Communication (Watzlawick et aL, 1967) is pertinent
in this case.
 THERAPEUTIC PROCESS 119

way, by hinting at possible secrets. In these circumstances, one

way to neutralize these insubordinations is usually to point out
the observed behaviour and, in a positive tone of acceptance,
furnish it with a positive connotation and prescribe it, leaving
the door open for a possible future change. For example: "I get
the feeling that you have difficulty in opening yourself [or to
cooperate or explain and describe something that is very pri­
vate]. I think that for the moment, you're doing exactly what you
should be doing and that it is important to think things over
before beginning to trust or cooperate with me; you see, the
reasons for your difficulties [or distress] are not quite clear yet,
and if you forced yourself now to behave differently, this could
result in great anxiety and worsen the situation." With this 16

definition the therapist:

1. assumes a listening stance towards the client;

2. respects and accepts the client's current behaviour, favour­
ing the construction of a therapeutic alliance;
3. attributes and delegates to time (the future) the task of
changing the situation (see the concept of ambitemporality
in Boscolo & Bertrando, 1993).

THE SESSION

Creating the therapeutic context

What exactly does it mean to create a therapeutic context that

favours the emergence of new stories and new evolutionary
paths? It is this major question that leads us to reflect on the
relationship between therapist and client, and on those ele­
ments that influence the therapeutic process.

16
A different interpretation of the concept of insubordination might intro­
duce the concept of resistance. From a systemic point of view, resistance is
not an intrinsic characteristic of the individual, but of the relationship among
people. The chief characteristic of Ericksonian therapeutic techniques (as the
one quoted here), which have considerably influenced the problem-solving
therapeutic models, is to avoid the formation of resistance on the part of the
client and favour a relationship based on cooperation.
120 THEORY

A necessary, but not sufficient, first condition required from

the client is at least some motivation—to change things, to
emerge from distress. This motivation should be investigated
first since it is difficult to create a therapeutic context without it.
A l l therapists would agree on the importance of the client's
motivation. It is significant that the therapists at the Mental
Research Institute (see Segal, 1991) distinguish between cus­
tomers and window-shoppers: it is simply not possible to con­
duct therapy with a window-shopper.
In parallel with motivation, it is necessary that the client
develops a trusting relationship towards the therapist and the
therapy. Though in some cases the client's motivation may be
weak at best, it is strong in those who are responsible in some
way for the client's presence in therapy (other members of the
family, friends, experts, etc.). It is not uncommon for clients to
come and have a "look around", more motivated by the idea of
asking for an opinion or a consultation, than an actual therapy.
In the preliminary evaluation session, the analysis of the refer­
ral and of the client's personal motivations is of primary impor­
tance to the therapist.
It is worth emphasizing at this stage that brief-long thera­
pies (such as the one whose characteristics were illustrated in
Chapter 2) are not appropriate for every client. In certain types
of psychotic disorders (such as schizophrenia), for example, it
would be wishful thinking to expect a resolution of the situa­
tion with no more than twenty widely spaced sessions. This
limitation is equally applicable whenever, rather than the ex­
plorative therapy we usually propose, the case demands what
may turn out to be an open-ended, supportive therapy (see the
case of Olga M , Chapter 5).
More complex are the requisites on the part of the therapist
necessary for the development of a therapeutic context. These
are, briefly, the following:

1. The ability to adopt a listening stance towards the client is a

primary requisite. This stance is more evident in individual
than in family therapy since the therapist is more directive
and active during the latter type of session.
 THERAPEUTIC PROCESS 121

2. The listening stance is more active than passive; it also em­

pathic, i n the sense that the therapist puts himself i n the
client's shoes and conveys feelings of emotional participa­
tion (see Chapter 2).
3. Curiosity (Cecchin, 1987) towards clients and their story,
and towards the evolution of the therapeutic process itself,
is a further important characteristic. It is through curiosity
that the therapist avoids becoming enmeshed i n the redun­
dant and repetitive exchanges that lead to an impasse.
4. We have already touched upon the capacity to make oneself
feel " h a p p y " or, at least, as happy as possible (Lai, 1985);
this resource helps therapists accept (and make more attrac­
tive) their work and their client's, thus positively influenc­
ing the latter. During their work, a question therapists
should ask themselves from time to time might be: "What
can I do right now to feel 'happier' so I can help my client
better?" It should again be stressed that to listen, to empa­
17

thize, to be curious, and always to think positively represent

some of the more important aspecific therapeutic elements
that work towards the successful outcome of therapy, ex­
plorative ones i n particular.
5. The systemic therapist takes an interest i n the internal and
external dialogue of clients and, thus, in their ideas, words,
and emotions about themselves, the systems they belong to,
and the therapeutic system.
6. It is a characteristic of the systemic model that therapists
adopt a circular view of events, as well as a linear one. This
perspective implies that what is considered is no longer an
event as an efficient cause of another, but tends towards
mutual relationships among events and human actions (see
Bateson, 1972; Watzlawick et al., 1967). Clearly the circular
vision applies not only to events occurring in the client's
world, but also to what happens in therapy. The principle of

By mamtaining at least a reasonable degree of happiness, therapists also

17

guard themselves against the so-called bum-out syndrome.

122 THEORY

circularity in the conduct of sessions is based on observation

of the feedback, i.e. the verbal and non-verbal messages of
the client. For further completeness, therapists should also
18

be aware of their own retroactive actions with respect to the

client and should assume an outsight position from which
to observe the interaction, which then leads to the three
observation points described previously and, therefore, to
a truly co-evolutionary conception of therapy. Each of the
therapist's interventions is based on the messages of
the client, which, in turn are related to previous messages.
More than a merely circular view, it would perhaps be bet­
ter to speak of a "spiral" (see Bateson, 1979), which takes
time into account. From this standpoint, events retroac­
tively influence each other, each time reaching a different
point from the starting one, a process that can in fact be
represented by a spiral.
7. The therapist should also be aware of the problem of power
with respect to the therapeutic relationship and the rela­
tionship with the client and the client's reference systems,
as well as to gender. The above two points have already
been described earlier in this chapter and in Chapter 2.
8. Something that should not be forgotten is that the therapist
should be aware of the fact that the proposed reading (as
any other) of the situation within the therapeutic context is
not objective but is filtered by the therapist's prejudices,
experiences, and theories. This awareness is a means of
maintaining a degree of autonomy and distance from them,
so as to be able to express one's own creativity.

Conducting the session

One of the main goals when conducting the session is to create

and maintain a relationship of trust between client and thera­
pist. It is a general principle applied by therapists from differ­

The tyranny of language, which is linear, usually leads us to punctuate

18

events—as in this case—starting from the client's feedback. We have already

mentioned how Bateson's example of the man who cuts down a tree (see
Chapter 1) clearly illustrates the dialectic between linear and circular vision.
 T H E R A P E U T I C P R O C E S S 123

ent theoretical schools and who distinguish themselves by their

interest towards specific aspects of the therapeutic relationship,
such as directivity, obedience, collaboration, respect, trust, em­
pathy, and so forth. The term "trust" is probably the one on
which most agree. It is perhaps important here to remember
that in individual therapy the attention given to the therapeutic
relationship takes a form that is different from the one adopted
in family therapy. In the latter, the therapist is more active and
concentrates on the mutual interplay of current relations be­
tween the different family members; multiple-voice dialogue is
directed more towards interpersonal relationships than intra­
personal ones. In individual therapy, on the other hand, the
dialogue is between two people, which implies on the part of
the therapist a greater interest in the client's internal dialogue,
which is to be de-coded by giving attention to the client's verbal
and non-verbal feedback.
Moreover, a greater leeway is given to listening, particularly
in the early phases of the session. A t the beginning of each
meeting, the therapist is in fact usually less active, at least from
a verbal point of view, and allows the client the choice of
themes, favouring communication with minimal verbal and
para-verbal interventions and with an attentive participation.
A n important aspect in the therapeutic relationship is silence
(Andolfi, 1994), which can at times assume great significance,
more so even than words. Family therapy does not make fre­
quent use of silence since the silence on the part of the therapist
or of a family member is often over-ridden by someone else's
contribution in the conversation. Not so in individual therapy,
where silence plays a leading role, though personally we tend
to utilize it with some discretion. Silence, particularly in the
first stages of the session, is used to help clients express their
reactions to the previous session and their thoughts on the
themes that interest or worry them; at other moments during
the session, it may be employed to give added weight to states
of mind or arguments of a special relevance. It is obvious that
the meanings taken on and channelled by silence are connected
to what is happening in the here-and-now of the relationship.
A sensitivity to the right balance between silence and words
is one of the principal qualities of a therapist. A t times it is the
124 THEORY

client who says little or nothing, and the therapist who, i n order
to avoid a sterile and mechanical exchange of questions and
answers, tells stories or anecdotes (see the case of Olga M ,
Chapter 5).
Another point that should be taken into consideration in
conducting the session concerns the theme or themes that
emerge i n the here-and-now. The professional background of
the therapist is, i n this question, very useful for developing the
sensitivity and insight necessary to identify those themes that
have a particular emotional significance and relevance i n the
client's life, with whom the therapist is then to explore the
various aspects involved.
This usually happens after the initial stage of the session,
when a significant theme emerges from the dialogue. This posi­
tion finds some analogy with that described by Anderson and
Goolishian:

Often people have many things they want to say and I elect
not to interrupt them. I let them say all that they want. First, I
want to respect the client's interests and p a c e . . . . Second, it
is a way of not directing or skewing the conversation in the
direction of my interests, and then missing what's important
to the client, what they want to tell me. So when I have a
curiosity or a particular word or phrase catches my attention,
I place it in my memory . . . This doesn't mean that I am
passive or withholding,... it simply means that my ques­
tions and comments are informed by the client, not my pre­
knowing. [Anderson, in Holmes, 1994, p. 157]

In the above approach there is, however, one important

point with which we do not agree. To our mind the idea that
" . . . my questions or comments are informed by the client, not
by my pre-knowing" is Utopian. It is not possible not to be
influenced by one's own "pre-knowing" or prejudices. We do 19

listen to the client, but we also listen to our own "voices", nor

19
Heinz Von Foerster (1982) went so far as to suggest that a pre-knowing
already acts at the first level of data collection, and therefore the term "datum"
itself should be replaced by the word "captum" (from the Latin), since the
observer's premises actively contribute to each perception.
 THERAPEUTIC PROCESS 125

can we ignore our past experiences. In keeping with a circular

view of reality, the questions or comments introduced by the
therapist are, of course, " . . . informed by the client and cannot
77

help but channel that pre-awareness and those hypotheses that

emerge in the therapist in the here-and-now of the session.
These hypotheses may connect themselves to important as­
pects of the client's relational life and the therapeutic relation­
ship itself, but they are also analogous or similar (isomorphic,
in the terminology of system) to hypotheses that emerged in
other cases and had a positive evolution. To avoid falling in the
trap of Truth, we should always bear in mind that hypotheses
are simply a means of temporarily connecting observed data in
a way considered significant at that moment (Boscolo et al.,
1987).
The listening stance adopted by the therapist towards what
the client is saying is not passive: connections form with what
was previously said in the current or earlier sessions and the
client's personal and social history. The questions that auto­
matically come to the therapist's mind are: "What exactly is the
client telling or implicitly asking me at this moment? H o w does
this relate to the previous sessions (the last one in particular)
and the overall development of the therapy? Do the client's
words and expressions indicate regression, stasis, or evolu­
tion?"
The product of connections occasionally drawn by the thera­
pist may find expression in an idea, a metaphor, or a hypoth­
esis, which can then be employed in a way the therapist sees fit
(through a statement or question) and which implicitly informs
the client what connections the therapist has made or is mak­
ing. The verbal or analogic responses the client then gives are
signals of the meanings attributed to the therapist's words or
questions.
External observers, who at times watch the session from
behind the one-way mirror or through a monitor, are occasion­
ally startled by how perceptive or illuminating therapists can
be in their questions and redefining intervention. These are not
simple intuitions that pop up from nowhere, but the product of
an intense underlying activity aimed at connecting scattered
elements. While the major focus of attention is naturally on the
126 THEORY

here-and-now, on the material emerging in the session, and on

the client's words, metaphors, and emotions, other elements
tend to remain in the background. From a temporal point of
view, it is the present that we privilege, and which we then
connect to past and future when the time is ripe.

The times and rhythms of the therapist and the client

The study of time in human relationships has brought us to

appreciate the importance of coordination between individual
and social time as a necessary condition for the "normal" devel­
opment of the individual and a better quality of his or her
intrapersonal relationships. To coordinate one's individual
time with that of others, one needs a range of temporal coordi­
nation options, i.e. sufficient flexibility. In the manifestation, for
instance, of a psychiatric problem within a family, we note the
difficulty in coordinating the times of the family members. C o n ­
versely, an intimate relationship requires a substantial capabil­
ity to coordinate the times within the relationship.
This leads us to state that the temporal coordination between
therapist and client, as well as the rhythms that express it, are a
weighty factor in the therapeutic relationship, too. Some au­
thors (see Minuchin, 1974) used the very apt metaphor of the
"dance" to represent the therapeutic relationship. The greater
the flexibility in the rhythms and movements between the two
dancing partners, the more likely it is that they are temporally
coordinated and that the therapy will have a positive evolu­
tion.
We are occasionally faced with cases of individuals with
little or no flexibility in their coordination of their own times, a
lack that can create quite significant problems in the relation­
ship. For example, the extremely slow and controlled times of
a client with severe depression or with serious obsessive­
compulsive disorders (who therefore has a great need to con­
trol) may sorely test the long-term coordination of the thera­
pist, who might feel bored or frustrated, develop a barely
repressed irritability, etc. The therapist could be similarly af­
fected by clients whose rhythms are very quick rather than
 T H E R A P E U T I C PROCESS 127

slow, as can be found in cases of particular anxiety, insecurity,

or maniacal euphoria. It has to be added that not all therapists
have the optimal flexibility required to coordinate their own
times and rhythms with the client's. A n awareness of these
limits is necessary in order to avoid, in extreme cases, having to
conduct therapy with specific types of clients. 20

In order to dance with the client, the therapist's rhythms

must be modulated to suit, within certain limits, those of the
client. The most difficult cases are, of course, those involving
schizophrenia or other psychoses, where the contact between
client and therapist is so unstable, forming and dissolving, as to
contribute to the therapist's already frequent feelings of futility
and impotence.
A second but different problem in connection with time i n
conducting the session is that of timing, i.e. exactly when,
within a dialogue, to introduce, accept, and abandon given
arguments. Just as the premature introduction of a given con­
tent may create resistance, so overlooking a significant topic
can diminish the client's interest and tension in the dialogue.
A s therapists we have to decide whether what we consider to
be interesting at any given moment is also interesting for the
client. Simply identifying verbal and analogic feedback may
not be sufficient to work out whether the client gives meaning
to the therapist's messages, and what that meaning may be. It is
for this reason that, at times, we ask the client whether our
questions make sense to him. Sometimes we ask whether he
has some suggestions to give us about which issues we should
go into. This consideration of the client's thoughts and feelings
facilitates the development of a trusting relationship and
avoids serious timing errors that could interfere in the thera­
peutic process.
To dwell too long on specific arguments or contents could
emphasize their importance and overshadow, in some way,
other significant aspects. This tract can prove seductive to both
client and therapist. A well-known example might be the ap­

20
In some of these cases drug therapy may be advisable, as it could substan­
tially contribute to a "normalization"of the client's rhythms.
128 THEORY

peal of stories concerning dependency on the mother and com­

petition with the father, which might lead to the risk of
reification and closure towards alternative stories.
We have pointed out (Boscolo & Bertrando, 1993) how dwell­
ing too long on past stories and associated interpretation may
have an opposite effect to the desired one and end up by con­
vincing the client that, given that past, a different present can­
not be derived. In this sense when exploring the past life, it is
useful to widen the context and use questions, particularly hy­
pothetical questions, which, by drawing out different possible
pasts, challenge the client's inadequate deterministic vision. In
Chapter 5, we present a case, "Luciano M . : Prisoner of a Family
M y t h " , in which, to overcome an impasse, it was necessary after
several sessions to turn the attention away from a rather inter­
esting family myth. Two errors had been committed: firstly, an
error of timing, in the sense that the theme of the myth was
introduced too early; and, secondly, the error of having been
too attracted to, or even seduced by, the myth itself, so much so
that it was impossible to get away from it for rather a long time.

THE PROCESS

Having described the evolution of our reference theory, the

method, the construction of the therapeutic context, the prin­
ciples for conducting the session, and the concepts of
deconstruction and reconstruction, we turn now to the thera­
peutic process.
We focus our attention on the brief-long therapy already
illustrated in Chapter 2, which is the type of individual sys­
temic therapy that we most frequently adopt with the majority
of clients with whom individual therapy is indicated. Other
cases that are not suited to this kind of therapy (such as those
involving severe psychotic disorders or requiring a support
intervention rather than a therapy) are dealt with in an open­
ended context, with a more flexible interval between sessions
and no fixed time limit. Before describing the different stages of
therapy, we deal with the first session, since it is of particular
importance and—in certain aspects—is different from the other
 THERAPEUTIC PROCESS 129

sessions. The first is a session of evaluation and consultation, in

which the goal is to determine whether there is a therapeutic
indication or not and, if so, which therapy is most appropri­
ate. 21

Given our roots in systemic family therapy, we ask those

who contact us to participate at the first meeting with the
whole family or, if a case of marital therapy is envisaged, with
the spouse. A t times the persons who contact us turn down the
invitation to come with the family or the spouse, preferring to
come alone to the first appointment. We, of course, accept their
decision. The first session (the assessment session) might there­
fore include: the person who asked for the appointment (who
might not be the "identified patient"), the family with or with­
22

out the identified patient, or the two parents, or both spouses.

In the first case, we might be dealing with individuals, who seek
our help to resolve their own specific problems, or who come to
gain a first impression of the therapists who are to take on the
responsibility of changing another member of the family (the
identified patient) through family or marital therapy. A t times
we have to deal with virtually the opposite situation: the family
agrees to come to the first session, but the moment they are
invited to initiate therapy they become unavailable and request
that the therapy be conducted with the identified patient only.
A l l these complications are connected with the context in
which we operate. Our centre has traditionally been known as
a centre for systemic family therapy, and only recently has its
name changed to the Centre for Individual, Marital, and Family
Systemic Therapy and Consultation. In any case, a careful
analysis of the referral, the motivations, and the assumption of

21
Unfortunately, the number of cases of brief-long therapy that have been
completed is still rather restricted (only eighteen so far) and is not sufficient to
perform a catamnestic analysis, which we therefore plan to effect in a subse­
quent work. For the moment, we find the results obtained quite encouraging,
reinforcing our expectations that this type of brief-long therapy could become
our favourite method of treatment; we also hope that colleagues in both the
National Health and private sectors might find it useful as well.
22
"Identified patient" is a term employed in family therapy to refer to the
person who, within the family, is defined as the carrier of the problem.
130 THEORY

responsibility is effected in the first session, regardless of who

is present.
We describe here how a first session is conducted with a
single client only. In such cases, where, despite the participa­
tion of the family in the first session, individual therapy is
offered, the second session (the first with the client alone) will
assume very similar characteristics to those of the first indi­
vidual session that we are about to outline.
The first session may last up to one-and-a-half hours and is,
in any case, often longer than the one-hour period usually allo­
cated to subsequent sessions. In the first session we examine
the significant system and how it has evolved in time with
respect to the problem presented (see Chapter 1). We should
first point out that the assessment (or diagnostic) process is not
distinct from that of therapy: the moment we request informa­
tion, we provide it, too (see Chapter 2).
A t the first session we have the written telephone report that
had been filled out by a member of staff (not the therapist) at the
moment of the first contact and contains basic information on
the referrer, the family members, and the problem presented.
There are two questions that the therapist must seek an­
swers to in the first session: what has brought this person to
search for help at this moment, and why our Centre or a spe­
cific therapist has been chosen. The answer to the first question
usually—but not always—emerges during the session through
the exploration of the client's story and the context in which the
client lives; the answer to the second is determined through
analysis of the referral.
The first question is usually "What has brought you here?"
or "Is there anything you wish to discuss?", leaving the client to
describe the reasons for requesting an opinion. The therapist
does not in fact ask, as would traditionally be the case, what the
problem is: to do so could contribute to an immediate distinc­
tion of pathology and the construction of a therapeutic rather
than a consultative context.
The most significant work concerns the exploration of the
meanings given by clients and their presentified others to the
" h o w " and " w h e n " of events, difficulties, and referred prob­
lems. Also explored are the relationships of clients with their
 THERAPEUTIC PROCESS 131

reference systems: hostility, seduction, disagreement, agree­

ment, support, etc. These data are collected through a series of
questions that refer to experiences, descriptions, and explanations
of the client and of the significant persons to whom he is con­
nected.
After having explored the present and the context in which
the client lives, we take an interest in the past—in other words,
the "memory of the p a s t " — i n order to look for connections to
23

and continuity with the client's present life. Moreover, we use

hypothetical questions to try to evoke possible pasts that might
foster the emergence of possible presents (and futures) and
thus pave the way for new evolutionary prospects.
One or more significant themes will eventually emerge dur­
ing the session, which will help answer the first of the two
questions for which the therapist is seeking an answer. Insofar
as the second question is concerned, we examine carefully the
reason for the referral, the story of the relationship with the
referrer, and previous contacts with other experts. Clearly, it is
very useful to be aware of any information concerning the
diagnosis, the therapy already effected, and, particularly, the
kind of relationship established on the part of these experts
with respect to the client, and vice versa. This information may
turn out to be extremely useful in gaining an idea of how the
client related to these experts and for introducing a degree of
novelty that avoids giving answers that the client has already
heard before.
A t the end of the session we give our opinion. If an indica­
tion for individual therapy exists and the client is suitable for a
twenty-session, brief-long therapy, the therapist then illus­
trates the therapeutic contract as follows:

The therapy we employ consists of twenty sessions at most,

including the present one, spaced at intervals of from two to
four weeks. In our experience, the majority of clients decide
to finish therapy before the twentieth session—at times in the

23
For an explanation of the concept that we only live in the present and that
the past is in our memory and the future in our expectations, see Boscolo and
Bertrando (1993).
132 THEORY

very first session, other times halfway towards the end of

therapy. A further assessment will be effected if, on the twen­
tieth session, you feel the need for further help. If I believe I
have exhausted my therapeutic options, I will not be able to
continue, and in this case you should feel free to turn to
another colleague if you choose. If you give us permission,
there might be some sessions where a team is present behind
the one-way mirror, and the sessions may be filmed. [The
financial aspects are then discussed.] If you agree with the above,
you can either tell me now or take time to think about it.

The first session is generally sufficient to reach this decision.

In some cases (e.g. Bruno K. in Chapter 5), a second consulta­
tion session may prove necessary. Examples of first sessions
that have been fully transcribed here are Bruno K / s and
Giuliana T / s (Chapter 5).
We stress again that the first session is therapeutic as well as
diagnostic: both the assessment and the therapy are part and
parcel of a reciprocating process. The therapist has an opportu­
nity of gleaning a more or less clearly defined idea of the case,
in terms both of the seriousness of the problems presented and,
above all, of the client's resources and potential. The therapist
will consider the client's story, particularly that which concerns
the client's personality, rigidity or flexibility, and capability to
face conflicts and resolve life's problems.
Though we consciously try to maintain a certain amount of
distance from ideas that we have about the client and our expec­
tations of the possible evolution of therapy, these cannot but
have an influence on the client, whose feedback may modify or
more or less confirm the therapist's expectations. This recursive
process is to be connected with one of the prejudices that we, as
systemic therapists, have gradually developed about the length
of therapy, in other words our therapeutic optimism.
We have already explained in Chapter 2 the reasons for se­
lecting twenty widely spaced sessions. It is, however, useful to
stress the importance of leaving to the client the decision to end
therapy whenever he decides to, thus acknowledging his com­
petence and his capability of overcoming a crisis, even i n a
short period of time.
 THERAPEUTIC PROCESS 133

After the first session, subsequent sessions, with due differ­

ences, follow a similar pattern. We begin each session by asking
the client what he has to tell us "today", by placing ourselves in
a Hstening stance, which favours the emergence of the client's
reflections, emotions, and fantasies associated with the last ses­
sion, the therapeutic relationship, and the client's own present
life. A s the session progresses, the therapist becomes increas­
ingly active and explores, with the client, one or more of the
themes emerging in the dialogue which have some particular
importance. The future is frequently introduced towards the
end of the session through questions, metaphors, anecdotes,
and so on: at times some final comment is also communicated,
as a metaphor or a story, which ties together the elements of the
session in a way that fosters the opening of new perspectives.
The comment is often developed on those elements emerging
from the exploration of a theme that appears of particular i m ­
portance in the client's life (see the transcription of the fourth
session of Susanna C , Chapter 5).
M a n y therapeutic approaches divide therapy into different
stages. A s far as we are concerned, we would distinguish an
initial stage, in which the most significant themes of the client's
life emerge; a central stage, in which these themes are worked
out; and, especially in those cases that go beyond the fifteenth
session, a final stage, in which the major theme frequently be­
comes separation from the therapist. To this extent, we identify
with Hoyt's observation (1990) that the macrocosmos of
therapy reflects the microcosmos of the session: just as it is
possible to divide a session into stages (initial, central, and
conclusing), so an analogous subdivision may be applied to
therapy as a whole.
With respect to the final stage of therapy, we can already
describe two types of cases: those that usually finish before the
fifteenth session, and those finishing after. In the first group,
the third stage is very brief or almost absent. Separation is a
relatively smooth process. In the other group of cases, how­
ever, the last phase is characterized by the intensity of the
emotions and feelings associated with the looming end of
therapy. These feelings may be strenuously denied, or openly
134 THEORY

expressed; in the latter case they are accompanied by the fear of

not making it or, more rarely, by explicit requests to continue
with therapy. The anxiety of separation may be so intense as to
make even the therapist wonder whether ending therapy is
such a good idea after all. In this case the therapist, often evalu­
ating his own feelings and therapeutic resources, might pro­
pose a new therapeutic programme or refer the case to another
colleague, as prescribed by the initial contract.
The striking inability of clients to recollect how many ses­
sions have passed is a fairly characteristic feature of the final
phase; it is therefore important for the therapist to remind
them. In one case (Susanna C , Chapter 5 ) , the client clearly
manifested an ever-increasing anxiety as the twentieth session
loomed nearer; this was eloquently illustrated by a very signifi­
cant dream where she found herself on top of a mountain range
halfway between her father's house and the therapist's studio,
frightened of falling down the precipice and asking herself why
she had decided to go on that journey. This was at the end of
the seventeenth session. The therapist suddenly interrupted
her to ask: " H o w many sessions do you think we have had to
date?" She appeared nonplussed, and after the therapist had
asked her which session she would have liked it to be, the
answer was: "the twelfth". To which the therapist added:
" T h e n today we have just finished the twelfth session. From the
next, however, I expect you to keep a tally of the sessions." The
client's answer was clearly one of relief. This, for the moment,
is the one and only exception to the twenty-session rule.
In the other cases in this group, the importance of facing the
theme of separation is expressed by telling the client that other
clients who had almost reached the end of therapy had decided
to stop at the eighteenth or nineteenth session, in this way
earning a "credit" payable by the therapist at any time in the
client's life. This separation ritual has proved itself to be thera­
peutic since it is a means to end—but not end—the therapeutic
relationship. 24

Please refer to Chapter 2 for the importance given by Mann, in short-term

24

therapies, to the mastering of the separation anxiety, which reflects itself in all
other neurotic anxieties.
 THERAPEUTIC PROCESS 135

LANGUAGE AND THERAPEUTIC PROCESS

A n important element i n the therapeutic process that has been

of a special interest to us i n recent years (Boscolo et al., 1993) is
that of language. The importance of language for systemic
therapy, though never having been overlooked, can be said to
have truly emerged after the advent of second-order cybernet­
ics and constructivist thought. Maturana's famous statement is
worth recalling: "Reality emerges in language through consen­
sus" (Maturana & Varela, 1980). In this way, language becomes
not just an instrument of knowledge, but the matrix upon
which we realize ourselves as human beings. Quoting
Maturana and Varela (1984):

Language was never invented by anyone only to take in an

outside world. Therefore, it cannot be used as a tool to reveal
that world. Rather, it is by languaging that the act of know­
ing, in the behavioral coordination which is language, brings
forth a world. We work out our lives in a mutual linguistic
coupling, not because language permits us to reveal our­
selves, but because we are constituted in language in a con­
tinuous becoming that we bring forth with others. We find
ourselves in this co-ontogenic coupling, not as a pre-existing
reference, nor in reference to an origin, but as an ongoing
transformation in the becoming of the linguistic world that
we build with other human beings, [pp. 234-235]

If "reality" emerges from language through consensus, then

in the dialogue with clients, by noting their language (and
therefore the way they perceive and conceptualize "reality"
itself) and of course our own, we can pave the way for the
development of new meanings and new "realities". In this
sense, language has become one of the protagonists in thera­
peutic dialogue and not merely, as used to happen, a means of
communication of which one is not usually conscious. W e have
therefore developed a new lens, the lens of language (it might
be more appropriate to add: and a new ear), to catch words,
verbal and analogic expressions, metaphors, and linguistic re­
dundancies and to grasp the structure of "reality" erected by
the client. Naturally, equal attention is given to the therapist's
linguistic expressions and the effect these have on the client.
136 THEORY

To describe this process, many authors (including ourselves)

have more recently employed Wittgenstein's (1958) theory on
linguistic games and, within the narrative model of the devel­
opment of new descriptions and new stories, Sluzki notes:
"What we call 'reality' resides and is expressed i n one's de­
scriptions of events, people, ideas, feelings, and experiences. . . .
These descriptions, in turn, evolve through social interactions
that are themselves shaped by the descriptions" (Sluzki, 1992,
pp. 5-6).
In our epistemology, the lens of language has added itself to
the characteristic and traditional one of the systemic m o d e l —
whereby the organizational and relational patterns are ob­
served—and to the lens of time that has been adopted more
recently (Boscolo & Bertrando, 1993). We would like now to
discuss what we consider, in the therapeutic context, to be the
most relevant of the linguistic elements that have recently been
in the limelight not only in the systemic approach, but also in
other approaches.

Rhetoric and hermeneutics

Considered from a linguistic point of view, therapy is a subtle

game of hermeneutics and rhetoric. By "hermeneutics" we
mean the work of interpretation and hypothesizing that one of
the interlocutors in a dialogue effects i n relation to the state­
ments of the other; by "rhetoric", we refer to the construction of
statements by each interlocutor with respect to the other. In
therapeutic dialogue, both rhetoric and hermeneutics are uti­
lized (though with different awareness) by both therapist and
client, as in fact happens in every form of psychotherapy.
It has been stated (Marzocchi, 1989) that, though in analyti­
cal therapies the client is a rhetorician and the therapist is a
hermeneutist (the client speaks and the therapist interprets the
client's words), in systemic therapy the relationship is turned
upside-down: the therapist is the rhetorician (the one who asks
questions) and the client is the hermeneutist, the one who fur­
nishes the meaning. The questions of the therapist implicitly
delegate the responsibility of interpretation, i.e. the attribution
of meaning, to the client.
 THERAPEUTIC PROCESS 137

The distinction outlined above is not absolute. It can be

stated for all therapies that the rhetorical/hermeneutic work is
reciprocal. For example, even the quietest analysts cannot ab­
stain from occasionally being rhetoricians as soon as they offer
an interpretation that places the client i n a position of attribut­
ing meaning. 25

We illustrate below some of the aspects connected with rhe­

torical and hermeneutic analysis of our way of conceiving and
conducting an individual systemic therapy.

Rhetoric

A treatment of rhetoric generally takes its cue from Aristo­

tle's definition: " L e t rhetoric be the power to observe the per­
suasiveness of which any matter admits" (Rhetoric, I, 2, 1355b).
Therapists belonging to given schools can be considered "occult
persuaders"—e.g. the strategic therapists (Watzlawick, Weak­
land, & Fisch, 1974), or the hypnotherapists (Milton Erickson
and followers: see Lankton, Lankton, & Matthews, 1991), who
have adopted the basic concepts of classical rhetoric. 26

Greek rhetoric considered the effects that could be obtained

through speaking—in other words, the relationship between
action and language—which is one of the central points of the
therapeutic relationship. The ancient world was, therefore, al­
ready aware of the intimate relationships existing between the
two aspects of communication; nor, more importantly, d i d they

25
Spence (1982) has shown how in psychonanalysis there is a "reciprocal
relation" between the patient's free associations and the analyst's evenly hover­
ing attention: if the patient's associations are truly free, the analyst's attention
must be "active and reconstructive" and engaged in finding a narrative sense
and continuity to the widely spaced fragments offered by the patient. If, on the
other hand, the patient actively builds a premeditated discourse, thus opting to
diregard the fundamental rule of free associations, the analyst can relax into
evenly hovering attention.
26
The latter group, in fact, employ paradox, symptom prescription, and
other behavioural prescriptions—that is, those interventions whose objective it
is to influence and manipulate the client with the therapeutic objective of extin­
guishing the client's symptoms.
138 THEORY

overlook the psychological aspects. In this sense, rhetoric was

the first discipline to act as a bridge between thought and ac­
tion; by contrast, logic severed one from the other. The art of
good speaking is secondary; what is of special relevance (at
least for us) is the way i n which a discourse (i.e. a given ar­
rangement of the elements in the discourse) manages to trigger,
in the interaction, emotions connected to given meanings. In a
nutshell, rhetoric excites strong emotions to change the listen­
er's way of acting.
For our purposes, however, the element of persuasion in
rhetoric is decidedly secondary. We approach it purely as a
means of using words to create a context i n which new mean­
ings may emerge. The particular regard given to the rhetorical
aspects of therapeutic work stems from the many common
points that, i n our experience, link these aspects to the type of
therapy we are involved in. In the first place, rhetoric is that art
(or craft, but certainly not science) which makes use of all the
facets of a word or phrase and in which that which conveys
meaning is as important as the meaning itself (Barilli, 1979).
A point where rhetoric and our systemic therapy overlap is
the fact that rhetoric renounces a priori the search for truth.
Since Protagoras's time, rhetoric is that domain i n which " M a n
is the measure of all things", and in which a range of truths is
admissible, truths that depend on further points of view. A s for
the systemic therapist, the rhetorician exists i n a multiverse i n
which multiple versions of reality exist.
A second point of contact between systemic therapy and
rhetoric is what McLuhan (1964) terms the " m e d i u m " em­
ployed by the therapist: the spoken word, the discourse. Rheto­
ric has, since antiquity, analysed the word as action. More
specifically, the evocation of the action occurs through the utili­
zation of a language rich i n metaphors: it is not by chance that
the image itself of the metaphor has been scrutinized since
antiquity (Aristotle) and, for centuries after, by actual scholars
of rhetoric. We deal more comprehensively with the subject of
metaphors later in this chapter, with particular reference to
those, almost always metaphorical, words that we have denned
as "keywords". Similarities and differences between a classical
rhetorician and a systemic therapist may be more easily traced
 THERAPEUTIC PROCESS 139

at this point. Both interlocutors attempt to achieve change

through language and through the emotions stirred by lan­
guage: both work with words and metaphors. However, unlike
the rhetorician, who has a given point of view to uphold, the
systemic therapist, in the dialogue with the client or family,
seeks for a range of points of view, which will never become
definitive: the effects of this search may amplify the horizon and
perspective of clients and generate new maps, new stories.
Paraphrasing Pirandello, clients in therapy can be viewed as
characters looking for an author, with whose help they may
enter a new script, a new story.
There is a clear distinction between therapies that employ a
problem-solving approach (e.g. strategic and behavioural ther­
apies) and systemic therapy, which may be framed in a rhetoric
of unpredictability. In this sense, the systemic therapist's rhetoric
may be included in a process of exploration that principally,
but not exclusively, relies on questions in general, and circular
questions in particular.

Hermeneutics

A n important linguistic correlation in our way of conducting

therapy is that which we communicate to the client through
our depathologizing and polysemic language. In contrast
27

with other therapists who tend to advise a client that they have
grasped the truth at the root of his symptoms or problems, we
implicitly communicate that absolute truth does not (for us)
exist, we deal only with different perspectives on things, differ­
ent slants. This overcomes the position of authority (in the
sense of possessing knowledge) and is, in its turn, therapeutic:
by not being obliged to think that the therapist holds the truth,
the other is free to do without it too, since nobody may possess
the truth. This is a hermeneutic position.

27
We would like to stress here the analogic component of the depatholo­
gizing language, which is, in many respects, more important that the verbal
aspect. The idea that the client's problems are more concerned with life's prob­
lems than the result of a physical ailment is transmitted principally by tone of
voice, mimicry, and posture and not simply through the verbal contents.
140 THEORY

Naturally, to adopt unreservedly a hermeneutic position i m ­

plies, in a way, a negation of the empirical perspective. A n d it is
impossible to conduct therapy without an empirical perspec­
tive. For example, we love to play with hypotheses and build
alternative worlds through them. But the principle of circular­
ity itself that we have adopted implies an unrelenting attempt
to verify or falsify our hypotheses in some way: even if we do
not believe that a hypothesis may be "true" or "reflect a given
reality", we do believe that the hypothesis must have at least
some sense for the interlocutor. Our verification, therefore, is
effected through a continuous monitoring of the client's verbal
and, in particular, emotional reactions, which allow us to assess
the degree of plausibility of our hypotheses; this may occur
through a significant emotional reaction, a state of particular
attention, or even through the client's explicit agreement with
what was expressed by the therapist.
The cornerstone of hermeneutic (and pragmatic) theories is
exactly this, to privilege the receiver, rather than the sender of a
given message: meaning is something that is attributed to the
message by the receiver. In Eco's (1990) words:

Different approaches such as the aesthetics of reception,

hermeneutics, semiotic theories of the ideal or model reader,
the so-called "reader-oriented criticism" and deconstruction
have elected to investigate . . . The function of construction—
or deconstruction—of the text through the act of reading,
which in turn is seen as an efficient and necessary condition
for the very activation of the text as such.
The assertion which is subject to each of these tendencies
may be stated as follows: the manner in which even a non­
verbal text works may be explained by considering, rather
than or in addition to the generative moment, the role played
by the receiver's understanding, comment, actualization, in­
terpretation, as well as the way in which the text itself is
geared for this participation, [p. 16; translated for this edi­
tion]

These lines highlight that what is generally termed the

hermeneutic model in fact refers to the model of textual analy­
sis. But the model is applicable to those "texts" that comprise
 THERAPEUTIC PROCESS 141

therapeutic dialogue as well. It is interesting that according to

Eco, the speaker participates in the interpretation of the text:
the text predicts its own use—even more so for a special type of
"text" such as the words pronounced by client and therapist in
the context of a session. Each one of us has intentions that must
be taken into account by the other. To use the language of
literary criticism, all clients have their own model therapist (the
therapist they wish to have), to whom they turn with their own
statements: in the same way, therapists have their own model
client, the client they think of when they devise their own inter­
ventions.
Such a position should lead us to tread warily with respect to
the possibility of arbitrarily attributing any meaning to what
the interlocutor says. There must be some economic principle
whereby the hypotheses developed cannot be totally free of all
constraints: if, according to Eco, we take hermeneutics to its
extreme limit, then everything may be interpreted in any way.
But if everything is interpretable in any way, then nothing is
any longer interpreted or interpretable. This open-ended inter­
pretation is taken to the level of absurdity by Eco himself in his
Diario Minimo (Eco, 1963), an interpretation of J Promessi Sposi,
in which Manzoni's nineteenth-century historical novel is read
symbolically as though it had been written according to the
allusive and allegoric categories of Joyce's Ulysses!
The limit to interpretation that is clearly required might be
represented by circularity as we understand it. The therapist
makes hypotheses but does not return these to the client di­
rectly: the therapist returns questions founded on those hypoth­
eses that might lead the client to make his own hypotheses. This
is why one client (Giuliana T., Chapter 5) when asked at the end
of a successful therapy what had determined the change in her,
answered that, after a number of failed attempts to understand
the therapist's "strategy", in other words to work out what the
therapist had in mind when asking the questions, she had de­
cided at a certain point to stop trying to understand the thera­
pist, and her interest was re-directed to the dialogue and
herself. With her words she was saying that she had become an
active participant in the therapy: not a receptor of interpreta­
tions or hypotheses, but a producer of her own hypotheses and
142 THEORY

attempts at interpretation, In this fashion, through questions,

the therapist helps the client to look within and to reflect on his
own relationships.
The systemic therapist, like a film director or a playwright, is
continually offering possible stories to the client, contributing
to the creation of a relational context in which it is the client
who decides, to accept these stories partially or fully or not at
all. The stories that we tell derive from the data of the client,
filtered through our experiences and prejudices and enriched
by the metaphors of our internal archives; it is then up to the
client to make sense of them. A t times the interventions are
similar to cryptic stories within which many meanings can be
made out; at other times they may be communicated in ritual
form to oblige the client to make sense of them personally.
However, the data we start with are always those offered by
the client, chosen and selected, of course, by the therapist as
observer on the basis of his theories and sensitivity.
This type of activity on the part of the therapist does not
make the client passive as, on occasion, other active therapists
come close to doing. Indeed, the systemic therapist's activity in
its turn generates activity in the client by resorting, where pos­
sible, to the rhetorical form of the question rather than to direct
statements (and, implicitly, injunctions) that would tend to fa­
vour the client's passivity.
In essence, applying systemic therapy implies diving with
the client into a complex network of ideas, emotions, and sig­
nificant characters, which are mutually connected and which
are explored by two interlocutors through the linguistic me­
dium. In systemic therapy it is the client who, in some way,
ends up by taking centre-stage and, with the therapist's aid,
develops a vision founded on relations and, at the same time,
processes. Moreover, the systemic therapist's way of thinking
is based on the complementarity of the concepts of linear and
circular causality, on the importance of a plurality of points of
view, and on an inclination towards self-questioning rather
than supplying answers; the ensuing effect over time is to
transmit to clients a way of connecting things and persons,
events and meanings, which frees them from a rigidly egocen­
tric vision of themselves and of the reality that surrounds them.
 THERAPEUTIC PROCESS 143

Gregory Bateson (1972, 1979) who inspired and fashioned the

systemic outlook, might have said that the therapy founded on
these principles can be considered as the generator of a context
of deutero-learning, in which the client learns how to learn and
how to connect "the patterns that connect".
Another way of describing the therapeutic process is to state
that through—mainly circular—questions the therapist fa­
vours the formulation, in the client's reflections, of hypotheses
on the possible typologies of the client's own experiences. It is
by capturing these possible typologies (e.g. a specific aspect of
the relationships clients have with their father, their mother, or
themselves) that clients may keep on reviewing their position
(and that of the Other) within the significant system of which
they are a part. In this way they can expand and delve further
into both their own sensitivity and the possibility of test­
ing out and seeing the events and stories that concern them in
a multiple perspective—rather than the acquired perspective
that tends to make clients relate in a rigid and repetitive way
towards themselves and others. Dipping into recent works of
fiction, we can therefore say that clients free themselves of a
distressing and burdensome story to enter a new one, one that
offers greater liberty, autonomy, and independence.
In this process it is clearly important to remember that, as
therapists, each one of us belongs to a given culture; however
much our theoretical approach tries not to be either instructive
or prescriptive, it cannot but have its own ideology on what
is " r i g h t " or " w r o n g " , "appropriate" or "not appropriate",
"healthy" or "unhealthy"; this ideology must be consciously
kept at a distance in order not to interfere significantly with the
client's attempts at finding a solution. There may be moments
in therapy when ethical, deontological, or even legal reasons
oblige us to take a clear and unequivocal position, accept our
responsibilities, and act on the basis of our ideology, which, in
such cases, leaves us no choice but to intervene. We are refer­
ring to cases of serious abuse and manipulation on the part of
the client, particularly against minors and individuals (fre­
quently women) who cannot defend themselves. In such cases,
the interruption of therapy and an involvement of the appropri­
ate authorities may be the only choice left. One must also not
144 THEORY

forget those cases where the worsening condition of a client—

with loss of contact with reality (e.g. in psychotic disorders) or
with a very real risk of suicide—forces the therapist to resort
even to forced hospitalization.
In less serious cases, the therapist may put aside understand­
ing or support and confront the client, even harshly, with re­
spect to his or her unacceptable behaviour and attitudes, which
would otherwise be implicitly confirmed and even reinforced.
We have repeatedly stressed the importance of the characteris­
tic positive view inherent in the systemic model; we do not
mean by this an unconditional declaration of acceptance of
clients' behaviours as some have understood: as can happen
between parent and child, the indiscriminate acceptance or
positive connotation may deprive the subject of the experience
of differences in value judgements, with easily imaginable
negative consequences. The art of conducting a therapeutic
28

dialogue resides in the ability to create a context in which cli­

ents learn by themselves the difference between values, be­
tween positive and negative, between good and bad, and in
which the therapist intervenes only in those very real situations
that inevitably require a stand to be taken.
A s may have been noted, the play of rhetoric and hermen­
eutics leads to an evaluation of a range of basic aspects of
the therapy. O u r model appears particularly open to us, in the
sense that it allows the greatest degree of freedom, both in
expression and in interpretation, to both of the actors in the
therapeutic dialogue. In this way we feel it might be possible to
realize the idea of dialogue expressed in that very clear and
incisive way by Hans-George Gadamer (1960):

We usually say "to have a dialogue", but the more authentic

the dialogue is, the less does the way that it develops depend
on the will of one or the other of the participants. The authen­
tic dialogue never happens as we would have wanted it to. In
general, it is rather more correct to say that we are "caught"
in a dialogue, if not altogether that the dialogue "seizes" and

Persistent and indiscriminate connotations of thoughts, emotions, and

28

behaviour in an individual may lead to extremely serious consequences—this is

equally true for positive as well as negative connotations.
 THERAPEUTIC PROCESS 145

envelops us. The way a word follows another, the way by

which the dialogue takes its own directions, the way by
which it proceeds and comes to a conclusion, all this cer­
tainly has a direction, but in this the participants are not
leading—they are, rather, being lead. We cannot know in
advance what will "result" from a dialogue. Understanding
or failure is an event happening in us. Only at that point can
we say that there was a good dialogue, or that it was born
under a bad star. A l l this suggests that the dialogue has its
own spirit, and that the words that are said in it bring within
themselves their own truth; they make "appear" something
that from now on "will be".

Language and change: keywords

A use of language that has revealed itself to be especially useful

in our therapy is that connected to "keywords". These are
words characterized by a high degree of polysemia, thus giving
the therapist the possibility of evoking in the most effective
way two or more meanings pertaining to the same word. Right
from the beginning of each session, the therapist pays close
attention to vocabulary (i.e. the client's type of language), con­
sisting not only of the repertoire of words but also the gestures,
stances, and the whole complex of non-verbal communica­
tions. This focus allows the therapist to weigh his or her own
words and emotions in order to integrate them within the con­
text created with the client.
The therapist thus becomes fully absorbed in a dialogue that
is as open as possible and in which language is a reciprocal
action between two people. In the complexity of the mutual
exchanges, countless networks of possibilities, actions, and
meanings stretch their tendrils. This reciprocity may be de­
scribed as the result of the effect of words and emotions of the
therapist on the client and, reciprocally, of the effects of words
and emotions of the client on the therapist. From the words of
clients, but chiefly from their analogic language, the therapist
may find guidance on the meanings that these attribute to the
therapist's own interventions, be they questions, stories, or
metaphors. A face that lights up, a look of understanding, or a
146 THEORY

sudden shaking of the head may all be signals that new per­
spectives are emerging. 29

We have repeatedly noted that during the session, the thera­

pist traditionally makes hypotheses about the therapeutic rela­
tionship in progress and on the relationship between the client
and his system of reference. We have recently started to take an
interest in the linguistic analysis of the therapeutic relationship
and the consultation. We have begun observing and concern­
ing ourselves with, in the first place, the words and non-verbal
signals that emerge in the dialogue with clients, particularly
those words to which the client seems to attribute a personal
significance. We have also concerned ourselves, as therapy
progresses, with the linguistic and lexical redundancies that
emerge in the therapeutic system (Boscolo et al., 1993), choos­
ing the most appropriate words and metaphors.
We are not saying anything new: texts on therapeutic tech­
nique have always underlined the importance of taking into
consideration the client's language in relation to social class,
ethnic group, and place of origin. These aspects, however, un­
derline a new evolution in our way of conducting therapy and
consultation—in other words, a new way of analysing thera­
peutic vocabulary, using words and expressions of the client in
their different meanings.
What we call keywords appear to us to be useful instru­
ments to associate with the use of metaphors. These words
exhibit specific polysemic properties: by being connected to a
wide range of different meanings, they can connect different
and opposing worlds. They are, in other words, bridge words.
They create states of ambiguity, they point things out, but they
do not denounce; they activate a kind of short-circuit between

Similar considerations have been made by Tom Andersen: "Many people

2 9

carefully search for words to express themselves. They search, at every moment
of time, for the words that are most meaningful for them. I find myself increas­
ingly engaged in talking with them about the language they use. Often unno­
ticed shades and nuaces in the words emerge through such talk and, very often,
this 'nuancing' of their words and language contributes to shifts of the descrip­
tions, understandings, and meanings that the language attempts to clarify"
(Andersen, 1992, p. 64).
 THERAPEUTIC PROCESS 147

the three different levels of cognition, emotion, and action

(Boscolo et al., 1993). Since keywords are polysemic and at
times ambiguous, they can evoke complex scenarios in the rela­
tionship between clients and significant persons and reactivate
distressing or traumatic past experiences removed by the sub­
ject's consciousness. Keywords also have a redefining power:
the breadth of their semantic range allows the collection of
different linguistic domains. We take up again an example
drawn from our article "Language and Change", which relates
to the context of family therapy.

If we are talking to the members of a family which has a

symptomatic member who—as often happens—has with­
drawn from social life, becoming a home-bound recluse, we
might say: " H o w do you explain the fact that she/he has
gone on strike?", and then say to him/her: " A n d why have
you decided to go on strike?" "Strike" is an ambiguous,
polysemic word covering a broad semantic field in which
various possible meanings come into play. The word be­
comes ambiguous because it is being used in a clinical con­
text where doctors would normally say "illness".. . .
Let us now return to our original word, "strike", and
examine the effectiveness of its connotations when it replaces
words like "symptom" or "illness" in a therapeutic conversa­
tion:
1. The word "illness" is a label which implies that all ob­
served behaviour should be regarded as unintentional; the
word "strike" introduces the connotation of voluntary, inten­
tional behaviour.
2. The word "strike" by definition connotes a relationship
since it suggests an action performed against or on behalf of
someone else.
3. By using the word "strike", the therapist sees his patient's
behaviour with people who are important to him as mean­
ingful.
4. As we have already seen, the various significata (i.e. con­
notations) of the word "strike" introduce ambiguity: a strike
may be justified or unjustified, may be called against or on
behalf of someone else in order to obtain or prevent some­
thing, may support a justified or unjustified cause, and so on.
148 THEORY

5. The temporal horizon implied by "strike" is different from

the one suggested by "symptom" or "illness". "Strike" sug­
gests a definite period in life, while an illness may be related
to an indefinite period, such as in cyclical or chronic diseases.
[Boscolo et aL, 1993, pp. 69-70]

Keywords may also be used in the individual context. In this

case they can help the client create new systems of meaning.
For example, in the interview with Giuliana T. (Chapter 5),
while exploring the relationships of the client with her o w n
family of origin, the therapist introduces at a certain point the
idea that the client's sister could be " i n love" with their father.
The keyword " i n love", with its ambiguous connotation i n the
context of a relationship between parent and daughter, stirs i n
the client a strong reaction, which contributes to defining the
boundaries of the network of family relationships in a clearer
and more emotionally significant way.
Similarly, in the case of Francesca T. (Chapter 5), a keyword
used by the therapist in the tenth session becomes of crucial
importance for the progress of therapy. The therapist uses the
word "hunger" (evidently important in the life of that bulimic
client) to connect it to the "hunger" for affection that the client
has had all her life and which is currently making her envisage
a continuation of therapy beyond the limit agreed at the begin­
ning, perhaps with another therapist.

THERAPIST: It's unusual that a client would have the idea of never
finishing, . . . and so it is possible that in your past you had the
feeling of not having had much devotion or love . . . and that
you have a great vacuum inside of you.
FRANCESCA [nodding in assent]: Yes.

THERAPIST: . . . and that at this point there is a great hunger inside

you, mixed with anger, because very often there is anger in
hunger.
[Francesca smiles.]

THERAPIST: Y O U also have a great hunger for your mother, and it is

somehow so huge that you think you'll need a whole life to
appease your hunger.
 THERAPEUTIC PROCESS 149

FRANCESCA: Yes. I need this.

THERAPIST; Satisfying your hunger. This is the idea that came to
our mind to explain to ourselves this very odd fact, because it is
rare that a client feels that therapy has to go on forever.

In this interchange, it is evident that the word "hunger"

acquires the characteristics of a bridge-word between the pa­
tient's symptom, her existential situation with respect to her
family of origin, and her relationship with the therapist and
with therapy i n general.
Words such as "intensity", " w a r m t h " , " l o v e " , and "hunger"
acquire other connotations when they refer to a relational con­
text. For example, to ask a client, " W h o is the warmest person
in your family?" introduces significant differences in the dis­
course and, perhaps, even in the client's perception of self. For
example: "Does your mother become warmer when she speaks
with your sister or with your brother?" A n analogous effect is
obtained through polarity: hot-cold, soft-tough, reversible­
irreversible, open-closed, and so on. News of differences al­
ways emerge: for example, "Who's the softy in your family?
Who's the toughest? D o you feel more at ease with a father
who is tough or who is a softy?"
It should be clear that keywords have no intrinsic effective­
ness if removed from the context of discourse. It follows that
certain ways of using given words are more effective than
others and are more likely to have a therapeutic effect. Fore­
most importance is given to temporal connotations: "Since
when . . . until when?" By asking clients, "Since when have you
been behaving like this?", it is implied that the behaviour had a
beginning, that this beginning is determinable, and that clearly
definable borders to the behaviour exist. One can continue by
asking, " A n d how long do you think this behaviour will con­
tinue?", the inference being that the behaviour will have an end,
which is then in some way controllable, and so on. It should be
noted that i n this case, too, a single word is sufficient to trans­
form the meaning of the discourse. To ask an anorexic patient:
" W h e n did you decide to stop eating?" implies power and
control, as well as resolve with respect to eating habits and
150 THEORY

decisions; to ask the patient: "When did you get the idea of not
eating?" implies dependency, or even slavery with respect to
the idea.
It is important that the therapist does not assume a moralis­
tic tone when using keywords, since these may also touch on
areas to which the client has a particular sensitivity. By taking
care not to assume a moralistic attitude, words that could be
understood as being provocative—e.g. "falling i n love" and
" m a r r y i n g " , between parents and children—will not risk the
creation of a schism between therapist and client. If, on the
other hand, the therapist creates a judgemental context, the
keywords often transform themselves into sarcasm and teas­
ing; i n this case, interactions may become destructive. Briefly,
one can say that the use of keywords presumes that the thera­
pist respects the solutions furnished by clients and, more fun­
damentally, empathically accepts clients as they are.

Denotation, connotation, and metaphors

One of the characteristics of keywords in therapy is their

strongly metaphoric value. A specific meaning of the term
"metaphor" is used here: A word or a group of words (a sign,
30

according to the semiotic definition) that has strong powers of

connotation.
Each sign placed in a system of. signification consists of two
elements—that which conveys meaning and the meaning itself,
indissolubly united as two sides of the same sheet of paper. The
relationship between meaning and what conveys it is, however,
not as straightforward as might first appear: it is unambiguous
only i n certain languages, such as computer programming lan­
guages; i n natural languages it is far more complex. Eco (1968)
distinguished very effectively between denotation (univocal
correspondence between meaning and that which conveys the
meaning) and connotation (a manifold correspondence be­
tween the two):

30
The metaphor may be considered as one of the founding priciples of
language, as well as of the conception of reality itself (see Cacciari, 1991).
 THERAPEUTIC PROCESS 151

Within a given code, then, a signifier denotes something that

is signified. Denotation is direct and unambiguous, and is
rigidly fixed by the code . , . Connotation happens when an
existing signifier/signified couple functions as the signifier
of some other significatum. This connotation may then gen­
erate a further connotation when, by the same process, the
previous connotation (itself a signifier /signified couple) be­
comes the signifier of a new significatum. [Eco, 1968, pp.
37-38; translated for this edition]

It is clear from what has been said above that keywords act
at a level of connotation. The more the terms employed are
polyvalent, rich in possible connotations, the more effective
they are likely to be. The therapist's discourse should channel
31

these connotations, as observed previously with respect to the

keyword "strike". A n equilibrium within the therapeutic dis­
course thus forms between the various connotations of the
words used. In this fashion, clients are not pushed into choos­
ing one meaning rather than another: they are, if anything,
stimulated towards choice.
Haley (1976), representative of the first Palo Alto group,
distinguishes two types of language—digital and analogic—
according to the dictates of the theory of communication classi­
cally adopted by that group. Haley's distinction has many
points i n common with our preferred one between denotation
and connotation:

The use of digital language to describe human behavior ap­

pears most appropriate when the subject is the study of a
human being dealing with the environment—when a person
is building bridges. This language begins to be problematic
when it is applied to human beings dealing with one
another.... When a message has multiple reference, it is no
longer a "bit" but is analogic, in that it deals with the resem­
blances of one thing to another. It is a language in which each

31
A n interesting analogy might be made between the concept of connotation
and the Batesonian idea (Bateson, 1972) of "difference that makes a difference":
polysemic words could be viewed as capable of producing differences and
therefore flexibility.
152 THEORY

message refers to a context of other messages.... Analogic

communication includes the "as if" categories; each message
frames, or is about, other messages. Included in this style of
communication are "play" and "ritual", as well as all forms
of art. [Haley, 1976, pp. 83-34]

The use of metaphoric language is both accepted and pro­

moted by different schools of psychotherapy and assumes the
passage be to a different style of communication, where evoca­
tion replaces the simple referral of facts. The use of a metaphor
is generalized and wide-ranging i n therapy; a metaphor may
consist of a single word (polysemic), as in the case of the key­
word, of a sentence, but also of a complex allegoric narration.
Analogies are also employed, such as the detailed description
of a case or of episodes in people's lives that are similar to those
of the client. This means of communication is frequently used
by Ericksonian therapists, who have codified a methodology
for producing therapeutic metaphors (Lankton et aL, 1991).

. . . the use of analogies, or metaphors, seems especially cen­

tral to the procedures of therapy. Quite different schools of
therapy have in common a major concern with the use of
analogic cornmunication... . The analyst's task was to apply
analogies of his own by interpretations and to explore the
connections between the various metaphors that the patient
was cornmunicating,. . .
Some therapists employ a systematic use of anecdotes
with patients. Milton Erickson has developed this procedure
more fully than most people. He tells the patient a story that
is formally parallel to the patient's problem and he views
therapeutic change as related to the shifts in the patient's
analogies provoked by the analogies he is receiving. [Haley,
1976, pp. 85-87]

In the case of Bruno K. (Chapter 5), we furnished an example

of this kind. The therapist picks out a metaphoric keyword that
recurs in the dialogue with the client, "journey" (understood
mainly i n the sense of travelling through life), and, at a certain
point, introduces a wider allegory, reciting the first triplet of
Dante's Divine Comedy: " A t the midpoint of the journey of our
life . . .". In this way, Bruno's journey is put in parallel with the
 THERAPEUTIC PROCESS 153

"paths" of Dante, thus enabling a significant exchange between

therapist and client. 32

According to Wittgenstein's theory of linguistic games

(1958-1964), it could be said that keywords and metaphors are
expended i n various linguistic games or, better, that they are
capable of favouring the passage from one linguistic game to
another, placing themselves i n the "interface" between them.
In Wittgenstein's words:

Systems of communication as for instance [those above] we

shall call "language games". They are more or less akin to
what in ordinary language we call games. Children are
taught their native language by means of such games, and
here they even have the entertaining character of games. We
are not, however, regarding the language games which we
describe as incomplete parts of a language, but as languages
complete in themselves, as complete systems of human com­
munication.

Often the patients whom we see i n therapy find themselves

locked into playing certain linguistic games and not others. The
use of words and polysemic sentences then assumes the func­
tion of a bridge between different games. The hypothesis u n ­
derlying such a procedure is that, if the patients manage to play
new games, then they can even escape from that type of need
that perpetuates suffering: experimenting emotionally (and not
only cognitively) with new language games therefore contrib­
utes to changing the premises and the view of reality.

32
The use of such a complex allegory was eased by the client's particularly
sophisticated and cultured use of language. As always, the warning about
tuning in to the type of language (of the world) brought by the client is valid
here, too.
PART II

CASES

Here, in the second part of our book, we are presenting a

series of cases to illustrate our therapeutic model. The
choice and order of these cases reflect epigenetic criteria.

In the fourth chapter, we present cases that were treated

mostly at the end of the 1970s, using a predominantly
strategic-systemic approach. Thus, this chapter shows a
way of working that nowadays we tend to use only in a
very limited number of cases, according to the indications
already given in the first part of the book.

The fifth chapter is dedicated to systemic therapies. It is the

longest chapter, because the way of working illustrated
therein is that which is, at present, most in syntony with
our current premises. These cases were all treated at the
Milan Centre for Family Therapy. The majority of them
were seen within our research on closed individual
systemic therapy, limited to a maximum of twenty
sessions. The cases in this chapter were chosen with
the aim of showing different phases and aspects of the
therapeutic process. Some thus follow the whole course of
therapy, whereas some of the others concentrate on a
specific phase (beginning or conclusion). The remainder
highlight specific aspects of the therapeutic process:
the therapist-client relationship, the use of language, the
presentification of the third party within the session.
CHAPTER 4

Therapy with a predominantly

strategic-systemic approach

T E R E S A S.: FORTUNE'S TRICKS!

A
t the beginning of the 1980s, a man telephoned our
Centre to make an urgent appointment for his wife,
Teresa, who had suffered for two years from every
possible phobia. When he was given the appointment, he said
that it was impossible for his wife to come to the Centre be­
cause of her overwhelming phobias, and that Dr. Boscolo (the
doctor whom Teresa's psychiatrist had recommended) would
have to go to their house, which was 20 kilometres from Milan.
The secretary finally convinced the man that Dr. Boscolo d i d
not make house calls, and so he agreed to bring his wife to the
Centre. O n the day of her appointment, the client was brought
there by ambulance, because she was afraid to travel i n a car
without medical supervision! Because of her fear of lifts, she
had to be accompanied by her husband and a nurse up the
stairs. A t the beginning of the session, she seemed extremely
apprehensive, almost to the point of having a panic attack. The
most evident phobia was agoraphobia, which had kept her
prisoner in her home for more than two years, since pharmaco­

157
158 CASES

logical and psychological interventions had had no effect.

However, even at home she was full of fear: fear of germs and
all sorts of illnesses, as well as fear of her own aggressiveness.
For example, she was afraid that she might take a knife and
stab her only son. A s a precaution, she made him move in with
his maternal aunt and the aunt's husband, who lived two floors
below in the same building.
During the course of the first session, it came to light that
Teresa had a peculiar relationship with her sister. The sister, a
pharmacist, was jealous of the client because Teresa had been
their mother's favourite and also because Teresa's husband
was an important person, an engineer and a successful indus­
trial manager. The sister was especially jealous because Teresa
had a son and she did not. The sister was married to an engi­
neer who was an employee of Teresa's husband. For the past
three years, the sister had been in analysis.
At the end of this first session, the therapist made the inter­
vention that follows.

THERAPIST: The situation seems clear to me. I think that three years
ago you began to be ill because you felt that you were too
fortunate, particularly in comparison with your younger sister.
Your having a more prestigious and more attractive husband
than your sister, your having a son who was good in school,
your having been your mother's favourite, your being in good
health while your sister had to go into analysis because she
wasn't well—all this has caused you to have deep guilt feel­
ings, which you have had to rectify by withdrawing into your
house, causing yourself to suffer much more than your sister,
and living a life of uncontainable anxiety.
[The client nods continuously, all the while looking intently at the therapist.]
THERAPIST: Now, I can continue seeing you for some sessions, but
on one condition: that you do not change at all for a long time.
That is because I fear that it is quite probable that you will start
to feel better after a few sessions, and I fear for your sister. Your
sister has been in analysis for three years, and if you begin
coming here and get better after two or three visits, with all the
symptoms you have, she could get very upset, leave her ana­
lyst, and find herself in a lot of bad trouble.
 STRATEGIC—SYSTEMIC APPROACH CASES 159

[Teresa starts and, in a tone of protest, says that she has the right to be well,
and that perhaps she's paid enoughfor being so fortunate!]
THERAPIST: Of course. I understand, but the situation is what it is. If
you happen to feel better the next time I see you, then I'll have
to make the intervals between sessions a lot longer. Because, if
your sister gets worse because you get better, then this will
become intolerable to you and you will have to get worse, like
the way you are now. Therefore, if, by chance, you should feel
a bit better, at least make the effort of not speaking about it to
your sister.

After this paradoxical intervention, Teresa began to feel bet­

ter. A t the time of the second session, she was able to come to
the Centre in the car with her husband, and at the beginning of
the session she said, with poorly disguised satisfaction, that she
felt better and that her fears were much diminished. She reas­
sured the therapist that she nonetheless was able to hide her
improvement from her sister. After only four sessions, Teresa's
symptoms had virtually disappeared, and therapy ended with
the seventh session. This case is typical of how a classical strate­
gic intervention of reframing and the prescription of the symp­
tom can lead to a notable therapeutic success. It is interesting
that later the sister called and asked to be treated by the thera­
pist, but he turned down her request on the grounds that she
was already the client of a fellow therapist, and the proper
thing for her to do would be to discuss with her therapist her
dissatisfaction with their current relationship. During the next
ten years, Teresa became one of our most enthusiastic sources
of referral, and she sent many cases to our Centre. One day, she
telephoned the therapist to discuss sending h i m one of her
nephews for therapy with him. Instinctively, the therapist
asked her about her life, and she replied that she was fine—but
unfortunately her sister had died of breast cancer at the age of
45, about two years after Teresa's therapy had ended.
A suggestive and fascinating hypothesis might be: was there
a relationship between the complete recovery of the client and
the sister's tumour and subsequent death?
160 CASES

GIORGIO B.; WHO ANALYSES WHOM?

This case is atypical and is a hybrid type of therapy. It began as

a classical analysis, with the therapist complying with the
wishes of the client. However, gradually it was transformed
into a predominantly strategic therapy. The duration of the
therapy also reflected this compromise. It was a long-term
therapy by strategic therapy standards, but it was brief com­
pared to the initial expectations of the client.
Giorgio was a 40-year-old, married professor of philosophy
at a northern Italian university. He made an appointment with
the therapist and showed up by himself. H e had been sent by a
friend who had finished a classical analysis with the therapist
ten years previously. The friend, who knew about Giorgio's
problems, had continued to exhort the professor to go to his old
analyst, because he was positive that this would have been of
great help to Giorgio.
Giorgio said that he was aware of the developments in psy­
choanalysis and also of the specific theoretical itinerary of the
therapist. H e knew that the therapist had passed from psycho­
analysis to systemic family therapy. However, he specified that
he d i d not have any intention of involving his family in
therapy, and that he wanted psychoanalytic treatment like that
which his friend (whom he held in great esteem) had had. A t
first, the therapist felt inclined to refuse, but by the end of the
session he felt mainly curious and challenged, and this stimu­
lated h i m to accept the request. Therefore, at the end of the
1

preliminary first session, he proposed an analysis three times a

week.
When Giorgio came the following time for the first real ses­
sion, the therapist let him choose between the couch and the

At this point, one could object that the therapist was not perfectly honest.
1

The most logical alternative would have been refusal, which naturally would
not have changed anything. The therapist, as an analyst and as a systemic
therapist, gave primary importance to the great trust (positive transference)
that the client had in his friend, and that Giorgio's friend had in the therapist.
Thus, he decided that this was a more than valid criterion for accepting the
client's request. In fact, the client's trust was one of the fundamental elements in
the success of the therapy.
 STRATEGIC-SYSTEMIC APPROACH CASES 161

chair. Without hesitation, the client chose the couch, and thus
2

began a "strange" analysis which continued without a hitch for

several months.
The therapist (who had now taken on the role of analyst),
while trying to be an analyst, nevertheless could not avoid
being influenced by systemic theory and praxis, with which he
had worked daily for a number of years. From time to time, the
client manifested his impression that the therapist was not
orthodox enough and did not go sufficiently into depth. The
therapist answered him by saying that this was quite possible,
but that he was trying his best. Twice the client actually criti­
cized the therapist in an irritated tone of voice, accusing him of
straying from psychoanalysis. "That's quite possible," was the
answer. Immediately afterwards, to satisfy Giorgio, the thera­
pist hastened to give an interpretation that was classically
Freudian, both in language and in content, of the dream that
the client had recounted shortly before.
A s time passed, a solid therapeutic relationship developed,
and the need of the client to be psychoanalysed diminished,
and later completely disappeared. Giorgio showed significant
change and, in time, became more and more curious about his
couple relationship and family relationships. Before the end of
the first year of therapy, he had changed to having one session
a week, face-to-face. After another six months he finished
therapy, to the satisfaction of both parties. The strange thing
about this therapy is that it began as psychoanalytic treatment
and, in time, it became transformed into strategic-systemic i n ­
dividual therapy. From a strategic-systemic point of view, one
of the keys of this therapeutic success was the initial one-down
position that the therapist took with regard to the client by
accepting, up to a certain point, Giorgio's request and thus
favouring the development of a trusting relationship that al­
lowed the patient to listen not only to himself but also to what
the Other had to say. Naturally, one could also make other
hypotheses. A psychoanalytic interpretation of the change

2
The first act of therapy was the introduction of a characteristic alternative
("yes, b u t . . . ") of the strategic approach.
162 CASES

might be that the therapist's basic attitude during the course of

therapy had allowed him to overcome the client's resistances.

ENRICA S.: THE LADY WHO WAS NOT ABLE

TO GO SHOPPING

A t the first encounter, this rather apprehensive 50-year-old

woman, Enrica, said that for six years she had been suffering
from a tenacious form of agoraphobia, which had kept her
from going past an imaginary circle situated at a distance of
about 150 metres from her house. Whenever she attempted to
go past this limit, she was assailed by an intolerable anxiety
and had to go back. It is significant that the closest shops were
about 200 metres from her house. To be able to go shopping,
she had to ask her husband or one of her three children to
accompany her; even when she was with them, her anxiety
about passing the 150-metre line did not completely go away.
Enrica lived like a handicapped person. She had already had
psychotherapy twice, but she had interrupted therapy both
times because, as she said, "It was always my past and my
family that was talked about, but my incapacity to go any dis­
tance from my house remained and is . . . still the same as
before." Often she felt frustrated by her misfortune and by her
need to depend upon her children, which interfered with their
life and their independence. From this information, her objec­
tives and expectations appeared very clear: "Free me of this
phobia!"
A t the end of the first session, the therapist (Boscolo) decided
to utilize a strategy that could be considered both behaviouris­
tic and strategic. H e told Enrica that, to organize a sound pro­
gramme that could free her of her "handicap", she would have
to bring some data to the following session, two weeks later.
O n three days out of each of the two weeks, she was to count
how many paces she could take in each of the four cardinal
directions before arriving at that fateful boundary. She was to
write down the results in a notebook kept for this purpose. A t
the following session, they would calculate together the aver­
age of the six measurements of distances in which she had
experienced no symptoms of anxiety. The therapist, by imme­
 STRATEGIC-SYSTEMIC APPROACH CASES 163

diately coming to the point and responding clearly and un­

equivocally to the client's request, had immediately created the
conditions for a trusting relationship, a prerequisite for ena­
bling the client to carry out such a tiring and laborious assign­
ment.
A t the second session, the therapist and the client accord­
ingly calculated the average distance in paces. The prescription
for the following two weeks was as follows: each morning
Enrica was to walk in the direction of the shops and stop at the
number of paces established from their calculations. However,
on alternate mornings, she was then to face up to her anxiety
and take five additional steps in that direction. It was empha­
sized that it was quite likely that she would still feel relatively
calm after these extra five steps and that she might well feel
tempted to continue ahead. However, she was absolutely for­
bidden to take even one more step; otherwise, she would have
to begin all over again. In this prescription, one can clearly
see techniques both of deconditioning and of strategic therapy.
For example, this is reminiscent of the experience of " o r d e a l " ,
typical of the interventions of Jay Haley and Milton Erickson
(Haley, 1973, 1976) and of the "rituals" characteristic of the
interventions of the Milan Approach group's strategic-system­
ic period.
A t the third session, Enrica seemed more relaxed. She con­
fessed that, to her surprise, the anxiety that she had feared she
would feel when taking those five extra steps did not material­
ize and that she had to fight the temptation to walk further.
After having given this a positive connotation, the therapist
told her that she was to continue following the same prescrip­
tion for the next two weeks. At the beginning of the fourth
encounter, Enrica, with an air of embarrassment—which, how­
ever, did not quite hide her joy—confessed that she had dis­
obeyed the prescription. She had not been able to keep herself
from continuing on to the shops, because her anxiety had al­
most completely disappeared. She had gone shopping alone
three times. Therapy was successfully terminated at the sixth
session, with the complete disappearance of the symptom. The
possibility of a resumption of therapy was left open in case
Enrica might eventually feel the need for it.
164 CASES

UGO B.: THE SLEEPLESS PAEDIATRICIAN

This was a typical emergency case that needed a direct inter­

vention on the symptom. The intervention in this case was
taken from the work of Milton Erickson (see Haley, 1973).
Dr. Verdi worked as a paediatrician in a hospital section for
premature infants. His job of treating these very young patients
required particular concentration.
Accompanied by his wife, he arrived at our Centre in a state
of agitation, which revealed deep worry. H e said that for some
time he had suffered from an intractable insomnia. Pharmaco­
logical treatment had not been successful, and he had not been
able to sleep at all for a number of days. H e had begun to have
the kind of chromatic hallucinations that are characteristic of
sleep deprivation. He had already been repeatedly absent from
work, and he was terrified at the thought of seriously harming
his tiny patients, due to the difficulty of giving endovenous
injections or of making other interventions that required calm­
ness and a focused his attention.
His wife revealed that both she and their two teenage daugh­
ters were also alarmed by various statements her husband had
made—for example, that he expected a catastrophe, perhaps
losing his job or even losing his mind. A t the end of the session,
the therapist told the client that there was a very efficacious
way of dealing with this situation—one that did not require
taking medicine but did require great sacrifice and great will­
power. Dr. Verdi insisted forcefully that he was ready to do
anything to get out of the infernal situation in which he found
himself. The therapist told him that he would absolutely have
to avoid sleeping for seven consecutive nights—that is, until
the next session a week later. "Is that all?", the client asked with
an incredulous expression. "But I am already not sleeping!"
The therapist replied that there must inevitably have been
some brief periods in which he had dozed off and that it was
impossible for him not to have slept at all for several days
because otherwise he would already have developed an un­
mitigated hallucinatory syndrome. The therapist calmly and
precisely explained that in order to fall asleep, a relaxed state is
necessary, and he added, in technical terms: " a state in which
 STRATEGIC—SYSTEMIC APPROACH CASES 165

the parasympathetic, that is, the vagal tone of the nervous sys­
tem, prevails", which for h i m had not been possible for quite
some time because of his agitation related to a continuous
prevalence of the "sympathetic tone".
The technical explanation seemed to have the desired effect.
The client said, "I see. I will make every effort not to sleep for
all of the nights until the next session." To help h i m in this
difficult endeavour, the therapist suggested that, from late at
night until breakfast time, he could remain upright, walk back
and forth in the room, perhaps reading while walking, or even
go out of doors to take a walk. If, however, he gave in to the
sleepiness, all of the work that he had done would have been in
vain, and he would have to start all over again from the begin­
ning.
The client came to the next session unaccompanied. H e was
visibly more relaxed. H e said that on the fourth night, at three
o'clock in the morning, he had given in to the strong temptation
to lie down on the couch for a couple of minutes and then woke
up after about ten hours. Naturally, his wife had not awakened
him. The next night, more or less the same thing happened,
and, for the first time in months, he began to feel calm and
relaxed. The following evening, since he felt so calm, he de­
cided to see if he could spontaneously sleep all night through,
and this happened. The therapist said that this was a positive
development, but that it was not yet the moment to declare
victory. The therapist asked the paediatrician to repeat the pre­
scription again for the following week. A t the third session, the
client said that the prescription had not been necessary, be­
cause he had spontaneously been able to sleep regularly. Since
no important problems had emerged, the therapist and client
decided together to terminate therapy.
CHAPTER 5

Systemic therapy cases

GIULIANA T: LIFE AS CONTROL

H
ere we present, practically in its entirety, the first of
nineteen therapy sessions that this client attended at
our Centre.
Giuliana was a tall, slender, and pretty 26-year-old woman.
She worked as a translator in the public relations department of
a company. She had been sent to the Centre by a doctor who
had diagnosed her as having chronic anorexia-bulimia. She
came to the first session wearing a close-fitting dress that ac­
centuated her curves, and during the session she moved with a
vaguely seductive demeanour. After the formal introductions,
she began to describe her symptoms.

GIULIANA: I've suffered from bulimia for many years. The first
time I had it—it was a particularly nasty form of anorexia­
bulimia—was when I was sixteen. It ran its course in about a
year. Then I had the problem again when I was eighteen or
nineteen. That time it lasted for a number of months. It always

167
168 CASES

began w i t h a diet, a very strict, low-calorie diet, of course.

A f t e r w a r d s , w h e n I h a d lost a fair amount of weight, I began to
have hunger attacks, actual b u l i m i c attacks, a n d I v o m i t e d .
A n d also this time the b u l i m i a went away b y itself. F i n a l l y ,
w h e n I was twenty-three, it arose again, and I've h a d it f r o m
that time on. It began w i t h anorexia. I went very q u i c k l y f r o m
m y u s u a l 52 to 54 kilos to 44 or 45 . . .
THERAPIST: Y O U speak of episodes of anorexia a n d of b u l i m i a . . .
GIUTJANA: Yes. A n o r e x i a a n d b u l i m i a . A l w a y s together.
THERAPIST: Y O U say always together. But does it begin w i t h ano­
rexia, a n d then later there is b u l i m i a as well?
GIULIANA: U s u a l l y I start out on a very r i g i d diet w i t h v e r y strict
control of what I eat, a n d then, w i t h i n a very short time . . .
THERAPIST: H u n g e r wins out.
GIULIANA: Yeah. O r , rather, at the beginning it's a p h y s i c a l need,
but afterwards it becomes a sort of addiction to food or, rather,
to specific kinds of food. I've been undergoing treatment for
some time n o w , w i t h the help of various doctors, dieticians,
and specialized clinics. I've tried a bit of everything, especially
this last time, beginning at age twenty-three. A t that time, I h a d
been going to a psychologist because I was going through a
crisis. For several years, I h a d h a d a relationship w i t h a m a n
w h o was m u c h older than I, and I d i d n ' t k n o w whether I
w a n t e d to break u p w i t h h i m or continue the relationship. So, I
went for advice, a n d then, after a few sessions, I went into
analysis. It was d u r i n g this analysis that m y problems of ano­
rexia a n d b u l i m i a began again. Probably they came on again
because I've always h a d them deep d o w n inside.

H e r first r e m a r k s s h o w her intensity a n d v o l u b i l i t y . She speaks

as i f u n d e r pressure, bent over a b i t , l e a n i n g f o r w a r d t o w a r d s
the therapist. H e r thoughts f l o w freely, a n d h e r d e s c r i p t i o n s
are v e r y d e t a i l e d . D u r i n g the course of the session, one gets the
i m p r e s s i o n that her descriptions s h o w the i n f l u e n c e of h e r
p s y c h o t h e r a p i e s a n d her v a r i o u s r e a d i n g s i n p s y c h o l o g y . H e r
last w o r d s of this segment i n t r o d u c e us to t w o i m p o r t a n t p e r ­
sonages: the m a n w i t h w h o m she has a r e l a t i o n s h i p a n d a
therapist.
 SYSTEMIC THERAPY CASES 169

T h e therapist m u s t a l w a y s m a k e a choice b e t w e e n v a r i o u s
alternatives, of w h i c h subject to talk about. A t this m o m e n t , i n
the b e g i n n i n g of the session, the therapist d e c i d e d to pass over
G i u l i a n a ' s r o m a n t i c attachments a n d , i n s t e a d , d e a l w i t h the
p r o b l e m s that t o r m e n t e d her a n d w i t h w h a t she h a d d o n e to
resolve t h e m . Therefore, he t u r n e d to the subject of the t h e r a p y
that G i u l i a n a h a d u n d e r g o n e .

THERAPIST: H O W long d i d y o u r psychoanalysis last?

GIUUANA: W e l l , I was w i t h that psychologist for a couple of years,
I think. Then I changed. I h a d decided, among other things, to
go a n d live on m y o w n w h i l e I was i n analysis. I m o v e d to
another city to be o n m y o w n , and there I consulted another
psychologist. I began to be treated b y this n e w psychologist,
whose name I h a d happened to f i n d reading an article o n
b u l i m i a i n a newspaper. A n d she really d i d help me for a
certain p e r i o d of time.
THERAPIST: H o w l o n g d i d this therapy go on?
GIULIANA: W e l l , for quite a bit of time, because I just stopped last
year. It lasted about three years.
THERAPIST: SO, y o u were i n therapy for five years, altogether.
GIULIANA: Yes. T h e n I tried other avenues: biofeedback, medita­
tion, just about everything i n order to get a grip o n this thing.
But the basic problem is that, i f I only h a d to control m y eating,
I c o u l d manage to live w i t h this anxiety of keeping myself
under control for a l l of m y life. Right n o w I'm controlling m y ­
self a lot, a n d , i n fact, I'm almost anorexic. That is, i n the sense
that I eat very little: some foods are taboo. I k n o w that if I eat
them, I ' d probably e n d u p w i t h an attack of b u l i m i a , so I e l i m i ­
nate these foods completely. A n d I live under control. But
keeping myself under control isn't easy, a n d also, w e l l , I k n o w
it isn't the w a y things should be.
THERAPIST: A n d w h a t happens w h e n y o u lose control?
GIULIANA: Then I start eating sweets, lots and lots of them. It de­
pends on where I am. If I'm near a supermarket, I go i n a n d
b u y whatever sweets the supermarket has. If I'm near a pastry
shop, I b u y them i n the pastry shop. A n y w a y , it's always sweet
things: sweet rolls, biscuits, p u d d i n g , ice cream, and so on. If
170 CASES

there's nothing else around, I'll even eat a can of corn, or what­
ever there is around the house.
THERAPIST: When you have an attack, how much do you eat, how
many kilos would you eat in a day?
GIULIANA: A n awful lot, because I eat and then I vomit and then
continue eating again and again.
THERAPIST: Give an estimate—more or less.
GIULIANA: I don't know. I could eat a cake and a packet of biscuits,
and then I'd vomit, eat a kilo of ice cream, a package of biscuits,
and another cake, and then vomit again, and then eat an egg
beaten with biscuits . . . I can't tell you exactly how much, but
it's an awful lot, because I have attacks one after another, that
is, I don't simply have one every day . .. right now, though,
I've been okay for several days. Saturday, for example, I had an
attack after ten days without one.
THERAPIST: Have you ever taken laxatives?
GIUUANA: N O . Because, you see, the day after, I always feel ill,
because at a certain point, there's actually a sort of physical
decline.
THERAPIST: Do you earn enough to manage with all this expense on
food, or do you need help to pay for it?
GIUUANA: Well, at the beginning, mostly, when I didn't work be­
cause I was still in school, naturally I was helped by my par­
ents. Then I began to work, and I had my own salary. Now I try
to manage without their financial help.

It is unusual to get such a rich and detailed spontaneous

description of the drama of an anorexic-bulimic person: of the
victories and defeats in the battle to keep control of food intake
and of weight, and also of the particular obsessions that are
characteristic of this person's life. In this last segment, the
reader can notice a parallel between Giuliana's voracity with
regard to food (which gets set off when she loses control over
the selection of "dangerous" foods), her taking in and vomit­
ing, and her relationship with the various specialists, whom
she first seeks out and then discharges.
She appeared to have difficulty in establishing a long-term
relationship with a therapist with whom she could relax and let
 SYSTEMIC THERAPY CASES 171

herself go. This observation was extremely important to the

therapist, because, early on, it offered him a key to understand­
ing what might be the best type of therapeutic relationship to
establish. A t this point, the therapist inquired into Giuliana's
family. •
Giuliana has a sister named Antonella, who is a year
younger than she. Antonella has a degree in political science
and works in marketing for a television studio. She had had a
few painful relationships with men and had just broken up
with her fiance, after going with h i m for four years. A t that
moment, as a result of breaking up, she was in a "terrible de­
pression". She had been in therapy for some time and was
living with her family. The younger brother, Luca, was 23. H e
was studying for a degree in political science and was engaged
to be married. "Everything goes right for h i m . . . he's excep­
tionally well-balanced." The father was 50 years old. H e was
the general manager of a large clothing company, of which he
was also one of the owners. The mother, who was 48, had
worked at designing jewellery in a workshop at home for many
years. The relationship between Giuliana's parents had always
been very tense and conflictual.
A t a certain point, Giuliana began to talk about her ex­
fiance.

THERAPIST: You were telling me that you had sought help for these
bulimic attacks. How are you doing now?
GIULIANA: Okay, Til explain how things went. Shortly before my
therapy with the psychologist ended, I met a man with whom I
felt very comfortable. He, too, had a rather complicated situa­
tion, but his problems were concrete ones. He had a child to
support and had had a rather complicated love affair. His
socioeconomic background was very different from mine, quite
a bit lower. He has a great healing capacity, and, anyway, since
I felt comfortable with him, we started keeping company. It
seemed to me that I was healthier with him. Now I have second
thoughts about all that. Naturally, it's typical that when you
have one thing occupying your mind, it drives out the other.
You have a new situation to deal with, so somehow you man­
age to keep certain things in check. And, above all, when
172 CASES

you're in love, you try to give the best of yourself, so I managed

to restrain myself. Apart from the fact that I didn't find a solu­
tion, not even with the therapy that I did before, little by little I
got the feeling that I was in a sort of a stalemate situation.
Sometimes I was okay, sometimes not. I'd have a good day and
then two bad ones, an attack or two, but not always—some­
times they eased up a bit, and there were periods in which the
attacks were few and far between, and others in which they
were close together. I couldn't manage to get really better, not
even inside me. A n d so, well, I decided to break off the
therapy. (I've always been the one to make the decisions.)
Then, after a few months, we decided that we'd live together—
naturally on my insistence—terrible, isn't it?—and . . .
THERAPIST: On your insistence?
GIULIANA: Yes, I always make the decisions. He was very insistent.
He is very attracted to me, and he's very possessive and jeal­
ous. He says that he finds me beautiful and intelligent. He's
fifteen years older than I am, kind of short, but very nice and
also generous. He's living with his mother and his five-year­
old daughter, whom he had by another woman. We've begun
to fix up this house that we've found, and naturally other prob­
lems have begun to pop up. I was under pressure because of
other things, and I began to be ill again. Certain things have
come out that weren't visible before, certain aspects of person­
ality, maybe difficulty in understanding. Well, it isn't easy for
him, either, to try to understand this kind of thing, because . . .
THERAPIST: Sexually?
GIULIANA: Sexually, okay, within my limits, because I've never
been . . . that is, I've always had a quite normal sexual desire,
like anybody else, but, I would say, I'm completely incapable
of orgasm. However . . .
THERAPIST: You've never had an orgasm?
GIUUANA: Well, not with penetration.

Giuliana's relationship with others and with the external

world appeared to be completely and rigidly conditioned by
the problem of controlling her food intake. She described her
relationship with her man-friend as if he were a kind of medi­
 SYSTEMIC THERAPY CASES 173

cine for preventing bulimic attacks: " . . . when you have one
thing occupying your mind, it drives out the other. Y o u have a
new situation to deal with, so somehow you manage to keep
certain things in check." Shortly before deciding to live with
her man-friend, she had decided to break off her therapy be­
cause there had not been any improvement. It was as if she had
stopped taking the "therapist medicine" and had turned to the
"man-friend medicine" instead. It was always she who decided
everything—to begin and end relationships. She seemed to be
prey to an existential uneasiness, which led her to consume
food, specialists, and men without ever managing to feel sati­
ated and without being able to find peace in herself. She ap­
peared to have particular difficulty in establishing an intimate
relationship with any person and to run away from relation­
ships in order to avoid being controlled. This uneasiness also
showed up in the way she expressed her thoughts and emo­
tions. It was as if she lived in a turbulent sea where everything
was unsteady. From a diagnostic point of view, her case resem­
bles that of a borderline personality, and, as we will see later, it
has many points in common with the cases of hysteria de­
scribed by Freud.
The therapist and Giuliana returned to the subject of family
relationships.

THERAPIST: Do your sister and brother approve of your father giv­

ing you money, or do they object to it?
GIULIANA: N O , they don't object to it. But now the financial situa­
tion has changed a bit, because my father's company, like all of
the others, is going through a time of recession. So my father
said to me, "Listen, if I don't give you money, it's also because
this is not such a great period."
THERAPIST: In other words, a moment of crisis . . .
GIULIANA [interrupting]: Exactly! But he also said to me, "If you
want, I'll give you money for taking care of your health prob­
lems, but for anything else, you'll have to manage by yourself."
But I'm content—I really mean that. Lately, I'm happy because
I know that I can't spend money, because I haven't any extra,
so I have to somehow keep tabs on myself. It's awfully hard. I
174 CASES

have to work with all of my might to keep myself in check, but

that's better than being ill. O n the other hand, not having any
particular physical discomfort, I manage to keep going. Do you
see what I mean? I haven't ever had any other illnesses—touch
wood! A l l I've ever had was colic one time.
THERAPIST: How's the relationship between your parents?
GIULIANA: They've always had disagreements, and four years ago
they went through a particularly conflictual period. It was re­
ally dramatic, and they were always dragging us in, and after
this, I. ..
THERAPIST: Y O U had the first attack?
GIULIANA: Yes. Yes, it was right then. I had this messy situation of
my parents going on, and at the same time I had decided to live
on my own and to break up with my boyfriend, so it was a
bunch of things all together. Since I already had a number of
problems, adding those on top of mine, I just couldn't manage,
and I couldn't stand it.
THERAPIST: A n d before that, what could have caused your eating
disorders?
GIULIANA: Well, all I know is this. From what I can remember—
and my memories, unfortunately, only go back to the time
when I was seven or eight—before that time, I remember prac­
tically n o t h i n g . . . mm, I had a whole bunch of huge anxieties
and attacks of depression, really terrible depression. I remem­
ber that I used to have an allergic form of asthma, which went
away by itself, around the time I was thirteen, without desensi­
tizing treatment. I'm sure it was psychosomatic. I remember
horrible anxiety attacks, especially at night. I don't think it's at
all normal for a child of six to wake up in the middle of the
night screaming, "I don't want to die!" I was very depressed. I
know that I was very depressed. I was a very solitary child.
I always played by myself. I had very few friends. Even though
I was very sparkling in any social situation, I was always rather
solitary. From what I can remember, from the time I was a
child, I always ate immoderately, and besides, I've had lots of
bad experiences, also bad love affairs, and maybe these, too,
added up . . .
THERAPIST: Have you had many love affairs?
GIULIANA: Quite a few, I'd say . . . yes, I'd say many.
 SYSTEMIC T H E R A P Y C A S E S 175

THERAPIST: Does it generally happen that the men win you over or
is it you who make the conquest?
GIULIANA: N O , generally I'm the one who makes the conquest.
THERAPIST: S O , it's always you who gives the message—right?
GIULIANA: Yes, I think so. Yes, I believe so.
THERAPIST; Y O U decide, "I like this one", and you give him this
message.
GIULIANA: Well, I'd say, I'm the type who is wooed. However, I've
always been the one to choose, even . . . mm . . . I don't know,
I'm not sure, but I think that it's unlikely that a person would
have any luck if I didn't like him.

In this last segment, the therapist had sought possible con­

nections between Giuliana's symptoms and various events in
her life, especially those of her family life. With respect to the
timing in a session (see Boscolo & Bertrando, 1993, Chapter 5),
i.e. the appropriate moment at which to inquire into "sensitive
topics", the exploration of such topics is introduced cautiously
only towards the end of the session, after a climate of coopera­
tion and trust has been established. A connection was seen
between the last and most serious episode of bulimia (which
had become chronic) and the beginning of a time of great strife
between Giuliana's parents. Giuliana had described a child­
hood of solitude, depression, and anxiety attacks, connected
with the first two instances of bulimia.
Later on in the session, the therapist inquired into the possi­
bility of sexual abuse in childhood. This is fairly common in
cases like Giuliana's. Moreover, Giuliana's inability to reach
orgasm and her need to be the one in control in her relation­
ships with men led to the idea that there might have been
traumatic events of this kind in Giuliana's past.

GIULIANA: The man I'm going with now is thirteen years older
than I am, and I am very faithful to him.
THERAPIST: Does he love you?
GIULIANA: Yes, he's a very good person, who has loved me very
much and who still loves me even though he knows my prob­
lems. He's a very good person.
176 CASES

THERAPIST: After six years of therapy and analysis, what do you

think of this situation? What have your therapists told you?
GIUUANA: At the beginning, when I went to this last therapist, he
had me take some tests. These tests showed a dramatic situa­
tion, that of a person who was practically on the brink of sui­
cide [laughs], a person with a frightful depression. Actually, it is
really difficult for me to assess what I might have got out of this
type of relationship, especially because Tve always had this
very strange sensation—that is, the sensation of somehow be­
ing able to deceive the therapist, of being able to make him say
what I wanted, and also to be able to say whatever I wanted to
and still be believed. Naturally, in this type of deception, I'm
the person who loses out, because it's all to my disadvantage, I
don't achieve anything.

The revelation about her relationships with her therapists

that Giuliana made in the first session is significant. It was a
confession, and it was also a warning about her need to ma­
nipulate and control her therapist. She described first seducing
and then controlling in her love affairs. She gave the impres­
sion of being a cat playing with a mouse. Her need to control
the Other seemed to shield her from the anxiety of a close
relationship, but she was nonetheless left thwarted, empty, and
unsatisfied. She had the bitter feeling that " i n this deception,
I'm the person who loses out, because it's all to my disadvan­
tage".
She had a similar behaviour pattern also with eating. When
she managed to control her consumption of food (anorexic
phase), she felt fine, but when she couldn't manage (bulimic
phase), she was overcome by states of terrible anxiety, which
bordered on panic. These states of anxiety were alleviated by
resorting to vomiting. It is interesting to compare Giuliana's
message to the therapist about what kind of relationship he
could expect in the future with her comment at the end of
therapy. A t the end of the final session (the nineteenth), the
1

It is o u r practice to dedicate a few minutes at the e n d of therapy to inquire

1

into what the client feels were the most significant moments of therapy, as w e l l
as those related to change.
 SYSTEMIC THERAPY CASES 177

therapist asked Giuliana what she thought was the reason for
her clear improvement and the disappearance of her symp­
toms. Giuliana looked the therapist straight in the eye and,
giving h i m a meaningful smile, said that from the very first
session, she had tried to guess his strategy. This had been easy
with other therapists, but this time it was to no avail. A s time
passed, she had stopped "racking my brains to figure out what
Dr. Boscolo is thinking". She paused, and then, as if she had
suddenly seen the light, pointed her finger at the doctor and
exclaimed, " A h a ! now I understand. Isn't the real secret of my
change in your not letting me know what you were thinking? I
tried and tried to understand, to no avail, and now I'm well. If
I had understood, maybe, I might still be at square one!"
One could take these statements as a comment on the thera­
pist's neutrality, which permitted the client to find her own
solutions.

GIULIANA: There's another thing that I would like to tell you. I

write a lot. I write stories. When I was in high school, I wrote
fairly well. I even had something published. Every now and
then, I reread them. In many of these stories, it seems as if there
were another person inside me. Very often I have this sensation
of being two persons. Sometimes it happens that when I wake
up, it seems as if there were another me resting on the pillow,
an evil me. It's this person that comes out when I'm not well.
THERAPIST: This person that's inside you, the other . . .
GIULIANA: It's the other face.
THERAPIST: What do you mean when you say "evil"?
GIULIANA: The evil part of m e . . . to me it's the evil part of me.
THERAPIST: When did you begin having this idea?
GIULIANA: Oh, years ago, many years ago . . . I don't know. Listen,
when I was a small child. . .
THERAPIST: Is it a spontaneous idea of yours, or did it come out in
therapy?
GIULIANA: No, it didn't come out in therapy. I would connect it
with an episode that took place when I was very young. When I
was a young child, I was terrified of the dark, of devils, and of
ghosts. I remember that at a certain point I had a fixation about
178 CASES

being possessed by a devil, because sometimes I would behave

in a very nasty manner. So it seemed to me that I behaved
nastily because there was something in me that made me be­
have that way. [She laughs.] I remember terrible tantrums, and
my mother would look at me terrorized [continues to be amused]
and say, "What is she saying?" I remember that when I made
my first confession for the First Communion, I had terrible
anxiety, because I wasn't sure of having said everything. I said
to myself, " M y confession isn't valid any more. I'm damned."
THERAPIST: Did you feel like one person or two? Did you hear
voices ...?
GIULIANA: N O . It wasn't like that.
THERAPIST: Did you feel as though you had more than one person
inside?
GIULIANA: Well, you know, this kind of conversation is rather odd,
because I've read quite a lot about it. I remember that when I
was attending university, before I went to interpreters' school, I
studied liberal arts for a few years, and I had Professor Fornari
for psychology. I was fascinated. I read many books, and so on.
I had also read something about schizophrenia, but that's dif­
ferent from what I feel, because I'm always aware of reality.
THERAPIST: Could we give a name to this second "person"?
GIUTJANA [laughs]: Okay, if you want to, but I wouldn't know what
to call her, I can't even think of one name. [She is still amused.]
THERAPIST: When was it that you last had a dialogue with this
other person?
GIULIANA: Yesterday morning. I had the strangest sensation. It
was as though there were this face, this face near me, and it
was my face, but it was as if it were stretched tight with the
eyes reduced to mere slits, as if I were swollen, like when I eat
and vomit and then become swollen because of retention of
water. I had been well for several days, and when I'm well, it
often happens that I have nightmares. I dream that I've eaten. I
wake up in a terrible state of anxiety and I say, " O h , damn it,
I've resisted up until today, and now I've pigged out." Then I
say, "What a relief! It was only a dream." So yesterday morn­
ing I woke up after one of these dreams, and I felt as though
there were this presence close to me, and it tried to strangle me,
 S Y S T E M I C T H E R A P Y CASES 179

and deep down inside me I thought, "Okay, come out! Come

out! Then we'll see who's the winner!" Do you know what I
mean? Because . . . "

Giuliana described herself as if she were divided into two

parts, a good part and an evil part. Sometimes it was as if she
communicated with another Giuliana, like when she saw her
double's face next to her own. (Another example is when she
woke up from a dream and felt as though there were another
presence next to her that tried to strangle her.) A t this point the
therapist thought about whether he should consider the possi­
bility of a multiple personality. This controversial diagnosis is
now very much in vogue in the United States. However, the
client was always very much on guard about the therapist's
possible motives. It seemed as though she believed that he was
looking for symptoms of schizophrenia. Citing her knowledge
about it, she reassured him that it was not schizophrenia. In
other words, here she put herself in the role of co-therapist!

THERAPIST: I notice that you speak very rapidly. Do you always

speak this fast?
GIULIANA [laughing]: Yes, I've always. ..
THERAPIST: Is it that you've always had a great need to talk about
things?
GIULIANA: Yes, I've always had a great need to talk.
THERAPIST: Is it like this at home, too?
GIULIANA: I've always talked a lot. When I was a child, people said
that I was a talking machine.
THERAPIST: IS it a need of yours?
GIULIANA: Yes. I have something inside me that I have to let out.
That's the sensation I have. Often. . .
THERAPIST: Y O U feel that you have something to let out. When
you're talking like a machine, does this somehow tend to at­
tract the attention of the other person . ..?
GIULIANA: Yes. Yes. I know that I'm egocentric.
THERAPIST: When you get together with other people, for example,
at work, you . ..
180 CASES

GIUUANA [interrupting): I am the centre of attention . . . the centre of

attention.
THERAPIST: I don't know. To me it seems like a sign of insecurity.
You do it, because otherwise it would be unbearable for you
that people .. .
GIULIANA [finishing the sentence for the therapist]: . . . might not notice
me.
THERAPIST: Might not notice you? Is it this?
GIUUANA: Yes. I'm sure it's this. I've always been . . . I've always
had a certain dualism in my character. I've always been very
insecure of myself, also about my looks, also because I was very
lazy as a child. M y sister, instead, was very good at sports. I
was lazier. I always had to be forced. I remember that when I
was about fifteen or so, my father used to say to me, "If you
don't do any exercise, you're going to get fat. Right now you're
fine, but later on you'll be sorry." That got me going. I began to
exercise—actually doing body-building. I developed a marvel­
lous physique. I was all muscle, and this gave me a certain
feeling of security. And I've always felt insecure about how my
face looked. I even had plastic surgery to correct my nose and
my chin, because I had a receding chin and a slightly long nose.
Nobody has ever noticed this, but I was paranoid about it. I
was sure that nobody liked me because of this physical defect.

Here Giuliana continued to act as a co-therapist, showing off

her diagnostic ability. In a few quick comebacks, practically
stealing the words out of the therapist's mouth, Giuliana made
the diagnoses of "egocentrism", "desire to be the centre of
attention", and of "dualism of character". She was quick and
accurate in guessing what the therapist had in mind. Some­
times it seemed that she was responding to questions as if she
were taking an oral exam at school, as if she were trying make
the teacher think of her as the best pupil. The therapist ab­
stained from making her see her behaviour, from evaluating
her, and from interpreting her behaviour, so as to avoid con­
tributing to a sterile awareness, which would merely have con­
formed to one of the many explanations she had picked up
about her behaviour.
 SYSTEMIC T H E R A P Y C A S E S 181

At a certain point, Giuliana started speaking again about her

sister and how she and her sister looked. She remembered that
when she was fifteen, her father had criticized her looks, lead­
ing Giuliana to take corrective measures. She also remembered
being obsessed by a dislike of her looks and consequently hav­
ing plastic surgery. Afterwards, she described her relationships
with her sister and her brother. She and her sister had always
had a friendly relationship, even though they had both secretly
envied the other. They were beautiful in different ways. She
was tall, blond, and blue-eyed. Her sister was petite, with black
hair and eyes, a classic type of beauty. The two sisters tended to
be anxious and depressed, but the brother had all positive
qualities. H e was extroverted and well-liked. These differences
could be attributed to the fact that the sisters had been drawn
into their parents' conflicts and open fighting, while Luca re­
mained out of all of this, maintaining a good relationship with
everybody. The therapist then asked about Giuliana's parents.

THERAPIST: N O W about your parents . . . what's your mother like?

GIULIANA: M y mother had a lot of problems—also psychological
ones. She comes from a lovely family that had serious prob­
lems. When my grandfather was still a young man, he had a
cerebral ictus, and was completely paralysed as a result. So, the
family, which had been quite well-off, suddenly found itself in
financial trouble, and my grandmother had to look after four
children and a completely paralysed husband. Also, after my
mother got married, the family had to move from place to place
all over Italy, because of my father's work, so she was always
far away from her relatives. She often had feelings of insecu­
rity.
THERAPIST: What's your relationship with your father like?
GIULIANA: It's been a real disaster...
THERAPIST: Has it always been a disaster?
GIULIANA [laughing]: Well, yes, for the last fourteen years, yes.
THERAPIST: When you were a child, did you feel closer to your
father or your mother?
GIULIANA: Well, from a certain point of view, I now realize that I
was closer to my mother, but, you know, certain things hap­
182 CASES

pened that I don't remember. I remember the first time my

father took me out, but this was told to me afterwards, because
I had completely blotted it out of my memory. M y sister says
that she remembers everything and that she remembers this
episode very well: my father had an affair with his secretary,
and he brought me along when they went skiing. He took me
skiing in the winter and boating in the summer. I don't remem­
ber it at all.
THERAPIST: H O W old were you?
GIULIANA: I was about five or six. I remember only that at a certain
point, my mother separated from him, and she brought us to
Milan to my grandma's, and then later they got back together
and moved away to another city, because my father had be­
come a partner in a new company. M y father is an exceptional
person in the business world—he's a real success. He's also
very well-known socially. I would guess that my mother had
all sorts of problems with him and has never been happy. She
was very jealous, and he was a real ladies' man.
THERAPIST: Did your mother also have affairs ..,?
GIUUANA: N O . M y mother, absolutely not. She has been faithful to
my father. I'd bet my life on it, because she just isn't the type of
person to do something like that . . . or even think of doing it!
THERAPIST: D O you remember ever, in the past, long ago, having
been in love with your father?
GIULIANA: I think I was always in love with my father. I admit it
openly. I don't have any difficulty in admitting that.
THERAPIST: A n d are you still in love with him?
GIUUANA: No, probably not any longer. No, not any more. I would
say that, especially since I've been in love with this older man,
everything has changed. I've always worshipped my father,
rather than loved him, worshipped him, luckily.. .
THERAPIST: A n d how did your father regard you?
GIULIANA: I've always definitely been the favourite in many ways,
even if he's a person who maybe doesn't show his feelings with
hugs and kisses, but . . . I was the favourite.
THERAPIST: Did this disturb your mother?
 SYSTEMIC THERAPY CASES 183

GIULIANA: M y mother?!? No, no, I don't think so. No! Also because
this is so ., .
THERAPIST: Didn't she even notice?
GIULIANA: Well, maybe she noticed it. She said, " Y o u know that
you are preferred over your brother and sister", so . . .
THERAPIST: A n d your sister, for example . . .
GIULIANA [interrupting]: Yes, this disturbed my sister a lot.
THERAPIST: Was she disturbed by this thing between you and your
father?
GIULIANA: Yes. Yes, she was.

THERAPIST; Did your sister prefer your mother or your father?

GIULIANA: Mmm. I think she preferred my mother, also because at
that time she worked in the same company as my father did
and she said to him, " D a d , if you're having an affair with your
secretary, please tell me, because this is a terrible situation for
me. Every day M u m asks me questions. If you're having an
affair with this person, tell me right now, because I don't want
to work with you any more." A n d he swore and swore again
that this wasn't true. Then my mother had him followed and
had photos taken of the two of them together, walking hand in
hand, and so [laughs] he could no longer deny it. M y sister was
especially upset by this. She said, "I wouldn't have said any­
thing to Mum. Of course I wouldn't have done anything about
it, but I would have removed myself from this awful situation,
that is, I would have avoided as much as possible being in the
middle."
THERAPIST: Had your sister been on your father's side . ..?
GIULIANA: Yes. She felt very bad, because she felt that she had
been deceived.
THERAPIST: Maybe your sister was also in love with your father.
GIULIANA; N O . You see, I would say that love, in classical or Oedi­
pal terms, doesn't fit, not even in my case. It was more a type of
worship, as if he were a mythical being, an idol. He is a suc­
cessful man, who towers over all the others, someone who
always does the right thing, who is always right. Besides, he's a
very youthful type. He does a lot of sports—he goes sailing and
hunting.
184 CASES

THERAPIST: He seems like a fascinating m a n . . .

GIULIANA: He plays tennis. He's really handsome. However, he's
very brusque and untalkative. He doesn't speak much at all.
THERAPIST: He seems like a very interesting type of person.
GIUUANA: Yes, very interesting.

In this long segment, the therapist inquired in detail about

the relationships between the parents and between parents and
children. The story that came out is reminiscent of the clinical
cases of Sigmund Freud, There was a mythified, youthful fa­
ther, who was a sportsman and a great social success. The three
women—mother and two daughters—have had a long-stand­
ing love-hate relationship with him. They were upset by his
infidelities with other women. H e was not very home-loving
and was very susceptible to female charms. The mother ap­
peared to have been an insecure woman who was in perpetual
conflict with her husband. She tried, without success, to influ­
ence and control him. She had sought the support of her daugh­
ters and had tried to involve them in her touch-and-go
relationship with her husband. Giuliana, her father's favourite
child, seemed to have been under the illusion of being the one
and only "apple of his eye", but it was an illusion, in that she
was constantly losing out to victorious rivals. She may have
had the feeling of having been seduced and abandoned; in a
similar way, she, too, seduced and abandoned the men she met.
The reader will note the contrast between Giuliana's expres­
sions of admiration for her father and the way she (immedi­
ately afterwards) described her current boyfriend: " . . . since
I've been in love with this older man, everything has changed.
. . . " She and her sister were similar in both having had a ten­
dency towards anxiety and depression. Both had had a not very
affectionate, "runaway" father as well as an anxious, fre­
quently depressed mother who had sought support from them,
rather than giving them support. The three women gave the
impression not so much of being mother and daughters but
rather of being three sisters, united by their common difficulty
in achieving a stable and satisfactory relationship with the
other sex. These hypotheses take account of the fact that
 SYSTEMIC T H E R A P Y C A S E S 185

Giuliana's memories and descriptions are her interpretations,

and as such, have been influenced by previous psychotherapy,
by Giuliana's readings, and by her relationship with the thera­
pist in the here-and-now. The session continued with the explo­
ration of family relationships.

THERAPIST: Was your sister always closer to your mother?

GIULIANA: Yes, I think so.
THERAPIST: A n d your brother?
GIULIANA: M y brother sided with my mother when he felt that she
was in the right. When my father kicked up a row, he would
side with her, but he was also able to say to her, " M u m , cut it
out, because you're being a real pain in the neck. You're mak­
ing a mountain out of a molehill."
THERAPIST: How does your father behave with his son?
GIULIANA: He respects him . . . yeah, I'd say he respects him.
THERAPIST: Is he also a bit proud of this child?
GIULIANA: Well, my father is the kind of person who never really
shows his pride in us. He's always said, "You're parasites.
You're like gypsies. Get moving and do something. Just be­
cause you have money, you think . . . " et cetera. He's never
been a big one for showing affection—except when we were
small children.
THERAPIST: Was he trying to motivate you . ..?
GIULIANA: Yes. I'm sure that this rigid behaviour has its roots in
his difficult childhood, because he really did have a difficult
childhood. He was forced to work at an early age to support his
family and to also make it possible for his brother (who is now
a doctor) to go to medical school. So, therefore he has a very
taciturn character. When he lets go and makes what he intends
to be a show of affection, like putting an arm around some­
body's shoulder or holding somebody's hand, it's funny. It's
comical [laughs]. Seeing him hand in hand with his secretary in
the photo made me laugh. It seemed comical to me.
THERAPIST: How was he with you and your sister when the two of
you became teenagers and started to be interested in boys?
GIULIANA: He was always very strict, especially strict about cur­
186 C A S E S

fews. For example, he'd say, "You can't go out after this hour",
or "You have to be home by eleven o'clock." I think he did this
because he was jealous.

The information about the father's difficult childhood, about

the need for him to earn money to maintain his childhood
family, gives meaning to his attitudes about duty and to his
brusque behaviour with his family. After the tragedy of her
father being paralysed, the mother, too, had had a rather diffi­
cult family life. When she got married, because of her hus­
band's frequent work-connected moves she was not able to
maintain a close relationship with her side of the family. Life
had been difficult for both parents in their families of origin,
and it continued to be difficult also in their marriage. The chil­
dren seem to have taken on the role of consolers and go­
betweens. The two daughters seem to have done this at the
personal cost of having later had difficulty in individuation and
in separation from the family.
The next segment deals with the inquiry into possible sexual
abuse in childhood. This is often an area of inquiry in cases of
bulimia and of disassociative disorders.

THERAPIST: Is it possible that when you were a child, there might

have been any episodes of you being sexually molested?
GIULIANA: N O , not when I was a child, except for the usual things
with other children, like "You pull down your underpants and
I'll take off my undershirt" and playing doctor. I have a very
unpleasant memory of the first time I had sexual intercourse as
a teenager and also of the person with whom I had it, because I
think he was a particularly difficult person. I seem to have a
penchant for seeking out mixed-up persons. Anyway, he was a
boy who I think had psychotic problems. He was argumenta­
tive and had loads of paranoid ideas. He was convinced that he
was in love with his cousin and that we couldn't love each
other because he had certain things inside him, stupid, just
absurd paranoid ideas. Anyway, I had a bad experience of
sexual relations with him—I even felt pain.
THERAPIST: Pain?
GIULIANA [looking at herself in the one-way mirror]: Yes, it hurt a lot,
and for a long time I was sure that I had been destroyed.
 SYSTEMIC THERAPY CASES 187

THERAPIST: D O you like our mirror?

GIULIANA: Yes, because I'm used to looking at myself in the mir­
ror—I've always done ballet.
THERAPIST: D O you like your body?
GIULIANA: Yes. I like my body when I keep myself in check, when I
eat properly.
THERAPIST: A n d when you don't eat properly, do you continue to
think about your body, that you are ruining i t . . .
GIULIANA: Yes. I'm actually terrified. I'm very anxious. In fact, I'm
very apprehensive about taking the pill. I'm terrified of getting
fat.
THERAPIST: A n d if you let yourself go a bit, is it like looking in a
distorting mirror?
GIULIANA: Yes. It's like looking in a distorting mirror: "Heavens,

I'm humongous! Just look at that—what a belly! Incredible!"

THERAPIST: H O W do you explain the fact that you, and not your

sister, came down with bulimia?

GIULIANA: You know, I've been trying for years to figure that out.
I've been trying for years to understand why it is I who has this
need to gulp down food and then chuck it all up. I don't under­
stand it, because both of us have been through the same diffi­
cult situations. I don't know. I've been desperately looking for
an answer. Maybe what I'm doing wrong is always looking for
this answer and hoping that others will give it to me.

This last sentence is reminiscent of what Jay Haley wrote

about his experience in psychoanalysis in his book Strategies of
Psychotherapy (1963). H e says that for a long time the patient
constantly tries to understand what the therapist thinks of h i m
or her and continually hopes that, in the future, he or she will
receive some answers. After going through this torment for a
long time, the patient gives up and gets better. We find this
point of view suggestive and worthy of consideration, al­
though we feel that it is not sufficiently developed and that it
does not explain the complexity of the process of change.
The inquiry into possible sexual abuse in childhood was
fruitless, even though it did lead Giuliana to talk about her first,
painful experience of sexual intercourse (dyspareunia) and her
striking sensation of having been damaged forever.
188 CASES

The unusual question of why she, and not her sister, came
down with bulimia implied that bulimia was not to be consid­
ered a disease but rather an experience that was tied to facts of
one's life. This is in syntony with the process of depathologiza­
tion in therapy.

THERAPIST: Are you content with your life? Do you think about
yourself in the future and in old age?
GIULIANA: N O , I don't think about old age. I do think about all of
the time that I've wasted eating and throwing up. A n d I also
think, "Look, even though I'm bulimic, I've managed to do all
of these things." I think about having realized rather important
goals, because I have a good career and a good job, I've had a
university education and a very interesting one at that. I've had
the opportunity to do a lot of sports, I'm able to manage my
own affairs, and I have a nice love life. A l l of this—independ­
ently of the fact that there are problems—but there are always
problems. Okay, it does bother me that I've thrown away so
much time.
THERAPIST: At work are they aware of your problem?
GIULIANA [interrupting]: I'm terrified, I'm really terrified of them
finding out.
THERAPIST: They don't know t h a t . . .
GIULIANA: That would be the last straw! If they knew that I was
bulimic, that is . . .
THERAPIST: But does the bulimia interfere with your work? You're
able to do very well at w o r k . . ,
GIULIANA: Yes, I do very well at work.
THERAPIST: Are they content with your work?
GIULIANA: Yes. Goodness, they have to be content. They are really
very content. I practically created my work from zero, because
this company didn't have market research reports, and my
boss and I created them together.
THERAPIST: H O W do you get along with your boss?
GIULIANA: Fine. I find him a very witty person, and I think that
right now it would not be a good thing to create an ambiguous
situation at work, because my work is the only thing in my life
 SYSTEMIC THERAPY CASES 189

that is truly mine—it's something that I've succeeded in by my

own efforts. If anybody tried to mess it up, or if I botched it up
by myself, that would mean that I would be without anything
that is secure in my life. So, Pm keeping a tight hold on the
work I'm doing.
THERAPIST: You came here with your mother, but you asked to
speak to me alone ,. .
GIULIANA: Yes, I prefer to be by myself. I had asked her to come for
moral support [laughs].
THERAPIST: Moral support?
GIULIANA: Yes. I said to her, "Come with me because I'm scared."
THERAPIST: Scared?
GIULIANA: Yes.

THERAPIST: Scared of what? Of talking with me?

GIULIANA: Yes. I don't know. I was scared. I felt uneasy.
THERAPIST: What are you hoping to get out of therapy?
GIULIANA: I want to discover why I am bulimic, and maybe if I
discover why, it'll go away.
THERAPIST: How did you hear of our clinic?
GIULIANA: I asked my sister, who is in therapy, to ask her psy­
chologist if he knew of a specialist in bulimia who could really
help me, because I'm sick and tired of it, I can't go on like this. I
can't continue to go on like this, like an idiot, going to an
infinite number of therapists, who are surely very competent at
certain things—but I want to stop seeking and find somebody
who really knows about bulimia. So, she asked her psycholo­
gist and he personally called me and said, "Listen, I know of
this clinic that does work in this field. Call them. I don't know if
you can get an appointment, but do try anyway." Even though
I did have to wait a long time, here I am. I wanted to quit
wandering from place to place [laughs], hither and thither, from
one place to another. I know that this is something that de­
pends on me. I want to finally get to the bottom of it to try to
help myself.
THERAPIST: Okay. Now I would like to go to my colleagues in the
other room for an exchange of ideas.
190 C A S E S

[After re-entering the therapy room]: We've discussed what

you've told us today. We need a meeting with you and your
whole family [he hands Giuliana an appointment card]. The next
session will be on . .. [gives her an appointment for a month later].

The last part of the conversation of this session dealt with the
positive relationship that Giuliana had with her work (free
from anxiety and conflict, a source of security and fulfilment),
the choice of a therapist, and what she hoped to get out of
therapy. Giuliana's last words were: "I know that this is some­
thing that depends on me. I want finally to get to the bottom of
it to try to help myself." Even though this statement was con­
sistent with Giuliana's need for control, it also revealed her
positive intention of helping herself as well as being helped.
This session was merely the first leg of a journey that could
intrigue, fascinate, and frighten the client, as well as stimulate
the therapist and rouse his curiosity, as when one sets about
reading a book that one hopes will be enriching through its
portrayal of new, conceivably possible versions of the human
drama.
O n this first leg of the journey, the therapist primarily i n ­
quired into the first significant system, the family. It is the 2

system into which one is born, in which one learns a language

and in which one learns the first patterns of and different roles
in living together. Most importantly, it is in the family that we
develop our identity and our feelings of security (or insecurity).
For each individual it is the only system that will remain un­
changed over time. A son or daughter always remains a son or
daughter, whereas membership in all other systems (the group
of one's contemporaries, the couple, work, and other social
systems) is ephemeral. One's surname is the symbol of mem­
bership in an indestructible system, as is emphasized by Laing
(1969) when he speaks of the "internalized family". What one

In the cases in which the client does not have a family of origin (if, for
2

example, he grew up in an orphanage), it is always possible to identify a first

group to which he belonged. One of the authors has had some consulting work
in Israel, where the family of origin was a subsystem of the large family of the
kibbutz.
 SYSTEMIC THERAPY CASES 191

introjects are not partial objects but rather the relationships

between those who represent one's family.
The symbolic Family, as a permanent system, is also a source
of dilemmas and paradoxes. One belongs to it but must leave it.
It is, however, always the anchor system, the one in which one
takes on an identity and in which there are the significant per­
sons, the system to which we return in moments of crisis. The
family can be therapeutic, but it also can be the source of anxi­
ety in cases in which relationships are ambiguous or confused.
It is significant that most symptoms and problems arise in ado­
lescence, that is, the period of separation from and independ­
ence of the family.
In conducting this session and other individual therapy ses­
sions, the authors have been influenced by their practical expe­
riences with family therapy and by family therapy theory. In
doing individual therapy, there is a balancing between the
viewpoint of the internal world of the individual and his exter­
nal world, particularly the family. Little by little, as the thera­
peutic work proceeds, the therapist inquires more and more
into the internalized family. However, it is necessary to be
cautious not to overdo things and skew the therapy towards
the family. In general, particular attention is paid to the family
in the first session in order to get a general picture of the most
significant relational context in which the client's personality
has been formed. This serves as a background for the therapeu­
tic work that follows. The therapist keeps this information in
mind during the course of therapy and modifies and enriches
it, while adhering to the principle of "flirting" with hypotheses
but not "marrying" them. Later on, the therapist-client dia­
logue unfolds more towards the present and future, with more
and more inquiry into the client's relationships outside the
family and with his or her self.
In family therapy, the first session or first few sessions take
place, when possible, with the whole family (all members who
live together) present. However, one of the most important
successive interventions is that of meeting separately with sub­
systems in order to favour separation and individuation of its
members. Thus, frequently in individual therapy the initial in­
terest is for the first significant system, passing later to the
192 CASES

interest in the client's relationship with other systems of per­

sons, ideas, and interests.
This has to be seen in a frame of co-evolution. While we
know that the family is important, it is necessary to avoid
reifying the strong family bonds. In this sense, the therapist,
3

relying upon the bond created between him and the patient,
can over time help the client to resume the interrupted journey,
take leave of the family-continent, cross the ocean, and land on
other shores, where he can express his potentialities.

BRUNO K.: "MIDWAY ALONG THE JOURNEY

OF OUR LIFE . .

Bruno is a Dutch psychotherapist who had called our institute

two years ago for couple therapy. A t the end of his analysis
(which coincided with the beginning of Bruno's marriage), his
analyst referred him to us on account of friction that had arisen
very early in the marriage. Actually, the reason for his request
for help was also justified by chronic backaches, which afflicted
h i m on and off. It is significant that when he contacted his
analyst for these problems, she had given him our address,
saying that, at this point, he needed a male therapist.
Couple therapy was finished in three sessions. In these ses­
sions, the client had said that most of the friction was due to his
wife's meddling, which made him feel dominated by her. The
couple therapy had been successful. The spouses had made
peace, and even Bruno's chronic back pains seemed to have
subsided. In this same period, to the joy of both, Bruno's wife,
Emanuela, had become pregnant.
About four months later, Bruno asked for an individual con­
sultation with the therapist. His reasons were the reappearance
of his backaches and a need to clarify his ideas about his exis­

3
However, in some cases (as, for instance, in chronic psychosis, in which
over time a separation has been created between the patient and his/her fam­
ily), it is important to work towards the formation of family bonds—that is, to
foster a sense of belonging that has been lost. We have often encountered
situations in which it appears that, in order to leave a family, a person must
obtain the approval of the family members. Otherwise, leaving the family can
seem impossible.
 SYSTEMIC THERAPY CASES 193

tential situation. A t the first session, Bruno began by saying

that the couple therapy had been very useful for both of them,
and that his wife was very happy that he had decided to
have individual sessions with the same therapist who had
treated them as a couple. Immediately afterwards, he changed
the subject to his somatic symptom, which had reappeared. H e
talked at length, describing the many years of suffering from
backaches that had brought him to seek help from various
experts. Orthopaedists, radiologists, physiotherapists, and acu­
puncturists were all in agreement in describing his problem as a
psychosomatic disturbance.
When the therapist asked Bruno why he had not consulted
his analyst, Bruno repeated what had been said to him: " N o w it
is best that you pass from the mother figure to the father fig­
ure/7

Asked his opinion about the referral, in his capacity as a

psychotherapist, Bruno replied he was in agreement with his
analyst. H e said, " M y relationship with my mother was clear
and easy, and I think I have resolved it. It is my relationship
with my father that is still unclear to me. I think that y o u can
help me with this." In his description of his family background,
Bruno emphasized the uncommon moral stature of his father.
His father had risen in the ranks from a simple manual worker
to become an important head of a company. H e had studied at
night, and in a short time managed to get his degree in econom­
ics and, by stages, climb up the corporate ladder. In spite of his
work as a corporate consultant and as a psychotherapist, Bruno
felt that he was still far from reaching the goals that his father
had attained.
Bruno was 38 years old. H e was the second of two children.
His sister, who was 40, was an elementary-school teacher. She
had married about ten years previously, and had two children.
Bruno remembered being his mother's pet and the fact that he
and his father were not close. He attributed this distance in part
to his father's reserved disposition.
Bruno seemed young for his age. H e was a bit shorter than
average, had a thick head of hair like an artist, and spoke i n a
soft voice. His speech was rather slow, like that of a person who
meditates before speaking.
194 CASES

BRUNO: In the session with my wife, with your metaphor, it was as

if you had hit the bull's-eye, as if you had found a connection
between the worsening of my back and the facts that emerged.
Something certainly has changed. I no longer have qualms
about my relationship with my wife, therefore the connection
that you made has had a very positive effect. For a certain
period, even my back was better. But now I have backaches
again . . . The other night, I had a dream. There was my father,
and at his side, a handicapped person. With this back of mine, I
feel like a cripple. I have the sensation that my back is not
straight, and that it's like an unstable main mast of a sailboat,
which, for this reason, is slow and hardly moves at all, I
thought of returning here also to have some sort of idea about
what to do after the birth of my child . . . I've thought about
that a lot.
THERAPIST: In this period, how is your life? .. . Are things okay
with your wife? . . .
BRUNO: Well, due to the pain, I feel blocked sexually, but the
relationship is fine.
THERAPIST: What impression does your wife make with her big
belly?
BRUNO: It has various effects. On the one hand, it's very lovely to
see the growth of our child, and, on the other, it's a bit strange
how it transforms a w o m a n . . .
THERAPIST: D O you listen to the heartbeat?

BRUNO: Yes [with a big smile]. When I speak with her about that, I
feel full of energy. Yes, it's beautiful. For the first time in my
life, with this child that's soon to be born, I have the sensation
of touching something spiritual. Yes, something very deep and
strong, something that is part of the life story of everyone. But I
don't understand the recurrence of these backaches.

It is possible that the resurgence of the backaches was due to

various factors. One of these might have been the aim of resum­
ing contact with the therapist to begin individual therapy. In
that case, the symptom would justify his request. This occurs at
times in cases that seem to have been concluded with success,
in which a symptom reappears, which leads to the resumption
 SYSTEMIC THERAPY CASES 195

of therapy. These are cases in which there is a persisting de­

pendence on the therapist, which is disguised by the symptom.
The story of Bruno was consistent with a hypothesis of this
kind. He had already undergone an individual analysis as well
as couple therapy, and he came back for a possible individual
therapy, stating that, among other things, he had wanted to
return in order to "have some sort of idea about what to do
after the birth of my child . . .". This request for "preventative
therapy" might indicate insecurity or a tendency towards de­
pendency—that is, a chronic need of therapy.

THERAPIST: Are the x-rays normal? Do you have, for example, a

slipped disc or ...?
BRUNO: N O . N O , there's severe muscle tension . . . and I feel as
though there were a battle going on in my back, as if my body
tensed up right here [with his fingertips he indicates the lumbar re­
gion]. Sometimes it scares me.
THERAPIST: What do you mean by it scares you?
BRUNO: Because I'm constantly preoccupied with my body. It's as
though this back had power over me, the power to make me
unsure, to make me feel unwell, as if something's not right,
something that's unaccountable and mysterious.
THERAPIST: Does this actually limit your physical activity?
BRUNO: Yes, because, for example, I can't go for walks for more
than a half-hour because then my back begins to hurt. A n d ,
unfortunately, I enjoy walking. M y wife and I spent a week in
Venice at Easter and . . . I was in pain.
THERAPIST: Does it limit you in other ways?
BRUNO: It limits me in moving my body. I can't move freely. I have
to pay attention, and sometimes I stiffen up . . .
THERAPIST: D O you have balance problems? Do you fall?
BRUNO: N O , it doesn't limit me drastically like that. Rather it limits
me psychologically . . .
THERAPIST: SO it's really become quite a worry!
BRUNO: Yes, it's become a worry.
THERAPIST: If I've understood properly, you feel this pain, this
spasm, this muscular tension after you've walked for a half
196 CASES

hour, but not before, you don't fall, and so on. Is it mainly a
psychological reaction?
BRUNO: Yes, yes. It's become stronger and stronger.
THERAPIST: Is it like an obsession?
BRUNO: Yes. When I visualize my body, as soon as I think of my
back, I feel like a cripple. It's almost a fixed idea. I'm sick and
tired of it. At this point it's been quite some time—more or less
from the time I got married—that I've gone on like this, con­
tinuously getting treatment for it.
THERAPIST: If this problem were to disappear suddenly, would
your life change? A little or a lot? Would it be the same? That is,
does this problem impede you in your progress towards the
future? Does it interfere with your plans or with what you do?

It is odd that the therapist was not curious about and did not
explore the association that Bruno made between marriage and
his backaches. It might be that the temporary improvement in
Bruno's backaches after couple therapy and the consequent
resolution of the conflict between the spouses had induced h i m
to attach less importance to the connection between Bruno's
backaches and his marriage. It might also be that a different
hypothesis prevailed in his mind. Looking at the case with
hindsight, one could say that it might have been very interest­
ing to explore in depth with the client the relationship between
his backaches and his marriage. As the reader will see, this was
done, but only marginally.

THERAPIST: Your backaches might even be useful to you with re­

gard to your wife, in that they exempt you from responding to
possible requests of hers. It's also possible that your backaches
might attract a bit of your wife's attention to you and less to the
baby. These worries might let you live the best possible life at
this moment. [Bruno laughs.]

The phrase "these worries" could stand for many other

things. For example, if Bruno were to say to his wife, " W h y
aren't I happy? It's because my back aches", then his wife could
not expect him to do things that he would be justified in not
doing because of his backaches. The therapist's remark, which
 SYSTEMIC THERAPY CASES 197

hints at the secondary advantages of the symptom, was unde­

fined, rather than ambiguous. Bruno could fill it in with what­
ever content he wished.
Bruno's laugh could be seen as the laugh not only of the
client, but also of the fellow therapist.

THERAPIST: If it were in my power as a therapist to eliminate your

symptom right now, I wouldn't do it . . . I would try to under­
stand better., .
BRUNO [in the manner of Hamlet]: . . . advantages . . . disadvan­
tages . . .
THERAPIST: You could be overcome by an even more severe anxi­
ety. You could lose your sense of direction, in the sense of
"What can I do with my life?" You might discover that, if the
main mast had no problems, the new problem might be " N o w
the boat moves, but where should it go?" You might have to
make some choices like Holland or Italy, wife or no wife, psy­
chotherapy or no psychotherapy. There might also be some
expectations from outside about where the boat should go. For
your wife, the boat might go in a certain w a y . . .
BRUNO: T O Milan.

THERAPIST: Right now you could say, "I can't because the mast
isn't working." 4

BRUNO: I feel like this . . . a bit as though . . . paralysed in the sense

of where . . . I feel as though I'm in a situation of paralysis.

A good deal of Bruno's material betrays a tendency to am­

bivalence as well as obsessive brooding, e.g. whether to choose
Holland or Italy, therapy with a man or a woman, the profes­
sion of therapist or corporate consultant.

THERAPIST: It might also be your work, in that you spend too much
time sitting, which accentuates your backaches. You are a psy­

4
A Freudian reading of this would emphasize an evident "fear of castra­
tion". The symbolism of a somewhat crooked, fluctuating mast suggests the
phallic symbol and the fear of castration. This symbol can be also found in
Bruno's dream, in the comparison of the "cripple" and the erect, tall, large
father.
198 CASES

chotherapist, therefore you spend a lot of time sitting. The di­

lemma might be " D o I or don't I like this life of being a psycho­
therapist? Should I stay seated or get up and do something
else?" I don't know, a consultant, for example, a consultant
spends less time sitting down.
BRUNO: I already do enough consulting work.
THERAPIST: Or do other things.
BRUNO: This seems to me a very good track.
THERAPIST: Which?
BRUNO: The one that we're following now. I do three
things: consulting work in a credit institution, teaching psy­
chotherapy in Holland, and a bit of therapy and consulting
work here in Italy. Even though travelling does bother me a bit,
it's better than being a manager in a firm. I like being free,
especially now, so that I can dedicate more time to the baby. I'm
almost forty years old, and I have little desire to change.

At this point, one of the dilemmas might have been: the child
or work? One of Bruno's disappointments was in not having
become famous, nationally or internationally. He could thus
justify his lack of success in work with having to dedicate time
to his child. However, one would expect that he would feel
disappointed for not having dedicated enough time to his ca­
reer. In this way, the boat has a breakdown.

BRUNO: Then there is another consideration about work. I am

gratified that I'm a well-known therapist in Holland. In Italy,
though, nobody knows me; therefore, there's quite a contrast
. .. one might say, "Why not choose?" . . . It would be impos­
sible. This description of a static situation is very apt.
THERAPIST: Y O U said that you're almost forty years o l d . ..

Marzocchi (1989) speaks of a "treasury of metaphors" that is

at the disposition of each therapist, on the basis of his own
personal culture and experiences. A t a certain point, things that
emerge in the conversation stimulate the therapist to use some
of these metaphors. When Bruno, in taking stock of his life, says
that he is almost 40, what suddenly came into the therapist's
 SYSTEMIC T H E R A P Y CASES 199

mind was the beginning of Dante's The Divine Comedy: "Nel

mezzo del cammin di nostra vita . . . " ["Midway along the journey
of our l i f e . . . " ] This refers to the beginning of a inner journey
5

that the poet makes which brings him to connect the past to the
future.

THERAPIST: At this moment the beginning of The Divine Comedy

comes to my mind: "Nel mezzo del cammin di nostra vita mi trovai per
una selva oscura che la dritta via era smarrita." ["Midway along the
journey of our life / I woke to find myself in a dark wood, / For
I had ventured off from the straight path" ] Dante Alighieri
6

was thirty-three when he wrote that.. .

BRUNO: The word "selva"—what does it mean?
THERAPIST: "Selva" means woods or forest; that is, I found myself in
a dark forest "che la dritta via era smarrita" ["For I had ventured off
from the straight path"], because I lost the main road, the
proper road.

Dante's metaphor seemed to connect the principal elements

of the subject being discussed, which included consciousness of
one's age and of the passage of time as well as having qualms
about being blocked and of not knowing which direction in life
to choose. This metaphor seemed to comprise all the others as
well. It is the metaphor about life as a journey and as a search
for one's self and one's autonomy. Bruno appeared to have
been quite struck by the metaphor. The therapist had also been
quite struck by the client's reaction to the therapist's saying
that the backaches might have been useful for slowing him
down and making him stop before deciding on his future.
Bruno had said, "This seems to me a very good track" (The
word Bruno used was "strada", which, in Italian, also means
" r o a d " , " w a y " , "path".) Bruno's use of "strada" [track, road,
way, path, etc.] and the phrase "I am almost forty years o l d "

Translation of the first few lines from Dante's The Divine Comedy, taken from
5

Mark Musa's translation in The Portable Dante (Harmondsworth, Middlesex:

Penguin, 1995).
Ibid.
6
200 CASES

may have struck a chord in the therapist's mind, causing him to

choose Dante's metaphor from his mental catalogue of meta­
phors. Of course, the type of metaphor used must be suited to
the client's cultural level. A lower level would have brought to
mind other metaphors.

THERAPIST: One of the keys to a symbolic reading of The Divine

Comedy is the fact that Dante Alighieri wrote it as a form of self­
help therapy. It was a way of expressing his wishes, his fears,
and his strong ties to Florence, whence he had to flee and stay
away forever. In fact, in Dante's description of Hell, there are
some of the persons responsible for his expulsion from that
city. Tongue in cheek, one could say that, since there weren't
any therapists at that time, Dante chose Virgil as a travelling
companion and therapist.
BRUNO: It's interesting. Coming here I was like a person who had
entered a dark forest, without light .. . but now in this forest a
light has appeared, but that's not sufficient... I don't know
what to grab onto. Coming back to the advantages you speak
about, on the contrary, these backaches hold me back.
THERAPIST: Yes, but they permit you to meditate, to think before
you come out into the light, as Dante Alighieri, in the end, had
found—he went to Paradise.
BRUNO [in a self-critical tone]: I think more about my back than about
these more interesting things .. .

This response could lend itself to two interpretations. It

could mean, "I, Bruno, am neither your equal nor Dante
Alighieri's in being so introspective and wise. I think of banal
things, like a common backache, and I'll never be able to reach
your level of self-knowledge!" If that were the case, the literary
metaphor would have been counterproductive and might have
crushed the person to whom it was addressed. O n the other
hand, it could have been a compliment to the therapist who
had helped him to find a bit of light in the "dark forest", as
Virgil had done with Dante. The phrase "now in this forest a
light has appeared" could have meant that Bruno was embark­
ing on his journey.
 SYSTEMIC THERAPY CASES 201

THERAPIST: If you were to take stock of your life, would you be

satisfied? What would you want to do in the future?
BRUNO: There are two things. One thing was very good for me—
marrying this woman and having this baby. The other thing
doesn't satisfy me. I've done a lot of things and had a lot of
experiences, and now I do free-lance consulting, work as a
therapist, train others . . . but I've never created anything that
remains, like, for instance, founding a school.

Bruno's satisfaction with his marriage and child is, at least in

part, the result of two sessions of couple therapy and, in par­
ticular, of a metaphor expressed as a nuptial ritual which was
prescribed as a conclusion of the second couple therapy ses­
sion. Bruno had expressed anxieties about his marriage. From
the very beginning he did not get along well with his wife.
According to him, his wife tried to put herself in a dominant
position. Bruno had had more relationships with women than
with men: in Holland he worked under the direction of the
female owner-director of a centre for psychotherapy, in Italy
he had undergone analysis with a woman therapist, and in his
childhood he had had a very intense relationship with his
mother. It seemed that, at this time, he wanted to resolve the
problem with his father and with men. His non-verbal mes­
sages, directed to the therapist, of esteem and almost of need of
affection, would seem to bear out this hypothesis.
It is not clear to what degree this was his own elaboration or
how much this was conditioned by his training as a psycho­
therapist, by his personal analysis, and by the message that his
analyst had given to him the last time he had contacted her:
" N o w it would be better that you go to a male therapist."
(At the end of two consultation sessions, Bruno and the
therapist agreed on systemic, rather than psychoanalytic,
therapy to last twenty sessions or fewer, about a month apart.
Bruno, however, had the tendency to act and communicate as
though he were in analytic therapy. H e often began the session
with an account of a dream, and he showed that he appreciated
the therapist's comments about the therapeutic relationship.
However, non-verbally, and often also verbally, he indicated
202 CASES

that he did not appreciate the requests that he should speak

about current relationships and hypothetical future choices.)

THERAPIST: You're satisfied as a husband and as a father, but you

don't seem as satisfied professionally. Do you feel that you
don't earn enough money?
BRUNO [smiling]: Well, I wouldn't mind earning more.
THERAPIST: Would you like to earn more money?
BRUNO: Yes.

Here the therapist was exploring the client's system of val­

ues, hypothesizing that one of these values might be his earn­
ing capacity and that there might be a relationship between
money and his sense of worth. The client's answer could have
been a simple confirmation or it might have introduced a dis­
tinction, as we will see later. A n exploration of the meaning of
money with regard to relationships is often useful in therapy.

THERAPIST: If you told your father and mother how much you
earned . , . For example, would your father be content if you
told him how much you earned.
BRUNO: H m m . . . this brings an image to mind .. . you know
people who go from door to door selling things—nowadays
they don't exist any longer—instead, once upon a time . .. well
. . . that's the kind of idea he seems to have of me. He's not
interested in money.
THERAPIST: A rather negative image . . .
BRUNO: Yes, exactly.

Bruno's doubts about his own worth and about the goals he
had achieved "midway along the journey of his life" stimulated
the therapist's curiosity. The therapist then explored the con­
nections between Bruno's doubts and the possible judgement
of his parents about the goals he had achieved. To do this, the
therapist, by asking a number of circular questions, utilized the
technique of presentification.

THERAPIST [glancing at two empty chairs]: If your father and mother

were seated here, and I were to ask them, "What do you think
 SYSTEMIC THERAPY CASES 203

of Bruno—of what he's accomplished and what he's now doing

in his life?", what would they say? Would you be interested in
their answers?
BRUNO: Would I be interested in their answers? Of course I would
be!
THERAPIST: More in your mother's or your father's?
BRUNO: In my father's. I know that my mother would say that
what I've chosen is fine if it makes me happy.
THERAPIST: If I were to say to your father, "Your son is now almost
forty years old. He's a therapist and a consultant and he's mar­
ried . . . " , what would he say? What kind of judgement would
he make of you?
BRUNO: He would say . . . well . . . " H e could do more. He could
do other things."
THERAPIST: A n d what would you say?
BRUNO [in a serious tone of voice]: I would say, " H o w come you've
never really been interested in what I was doing?"

Here the importance of and need for paternal approval

emerged, as well as an evident protest for the distance that
Bruno's father had kept from him. H e seemed to have had
meaningful approval from the women in his life, beginning
with his mother, but this did not seem to be sufficient. It
seemed that his legitimization as a man had to come from his
father or from father substitutes.

BRUNO: Then he'd say to me, " H o w come you're still working for
your colleague? Why don't you do something on your own?"
Instead my mother . . . [smiling] she believes in my abilities and
would say that I have other potential abilities.
THERAPIST: Potential that you haven't yet shown?
BRUNO: Yes.

THERAPIST: It seems, that there are still more expectations about

your future . ..?
BRUNO: Yes. That's right. There are expectations on the part of
both of them. They expect me to create something that will
make them happy and make me happy, too.
204 CASES

THERAPIST: Are they happy that you married an Italian woman?

BRUNO: Yes, they're happy about that.
THERAPIST: It seems that you are somewhat in agreement They're
happy and so are you. In fact, today you began by saying that
you were happy that you married this woman and are going to
have a child. Could this be the light that has appeared in the
dark forest? At the beginning of your journey towards para­
dise?

Bruno revealed, in a very evident manner, that he still had

strong ties to his parents and that he was not yet independent
of them. O n the one hand, he expressed resentment at not being
approved of by his father, but, on the other hand, he seemed to
agree with their expectations. He was partially content with
himself, as were his parents. A l l of them were happy that he
had married and had a child on the way. But the tests of life
were not yet finished. H e still had to think about his career,
even though he had, indeed, already done much.
The therapist widened the context with his questions and
opened up various hypothetical scenarios, avoiding, as far as
possible, passing judgement on Bruno's thoughts and choices.
Although at times he might have seemed to be "didactic", his
rhetorical questions gave the client the responsibility for inter­
preting them or specifying their meaning. In line with a posi­
tive point of view, the last question reintroduced the metaphor
of Dante's journey.

BRUNO: This problem doesn't exist any longer. They no longer say,
"When you get married . . . when you have children . . . "
THERAPIST: It appears that you are worried about doing something
in life in order that your parents can finally say that they are
happy. From whom would it please you most to have this
statement of esteem?
BRUNO: From my father.
THERAPIST: Y O U could tell your father that your back problem ham­
pers you in accomplishing your projects . . . that you have a
problem.
 SYSTEMIC THERAPY CASES 205

The therapist again pursued the metaphor with regard to the

subject of the backaches, which at this point in the session could
have referred to Bruno's ambivalence about the goals that he
"ought to" attain and about his parents' expectations (which, in
part, were also his). This ambivalence could be translated as a
pair of opposites between which Bruno continued to oscillate:
"I can" and "I can't". The suggestion that he could say to his
father, "right now I can't" had the objective of making him see
a different kind of father-son relationship, one in which the son
could admit his weakness and the father could accept the par­
ticular moment in his son's life, (From a psychodynamic point
of view, one could speak of a "corrective emotional experi­
ence", in which the therapist behaves like a positive and accept­
ing father, which is different from the type of father the client
perceives his father to be: see Alexander & French, 1948.)

BRUNO: Yes, I could say that . . , but I wouldn't do that . . . I don't

know .. . imagining myself speaking to him about this prob­
lem, I'm not able to see myself with the problem .. . it's strange
. . . I don't know . . . it would give me a different image of
myself. A n d besides, it isn't that my father could say something
that could .. . you know, it's something inside me . .. yes,
something inside me .. .
THERAPIST: D O you mean, this external conflict, the judgements of
which you were speaking are inside you?
BRUNO: Yes. It isn't as if I go there and he says. ..
THERAPIST: D O you mean that it isn't the real father but instead the
internal father?
BRUNO: Yes.

When the therapist alluded to the possibility of not only

outer voices but also "inner voices", that is, to the importance
of the internalized family and the internalized father, Bruno
nodded emphatically. Bearing in mind the Bruno's double role
as his client and also as a predominantly psychodynamically
oriented psychotherapist, the therapist was not surprised by
this answer. From time to time, he passed from the analysis of
the internal world that was congenial to his client to current
206 CASES

relationships. The therapist continually kept under considera­

tion both his and the clients biases, so as to avoid considering
them as Truths.

THERAPIST [glancing towards the two empty chairs]: If your mother and
father were here, and I were to ask you to give your judgement
of them, what would you say?
BRUNO: I greatly admire my father. He, the son of a manual
worker, worked and studied at night. He had an incredible
career. He got his degree and became an important manager.
M y mother was very close to him and made a whole bunch of
sacrifices for him.
THERAPIST [with emphasis]: Two heroes, two giants. You are the son
of two giants. It's difficult to be the son of heroes and giants.
I'm wondering what it was that prompted you to return here to
me. Perhaps it was the hope that by talking with me, some­
thing would make you get out of this impasse in your life.
BRUNO: Yes.

THERAPIST: You're at a standstill. You described a dream in which

there is a handicapped child next to his father. Right now I
have a picture in my mind of a final dream in therapy that you
might tell me after the birth of your child. In this final dream,
you are at the side of your exuberant child, who is full of life
and happy to be next to a proud father. In the background is
the paternal grandfather, who finally feels gratified.
BRUNO [somewhat moved]: I don't know why, but now I feel a "yes"
inside.

The two parents appeared by means of the responses to the

circular questions about the "presentified family". The thera­
pist defined them as two heroes or two giants whose life is
difficult to emulate. Immediately after making the remark that
"it is difficult to be the son of heroes", the therapist asked
Bruno whether or not his decision to get back into contact with
the therapist was motivated by the hope of getting out of his
existential impasse. After the client said yes, the therapist pro­
posed a possible future scenario in which, by the end of
therapy, Bruno would have recounted a hypothetical dream of
 SYSTEMIC THERAPY CASES 207

resolution of his anxieties and his feeling of inferiority. His

verbal response and especially his emotional response indi­
cated that something had touched Bruno deep in his heart.

THERAPIST [after a pause]: Today, did you come to talk with me, to
consult me, or to have therapy?
BRUNO: After the last time we saw each other, I wanted to write
you a thank-you note because I didn't think I would see you
again. But later on, in these last few months, I've begun to feel a
sense of uneasiness and growing preoccupation. So, I thought
I'd come here more for a clarification—to get out of this im­
passe—than for therapy. I've already worked on myself a lot in
the past. . .
THERAPIST: What did your wife think of you coming back to me?
BRUNO: Oh, she was pleased. Now our relationship is fine and she
is happily looking forward to the baby's birth. In fact, she said,
"Go to the doctor. Surely he will help you."
THERAPIST [smiling]: So your wife hopes that I'll straighten your
spine.
BRUNO [laughs]: That would make her happy! I would like to add
that I would like to come back again once more.
THERAPIST: I'm going now to consult with my colleagues.
[The therapist leaves the therapy room. After a long pause, he re-enters,]
THERAPIST: The impression that my colleagues had was that of
Atlantis with the world on his shoulders. They see you as a
person who has borne these two giants, your parents, on his
shoulders for a long time. This weight is so heavy that it has
unbalanced your spine. They are struck by the fact that your
burden has not been lightened after your marriage and your
wife's becoming pregnant. We would not have been surprised
if the opposite had occurred!
BRUNO: That will take time . . .
THERAPIST: They agree about the possible final dream of therapy
that I related to you. In the dream that you recounted about
your father with a handicapped child, they see you also as a
father, and they sensed a fear in you, at the bottom of your
heart, that a child might be born who doesn't satisfy the expec­
tations of the grandfather. If the child that is to be bom were
208 CASES

perfect, then it would have resolved your problem of your

parents' expectations. Generating a perfect child would qualify
you as an authentic adult. In this sense, the handicapped per­
son of the dream might be the symbolic expression of deep
anxiety about creating a child who also will not manage to
satisfy the expectations . . . This is the conclusion of today's
session. I also discussed with my colleagues your request for a
second session. We were all in agreement and [rising and giving
Bruno an appointment card] here is the date of the next session.
[Bruno had listened to the words of the therapist with much concentration,
nodding almost imperceptibly. When he received the offer ofa second ses­
sion, he relaxed and appeared clearly satisfied.]

The final comment devised by the therapy team used these

elements of the session: the dream Bruno recounted, the hypo­
thetical dream of the final session, and Bruno's sense of finding
himself in an impasse and of not satisfying his father's expecta­
tions. The comment began with the graphic metaphor of
Atlantis who is carrying the weight of the world on his shoul­
ders. It ended with a possible interpretation of the hypothetical
final dream: by creating a perfect child for his father, Bruno
could finally be considered to have the qualifications of an
adult and thus get out of his impasse. The content and language
of this intervention is tailored to the client, keeping in mind the
session's material, the knowledge of this client (who is also a
therapist), and the praxis of system therapy. 7

The reductio ad absurdum of the grandfather-son-grandchild

relationship might have triggered the onset of new emotions
and meanings, which might have contributed to the solution of
the client's existential crisis. A global analysis of the session
could begin with the observation that the therapist worked
with themes and frequently used metaphors. In other words,
the therapist identified what L a i (1985) calls a "motif". The
therapist continually referred to the "motif", and the patient

7
The comment at the end of the session contains some elements that could
apply to psychodynamic therapy. Nonetheless, these are introduced into the
characteristic framework of the systemic approach. The comment could be
considered a typical reframing intervention.
 SYSTEMIC THERAPY CASES 209

responded. A t a certain point, three motifs were identified: the

back, the journey, and fatherhood. Like the notes in a musical
piece, the therapy, using metaphors, revolved around these
motifs. In this way, a story was constructed that drew upon
emotional and cognitive elements of both participants. The
story began with Bruno's backache problem being connected
with his feeling of being at an impasse. The therapist offered a
vision of the symptom as being something positive, rather than
being a negative thing, in that it gave the client a period of time
in which to reflect on himself and on his future. The client
appeared quite struck by this reframing, and he opened up to
the possibility of exploring the elements that might have been
responsible for his crisis.
In a certain sense, the therapist communicated to Bruno that
he was not yet ready and that he had to clarify the impasse in
order to allow the boat to continue its journey. Bruno felt that
he only needed a helping hand or some temporary assistance
by the therapist in clarifying his ideas in order to get back onto
the road of his development. Bruno was an excellent subject for
a rich and meaningful session, not only because he was highly
intelligent and sensitive, but also because he had already been
through a long therapy and had a professional knowledge in
the field as well.
The constructions and the language in the session were both
rather sophisticated, and they reflected the capacity of both
participants. It is interesting to note the quantity of themes that
were brought to light, which were to be dealt with later in the
following sessions. One gets the impression of a rich dialogue
that condensed, in little more than an hour, the main themes of
the client's life. It was a typical dialogue of a consultation ses­
sion, which was particular and consistent with the client's re­
quest for a "clarification" rather than a therapy, and was
stretching the metaphor of the boat. One could say that this
particular session was like a journey in which there was a boat
driven by both participants, each with his own expertise and
knowledge of the sea. The therapist had his storehouse of meta­
phors, but the client also had his own supply. They worked
together, and the boat moved—Bruno alone couldn't manage
it, but, together, client and therapist were able to make it.
210 CASES

The second session

BRUNO: There are two things that I would like to talk about. I was
in Holland, where I held a seminar, and I also saw my parents.
Reflecting on the story of my father, which we talked about last
time, well, this likening of me to what he thinks of my career
. . . I felt as if I were going back over a route that I had already
travelled. By my moving in this direction, old wounds ap­
peared. At the time I stayed at my parents' house, I dreamt a lot
about things that I had already left behind me and about the
danger of opening up again the subject of my relationship with
my father. That is the first thing. The other thing is that in these
last two or three weeks, my back has got worse. I feel more
pain, and I feel less steady on my feet. It seems that everything
is going wrong. I had some tests done. There's been a slight
displacement, towards the left, of my spine, and to put me back
into balance, they've given me an arch support [he points to his
right shoe].
THERAPIST: What do you think is the reason for your back getting
worse?
BRUNO: O n the one hand, I think that it has to do with talking
about my father last time. This brought me back to my analysis
and I thought I had overcome it. On the other hand, I'm cling­
ing to a physiological type of explanation. I'm no longer able to
distinguish how much there is of psychological or mental in
my back condition and how much, instead, is physiological.
THERAPIST: From what I remember about lower back pain syn­
drome, it's difficult to say how much of it is caused biologically
and how much by other things. In other words, it's difficult to
say how much is psychological, how much is somatic, and how
much is psychosomatic.
BRUNO: I've been thinking about what it could be that might go
worse if I didn't have these symptoms, but I haven't come to
any conclusion . . .
THERAPIST: In what frame of rnind did you come here today?
BRUNO: Quite in despair. [He corrects himself.] Rather, I'd say a bit of
despair.

Surprise! The therapist, or rather, the therapeutic team,

would have expected at least a symptomatic improvement after
 SYSTEMIC THERAPY CASES 211

Bruno's first session, as had occurred after the previous two

encounters with the couple. This expectation was also based on
the feeling of having had a good session. The aggravation of
Bruno's back condition brought everything back in discussion.
One could ask the following questions: Was this a sign that
Bruno could not give up the secondary advantages of the symp­
toms, due to causes that were not as yet clear? Was it a sign of
his dependence upon therapists, with whom he tended to estab­
lish an "interminable" relationship? Was it a sign that transfer­
ence with his referring analyst had not been resolved and that
Bruno's condition grew worse because his former therapist had
not taken him back in therapy when he returned to her the last
time and, instead, had sent h i m to another therapist? There
might also be other, simpler possible explanations. One might
be Bruno's difficulty in accepting and living with a common
chronic complaint, for which people do not generally resort to
psychotherapy. Another might be an error in the therapist's
timing in directly dealing with Bruno's relationship with his
parents as if he were already in therapy rather than limiting the
session to a simple exploratory one. A third possibility might be
that the backaches had a function in the couple's relationship, in
that their presence permitted marriage conflicts to remain u n ­
der cover. The back trouble might also have had the function of
attracting his wife's attention, focused on the newborn child,
onto himself.

THERAPIST: In what sense are you in despair? For example, did you
come here to put yourself in my hands, with the request, " D o
something to help me"—do you mean it in this sense? Or are
you in despair in the sense of losing hope that I could do some­
thing?
BRUNO: No. I have hope.
THERAPIST: But do you think that I can do something for your prob­
lem?
BRUNO: Yes. We can clarify something so that I would have clearer
ideas . . , Like what happened last February, when I left here
with Emanuela: the things with her were clarified, and there
were no longer any more arguments. The discussion about my
212 CASES

father opened up wounds that had been closed, or, at least, I

think . . .
THERAPIST: Right now, I would like to say what I think. When you
said that your backaches had got worse since the last time, I
was very surprised, because I would have expected that the
last session could have made them better. At this point, the
hypothesis that comes to my mind is that with body lan­
guage—that is, the worsening of your backaches—you are say­
ing, "I've got worse. Don't leave me. I want to continue my
journey with you, because I can't walk by myself. I want to
walk with you"—you know, like Dante with Virgil. A n d to
lean on me, you have to somehow have a reason, and that is
having more back trouble. I don't know if my way of reading
the situation makes sense to you.
BRUNO [after a long silence]: . . , But . . . it's not rational, I couldn't say
that I still want to work on this . . .
THERAPIST: If we leave aside the problem of your backaches, how
do you see your life now? Do you think you need help; that is,
do you think you have the kind of problems for which you
need therapy?
BRUNO [after a perplexed silence]: . .. No.
THERAPIST: SO you feel sure of being able to proceed on your way
in life. Do you have need of a Virgil to accompany you?
BRUNO: N O . There are two sides to this matter . . . on the one hand,
I don't feel that I need therapy, but on the other hand, my body
is speaking another language, and it says to me, "That's not
true. You need somebody to support your back." In this sense, I
came here looking for support . . . without the problem of my
back . . . if I felt well, I'm not . . . not sure .. . that I would have
come back here.

The situation was becoming clearer in that the client ex­

plicitly communicated that, if he had not had back problems, he
would not have sought psychotherapy. Nevertheless, because
the pains moved around and were widespread, all of the other
specialists (orthopaedists, physiotherapists, and the acupunc­
turist) had emphasized the psychological component in the
genesis of the symptoms. N o w the client's last statement intro­
 SYSTEMIC THERAPY CASES 213

duced a paradoxical component in his request for help. H e

asked for psychotherapy to resolve a psychosomatic problem,
without doing psychotherapy! In fact, his feedback to the pre­
ceding session was that it had been useless, if not actually
harmful! It will now be interesting to see how the psychothera­
pist managed to get out of the paradox. Looking at this situa­
tion with hindsight, one could say that, although the client had
explicitly asked to be freed from his backaches, from the time of
the first few verbal exchanges the therapist had already de­
cided to work on the "person" and on his conflicts. If the thera­
pist had felt that the elimination of the symptom was of
primary importance, he would have used a strategic therapy
type of intervention.

THERAPIST: Last time, you came out with a sentence that left quite
an impression on me. You said, "I should be well-known. I
should be recognized for the work that I have done." Being
recognized as the leader of a movement, as somebody who has
done something important, is something that you, instead, feel
you have not achieved. Is it possible that your backaches allow
you to avoid a stronger pain, or rather, disappointment, a nar­
cissistic wound, for not being able to reach the goals that you
feel you ought to be able to reach? You spoke of your father last
time, in this context, because your father has achieved incred­
ible goals in his life.
BRUNO: Here, maybe, there are two subjects to discuss. One is the
one you touched on, and the other is the subject of being a
father . . . while you were speaking, I thought that if a child is
born . . . it's difficult .. . it's like an image that goes like this and
like this. [He makes gestures as if there were two pictures on different
sides of the same sheet ofpaper.]
THERAPIST: I've noticed that, sometimes, while listening to how
you speak and express yourself, I get the impression of Hamlet
here in front of me. You know, Hamlet, holding a skull, who
says, " T o be or not to be, that is the question." "To sleep, to
dream", that is, as if you were constantly in a dilemma. "Walk
or stay put?" maybe. [Both men laugh.] To go ahead or stop? To
do therapy or not to do therapy?
214 CASES

The therapist did not try immediately to get out of the im­
passe, i.e. the paradox in which the client had put him, asking
him, for example, what he, the client, would advise him to do.
Instead, he preferred to return to a subject dealt with previ­
ously, thus putting off the search for a way to get out of a
situation that could have become absurd. A priori, this choice
appeared, to the therapist, to be the "best possible choice".
N o w , with hindsight, this seems doubtful, in that it fostered a
tendency towards a symmetrical, opposing relationship be­
tween the client and the therapist (confrontation). The more the
client communicated that he didn't need therapy, the more the
therapist did therapy. After the client said, in a confused man­
ner, "Here, maybe, there are two subjects to discuss . . . " , the
therapist became a bit agitated. (On the videotape, it appears
that the therapist had difficulty hiding a poorly masked irrita­
tion.) H e reeled off a list of the client's dilemmas, including the
most important, i.e. whether or not to have therapy. One might
hypothesize that the therapist's reaction might have been, in
large part, due to predictable "distress" at finding himself in a
paradoxical relationship in which his competence was un­
acknowledged, especially after having conducted what he felt
to be a " g o o d " first session, from which he expected a positive
evolution. Another reason that might have led the therapist to
enter into a symmetrical relationship could have been his pride
having been hurt by a client/fellow therapist who had criti­
cized his work. However, the note of humour that the therapist
introduced with the comparison of the client to Hamlet had the
effect of diluting and toning down the symmetrical escalation,
as demonstrated by their shared laughter.

BRUNO: Yes, that's true. I am aware that sometimes I play a part

rather than speak clearly. I feel a bit confused. I had three years
of therapy with my analyst Dr. Verdi, and then I said that I was
tired of it. However, later I went back to her because of my
problem with my wife, and she sent me to you.
THERAPIST: So, here in Italy you've found another set of parents. A
bit like your father and your mother . . . You've had a long
period of therapy, first with Dr. Verdi, and then you came here.
 SYSTEMIC THERAPY CASES 215

BRUNO: A n d now I'm asking myself what it is that I'm looking

for ...? She advised me to come to you.
THERAPIST [smiling]: So she advised you to come here . .. like a
mother who says, " G o to Dad. Now resolve your problems
with him."
BRUNO: Yes, because . . . yes, that's right. She had the idea that
something wasn't right in my relationship with Emanuela. We
came here, and what you said to us had a powerful effect. I
understood your message this way: I've arrived at the end of
all these peregrinations, and now I can make my own way.
This had a powerful effect . . . So now I don't understand what
it is that I'm looking for. It seems to me that I'm seeking help
for this symptom . . . I could say, "I'm not able to walk by
myself" . . . I don't know. I don't know what.. .

Back to square one. The client said, "It seems to me that I'm
seeking help for this symptom", because he felt he had already
resolved his relational and existential problems. Nonetheless,
the last exchanges revealed his underlying sense of insecurity,
his need for approval from others, and his dependence on the
judgements of others. Notwithstanding his appearance of be­
ing a gentle, polite, non-aggressive person, he gave clear mes­
sages of fighting for his ideas. The following question was
typical of a first session, as if the subject had to be dealt with
again from the beginning.

THERAPIST: If, for example, I were to ask you what you would like
changed in your life, what would you change?
BRUNO: . . . I would like to be a good father . . , but that's not a
change . . .
THERAPIST: Let's say that tonight a miracle would happen and that
tomorrow whatever you really want changed would be
changed, then what would be changed? [There is a long silence, in
which it appears as if the therapist is waiting for an answer, which, how­
ever doesn't come.] Or, in other words, what would have to
change to make you content? For example, would you have to
change the country, Holland or Italy? Or work? Or something
in personal relationships? What is it that would have to
change?
216 CASES

BRUNO [after a long pause]: Well . . . that's a difficult question.

THERAPIST: Think about it. Take your time.
BRUNO: Well, I could only repeat what I said before—that I'm not
content with my work, but it's difficult to say what I would
like—a fixed job or to travel, to do what I'm doing now or to
develop other interests. I would like to have created a school,
an institute, but . .. it's not easy.

The long silence in the middle of the therapist's question on the

miracle, the long pause before Bruno answered, as well as the
content of his answer (which referred to things he had already
said a number of times) are all evidence of the therapeutic
impasse. The two participants appeared to be on two different
wave lengths.

THERAPIST: SO, do you mean there's a certain internal torment, an

existential torment?
BRUNO: Yes, you could call it that . . . maybe it's also because of
my age . . . to create something as a freelance professional re­
quires a number of years . . . Leaving what I'm doing for a fixed
job would be a decision that one couldn't revise the next day
. .. nonetheless, at this point, I feel trapped. ..
THERAPIST: Are you confused?
BRUNO: Yes.

In this segment, the reader can note the attempt, especially

by the therapist, to get out of the impasse, to find a way out of
the vicious circle in which the two men were trapped. With the
following question, which was different from any of the others,
the therapist asked Bruno if and how he, as a therapist, would
end the relationship with Bruno the client. In this way, he tried
to get out of a repetitive, symmetrical-escalation type of situa­
tion by letting the client get himself out of the aforementioned
relational paradox.

THERAPIST: If, right now, you had a patient in your situation, what
would you do? Would you stop and conclude the relationship
today, or would you continue and offer him therapy, or would
you send him to another therapist?
 SYSTEMIC THERAPY CASES 217

BRUNO [gets up and changes his seat for a nearby one]: I'm going to sit
here because that way it's easier to speak about myself. [He
points to the place where he had been sitting.)
THERAPIST: Fine. Do that. [Bruno laughs.] If you want, I'll let you
speak. I can sit in the chair you just left and change roles and
act as the patient, or else I can remain where I am and be an
observer. You decide .. .

Unexpectedly, Bruno changed chairs. H e seemed rather

amused with his sudden invention, which brought h i m to split
the roles of client and professional colleague. The idea might
have come to h i m through the previous session in which the
therapist had indicated two empty chairs in presentifying
Bruno's parents, or from the client's readings about work on
role playing. The therapist, in turn, "raised the b i d " , offering
him the choice of two possible scenarios: one i n which the
therapist could assume the role of client, as i n the exercise of
role-playing i n training, or he could maintain the role of
therapist-observer, leaving to Bruno the double function of
therapist and client.
One could make two observations about this. First of all, the
therapist got out of the symmetrical position by accepting the
decision of the client to change chairs and especially by asking
him to choose between two possible behaviours that his thera­
pist could assume. These two roles, being the client or simply
being an observer, are both complementary positions. Sec­ 8

ondly, Bruno, i n the position of therapist to himself, had the

possibility to connect emotions and meanings deriving from
his own two roles as well as those from his actual therapist.
It was a vaguely Pirandellian situation. In the therapist role,
he was observer of himself as client, but, at the same time, he

8
In the 1970s, in the wake of Jay Haley, and using the terminology of that
time, we would have described this as a "pseudocomplementary" move of the
therapist, which would have permitted him/her to maintain the one-up posi­
tion while giving the client the illusion of having control of the relationship.
Nowadays, we look at this from a different viewpoint. Now the emphasis in the
therapeutic relationship is more on listening to the client and collaborating
rather than on the way, direct or indirect, of exercising control over the relation­
ship with the client.
218 CASES

was observed by his actual therapist. It was a situation similar

to, but more meaningful than, that in which a client is asked to
watch a videotape of one of his sessions, i.e. to observe the
therapist who observes. This situation, in which the client is
both to observe and to observe himself from various points of
view, may have the effect of triggering a flash of creativity.

BRUNO: Let's leave it empty. It's better that way [indicating the empty
chair]. The first impression that I have of him is that there is
something that's dragging him into a tomb, from behind. He
wants to stand up and .. . I'm telling you what comes to my
mind . . . and then he told me that, when he had therapy with
Dr. Verdi, at the beginning he had had this picture of his father
who is standing up in front of him [Bruno, as a child] who
couldn't yet stand up and his mother who goes away, and this
father who remains rigidly standing, and this little boy tries to
stand up and doesn't understand where this father wants him
to get to, and how the client still finds himself in this situation.
He doesn't know that he can stand up! It's like he's in front of a
giant, who's standing there and doesn't move. The one thing is
to get there, but to do that when one is little, there's the risk
then of breaking one's back. A n d this is the idea that pulls him
down. So what should I do? . . . I should look a bit with him . . .
he's looking for something that, after all, he already has, but
he has doubts that he has to resolve, as you said, whether
they are existential or not . . . I think that a patient who asks
you or me, "What can I do to . . . ? " has a lack of ideas about
how to get out of his predicament. Another hypothesis comes
to my mind. Maybe he needs another man to hold his hand and
say, "You've done well. Now I'm going to take you by the hand
and show you another situation."
THERAPIST: As a client, would you request this of you as therapist?
BRUNO: Yes, this patient [he indicates the seat where he sat previously].
THERAPIST: You say, "He's looking for a man, a man to lead him."
BRUNO: Who says, "This isn't the only situation that exists in life.
There's another."
THERAPIST: H O W do you read the message that is given to you as
therapist?
 SYSTEMIC THERAPY CASES 219

BRUNO: He is desperate and expects me to take his hand.

THERAPIST: A n d do you feel inclined to give him your hand? Do
you intend to help him?

It is significant and also rather surprising that the client, in

role-playing, centred on the subject of his relationship as a child
with his father, which previously he had indicated as already
resolved by his analysis. In fact, in this very session, he had
criticized the work of the therapist who had touched on that
subject in the preceding session. He said that this had caused
old wounds to open and had perhaps caused his back to get
worse. But right then, he not only centred on the father-son
relationship, but he also did so echoing the opinions expressed
by the therapist during the preceding session.
In this segment, one gets the impression that the client took
the prerogative of indicating to the therapist what would be the
"direct path" to follow, as Virgil did with Dante Alighieri. This
reversal of roles in the therapeutic relationship might also be
considered to be a consequence of Bruno's double role—as the
client and fellow therapist—that could shift the relationship to
a number of levels: therapy, training, and supervision!

Bruno: He expects something from me that his father had not

given him. I should act as his father.
THERAPIST; T O whom did his father give a hand? To whom did his
father give it, if not to him? [Pointing to the chair that the patient had
vacated] Did he give it to his wife? To his daughter? Or to no­
body at all?
BRUNO [appears moved and stretches out his right hand]: He didn't give it
to anybody because it was a hand that was full of sadness and
hardness. He protected his son that way. He protected him by
not giving him his hand ., . He, too, wanted help. This father
asked for help, and, at the same time, he was full of anger . . .
He wanted help from his son.
THERAPIST: H O W come his son didn't give it to him? Is it possible
that the son didn't give it because he was unaware of this
father, because the son was giving his hand to his mother, for
example? Or rather, was he giving both hands to his mother?
220 CASES

BRUNO: Yes . . . but this man was also very rigid. He never bent
down to the level where he could reach his son.
THERAPIST [jokingly]: His son should have bent d o w n . . ,
BRUNO [indicates with his hand the height of a child and smiles]: But I was
little!
THERAPIST: In this moment in the life of your client, what do you,
as a therapist, think about his future? Do you intend to give
him a hand? Or would you not give it to him because it
wouldn't be helpful, because it might keep him dependent?
BRUNO: No, he won't remain dependent. [He touches his forehead.]
Now I'm a bit confused because you said this thing about giv­
ing him a hand .. . This patient had never given a hand to his
father. This patient had always thought the opposite.
THERAPIST: Earlier, I expressed the hypothesis that he didn't give a
hand to his father because he was giving it to his mother.
BRUNO: Maybe his fear [indicates the "patient's" chair] is that his child
might be a boy. Maybe he doesn't know how to give his hand
to a boy.
THERAPIST: When your child is born, there will be a time when he
or she, like all small children, will give his or her hand to the
mother and not to you. Maybe you'll feel excluded [smilingly].
Maybe you'll have a kind of "post-partum depression", like
fathers who suffer when a baby is born. You might feel the way
you described your father before, a bit alone because the child
won't be giving a hand to you.
BRUNO: Maybe.
THERAPIST [pointing at the empty chair]: It might be that, deep down,
he feels that he is at a standstill, that time has stopped at a
certain point in his life. I'm speaking of emotional and psycho­
logical time, in the sense of being fixed at a situation connected
with his family of the past. Chronological time never stops, so
he has grown up biologically, but inside there's still something
unresolved.
BRUNO [in a deeper and slower voice]: But he has discovered his hands.
He told me that formerly he did not have any sensation in his
hands, but now he has discovered his hands. He has started to
have feelings of warmth . . . In the past, he even had the sensa­
 SYSTEMIC THERAPY CASES 221

tion of not having hands, but now he has them . . . Now he

needs somebody to pull him up. [He makes a gesture of helping the
"patient" to rise.]
THERAPIST: Yes, but what do you, as therapist, think right now? Do
you think that he has a need of continuing with you or not?
BRUNO [intently]: Yes, he needs me, to come out of these doubts,
like looking in a mirror and seeing what he has inside him . . .
Maybe this could help h i m . . .
THERAPIST [rising]: I'm going to go now and consult with my col­
leagues.
BRUNO: Okay. Excuse me, should I go back to my seat or stay
here?
THERAPIST: Y O U may go back. You may leave your role now. [He
leaves the room.]

In this segment, the dialogue between Bruno, in the role of

therapist, and the therapist became more concise and deeper.
The content of the dialogue was the same, but the perception of
it was different. A t times, Bruno appeared deeply moved, espe­
cially when he described the solitude of his father and the
mutual difficulty in opening themselves up to a relationship of
intimacy, as well as when he talked about having discovered
his hands. The therapist's tone, too, denoted a greater emo­
tional involvement. The previous comment formulated the
hypothesis, or rather, suspicion, of a reversal of the client­
therapist relationship, in which the client indirectly communi­
cated the course that the therapist should follow. However,
reading this segment, particularly as far as emotions are con­
cerned, one might think about a hypnotic relationship, facili­
tated by the construction of a three-party dialogue between
client, fellow therapist, and therapist. Nevertheless, the thera­
pist does not practice hypnosis.
It is noteworthy that the therapist had tried three times to get
Bruno, in his role as fellow therapist, to state whether or not he
would have continued therapy with his client. Only the third
time did Bruno give a definite affirmative response, thus giving
rise to the necessary conditions for the following final com­
ment.
222 CASES

[The therapist re-enters the room.]

THERAPIST: In the discussion with my colleagues, we came to the
idea that individual therapy is indicated. I do therapy that
consists of a maximum of twenty sessions about two or three
weeks apart. These twenty would include the two sessions al­
ready completed. Many clients finish before the twentieth ses­
sion. If at the twentieth session the client feels that he or she has
need of further help, then I would evaluate the situation. If I
felt that I had exhausted my resources, I would not be able to
continue, and in that case the client could go to another thera­
pist. Most individual sessions take place without the therapy
team, and if the client gives permission, the sessions are
videotaped. [The financial terms are stated.] If you agree to con­
tinue, you can either tell us now, or take time to think it
over . . .
BRUNO: No, I have already decided to continue.
[The therapist sets up an appointment for the next session.]

Continuation of the case

Beginning with the third session, Bruno no longer com­

plained about his backaches. H e continued to act as though he
were in analysis, beginning each session telling of one or more
dreams that he had recorded in a notebook. A t the fifth session,
he joyfully announced the birth of his son, who, for a certain
period of time, had focused his attention as a man and proud
father. H e spoke very little about his relationship with his wife,
as if the conflicts were resolved. The main subject of therapy,
frequently present in Bruno's dreams, was his self-confidence,
particularly with respect to me, and the confrontation with
other men, especially with important and prestigious men, to­
wards whom he expressed a desire to be accepted and ad­
mired.
In order to avoid symmetry, the therapist adapted to this
hybrid way of doing therapy, which was not customary for
him, by virtue of the importance of accepting what the client
brought.
 SYSTEMIC THERAPY CASES 223

A t the present time, Bruno has had fourteen sessions. The

most important session so far seems to have been the twelfth.
This session began with Bruno's rather weak protest about the
marked lateness of the therapist (twenty minutes), this tardi­
ness being, moreover, not an unusual occurrence. After offer­
ing his ritual apologies, the therapist asked why this legitimate
protest about his lateness was made with such a subservient
tone and why Bruno's anger did not come forth. Bruno imme­
diately told about his dream of the previous night, which was
of a familiar scene from his childhood, with which he had asso­
ciated a fear of asserting himself, similar to what had just oc­
curred in the session.
A n analysis of the material of this dream and some of
Bruno's new memories of the past stimulated the therapist to
describe a new scenario in Bruno's life. Bruno, as a child, in his
relationship with his mother, seemed to have had the illusion
of being on a pedestal. H e did not see that his mother was
bound to her husband by deep feelings of affection and great
admiration for him. Bruno's sister and father also had a rela­
tionship of love and mutual understanding. The missing con­
nection of his hand with that of his father, which had been the
central theme of the second session, was probably due to a lack
of interest in Bruno on the part of his father. Although Bruno
was not conscious of it, this situation seemed to have under­
mined his self-esteem and self-confidence. It was as if there
had been a collision between the illusion of being on a pedestal
and the "reality" of being out in the cold, and, according to
the therapist, it was this that Bruno was trying to resolve in
therapy.
While the therapist was making these reflections, Bruno, at
first, became pale, as though he had received a shock, and then
his eyes and his face became red and he burst into tortured
sobs, followed by a long silence from both men. The silence was
broken by Bruno with a sigh of relief and with the statement,
"We've finally got to the crux of it a l l ! " In the following ses­
sions, Bruno seemed more serene and secure, and he no longer
had the former meditative look about him.
224 CASES

LUCIANO M.: PRISONER OF A FAMILY MYTH

This case has its roots in the past history of the M . family. The
father of our patient Luciano had been a specialized worker in
a company. H e had invented a very innovative type of loom.
H e immediately proposed this invention to the top manage­
ment of the firm, and they, laughing, quickly sent him away.
M r . M . was convinced that his invention had a future, so he
resigned from the firm and, together with a few other workers,
founded a workshop to try out his invention.
The trial was successful, and people from everywhere started
ordering the loom. In a short period of time, the workshop
became a factory, and then the factory grew and grew, until it
became necessary to establish branches in various foreign
countries. The patent's success made the inventor famous all
over the area. He became a mythical personality, and after his
untimely death, at the age of 35, due to an accident, this myth
became more and more embellished and exaggerated.
A t the time of M r . M.'s death, his daughter, Maria, was 8
years old, and his son, Luciano, was 4. The factory had passed
into the hands of Mr. M.'s wife and his older sister. The latter
energetically took control of the firm, and she was currently still
the managing director. The ownership was divided, with M r .
M.'s children each having 35% of the shares and their mother
having only 5%. The dividends from these shares were suffi­
cient to assure the family a high standard of living,
Luciano's sister Maria was married to a young man who had
very early arrived at a high position in the firm. Maria and her
husband lived in a recently built villa. Luciano and his mother
were to have lived in a twin villa a short distance away, but, for
the time being, they lived together in an apartment,
When he began therapy, Luciano was 24 years old. His prob­
lem had begun three years previously with a series of panic
attacks. The first of these took place during a trip to England,
forcing him to return home. From then on, his symptoms re­
turned from time to time, keeping him from travelling or going
very far from home.
Luciano was a major stockholder in his father's firm, and he
did go there regularly, but he nonetheless had failed to carve
 SYSTEMIC THERAPY CASES 225

out a niche for himself in the company. His aunt urged him to
be more active in the firm, and it was she who had contacted a
doctor who, in turn, contacted the therapist. It was decided to
follow this case as a team, and the first session took place with
Luciano's mother present.
Luciano was a handsome young man with long, well­
groomed hair, who had a tendency to smile often, giving us the
impression that he wished to hide a persistent feeling of embar­
rassment. The therapist felt him to be ingratiating, as if he
wanted to present himself as a "fine young m a n " who liked
everybody. However, he was not very highly esteemed by the
people of his town, who attached great importance to working
ability and to masculine competition, and who more or less
covertly disdained him for his indecision and fears. He be­
haved more like an adolescent than like a mature man. He said
that he felt closer to his aunt, and spoke badly of his mother,
even though he lived together with her. After the death of
Luciano's father, his mother had dared to go against the wishes
of her powerful mother-in-law and sister-in-law. She had de­
cided to live her own life, instead of spending it near their clan,
in remembrance of her husband. Although she had initially
gone to live with her mother-in-law, Luciano's mother soon left
her mother-in-law to go and live on her own, comfortably, with
the income that she had from the firm. According to Luciano,
the women in the father's family did not care very much for
Luciano's mother, and they seemed to have taken on the role of
being his mother. Since Luciano's mother was again single, she
had become romantically involved with another important in­
dustrialist of the area, and she seemed quite happy with him.
Her companion, who was a widower, also had children, and
Luciano had developed an almost brotherly relationship with
one of them. Nonetheless, it seemed that he constantly re­
proached his mother for paying more attention to them than to
him.
The first two encounters were mainly devoted to recon­
structing this complex family history with the help of the
mother, who was present at the first session, and of the sister,
who was present at the second session. The sister clearly ex­
pressed over and over again her disappointment in the (pre­
226 CASES

sumed) incapacity of the brother to take an important role in

the firm in the name of their mythical father. With her help, it
came to light that although Luciano had not managed to obtain
an important role in the firm, two other men of his generation
had managed it: one was her husband, who was, to all effects,
the number two person in the company, and the other was the
aunt's son, whose career was continuously on the rise. After
these two preliminary sessions, it was decided that this would
be an individual therapy and be part of our research study of
therapy limited to twenty sessions.
In the initial sessions, a fundamental theme emerged: the
myth of the father. Luciano was apparently the victim of a
myth, the myth of his father, who was an exceptional and i n ­
genious man. After the death of Mr. M . , everybody expected
that Luciano, being the only son, would be the one to take his
father's place. The weight of this myth had been the reason for
his anxieties, and these, in turn, had caused him to be unable to
give his life direction. His sense of failure, which seemed to
permeate his existence, derived from this situation. In contrast
to Luciano, his sister had attempted to have a role in the firm,
but after having had differences of opinion with her aunt, she
ended up on bad terms with her. Afterwards, Maria seemed to
have created a relationship with her husband that was very
similar to that which she had had with her father. After having
mythified her father, whom she had loved very much, she now
mythified her husband. Luciano fully accepted the therapist's
refraining. In fact, he said that every time he heard the name of
the firm, he had new anxieties and had a vague sense of nausea.
To the therapist, Luciano seemed like a pre-adolescent,
strongly attached to his aunt and, unlike his sister, unable to
criticize her. Luciano's relationship with his peers was rather
peculiar. A s he was the richest of the group, he tried to buy
acceptance from his friends by continually giving them gifts,
paying the bill in restaurants, buying stadium tickets for every­
body, and so on, in an attempt to earn their good will. H e
manifested the same altruistic behaviour towards his impor­
tant relatives, especially his aunt, to whom he gave expensive
and very tasteful presents. He avoided speaking about his own
ties with women. It appeared that he had never had any really
 SYSTEMIC THERAPY CASES 227

significant relationships. A t a certain point, the therapist put

forward the hypothesis that Luciano might have had doubts
about his sexual identity, which Luciano accepted as plausible.
For two or three sessions, the therapist concentrated his ef­
forts on conveying to Luciano the idea that, since Luciano had a
large block of shares, he could very well have limited himself to
taking advantage of his shares and stopped worrying about his
role in the firm. There was already a role available to him, the
role of owner, and in principle he could have avoided all the
problems connected with the management of the firm. The
problem was that Luciano just wasn't able to do this. The myth
that he had to be the proper heir of his father and continue his
father's work seemed untouchable.
After about six months, the sessions started getting monoto­
nous. We advanced the hypothesis that Luciano had finally
found a nice father-substitute who was ready to listen to him
and to accept him, and that at this point, he continued to come
to therapy because it was more gratifying than trying to change
in any way and that this could also serve as an alibi to give to
his relatives to explain his absences from work. The therapist
verbalized these impressions at the end of the last session be­
fore the summer vacation, and he urged Luciano to search
inside himself for some significant theme that could be used to
make progress in therapy in the following sessions.
When he returned from vacation, Luciano began again to
dwell on the same subjects, without any noticeable change ei­
ther in the subjects or in his attitude. He came back smiling and
engaging, and talked about a couple of aborted attempts to
become independent. H e also said that he felt well because he
had avoided long trips, but sensed a weight inside and didn't
know why. He felt bad both alone and in company, and when
he was alone he always brooded about his problems. H e really
only felt well when he was together with his mother, who
accepted him the way he was and did not compare him to his
father. H e said, "It isn't my fault that I have received what I
have, but they oppress me with it."
In this session, we reformulated Luciano's accounts as dem­
onstrations of the "force of passivity". His not doing what the
others expected of him demonstrated his independence and
228 CASES

that he was able to be strong like his father. Also, in this case,
Luciano accepted the therapist's hypothesis as though it were a
significantly new idea, but he returned again for the seventh
session as though nothing had changed. A t this point, the
therapist explained to Luciano his idea of acting as his father
during therapy, because his real father had probably died too
soon to have given him the security of the father figure and had
left him in a world occupied only by women.
A t the beginning of the eighth session, Luciano seemed quite
relaxed. H e said that he had come to Milan with his mother to
bring her shopping. (Luciano usually came to therapy carrying
bags or boxes containing presents from prestigious shops for
himself and for relatives.) The therapist, curious about the
great amount of money that Luciano's mother had at her dis­
posal, asked Luciano where his mother's money came from. It
turned out that she had quite a great deal of money of her own
from the dividends on her stocks in the family firm. However,
he also discovered that the administration of the whole legacy
continued to be entrusted to Luciano's aunt.

CONSULTANT: But what if your mother should happen to find her­

self without any money in the bank.
LUCIANO: M y aunt would put more in.
CONSULTANT: A n d what about you?
LUCIANO: M y aunt takes care of me, too.
CONSULTANT:But, listen, who manages your inheritance—you or
your aunt?
LUCIANO: M y aunt! Although last year she told me that I ought to
start to take care of this personally.

In short, it came to light that Luciano's aunt was the one and
only person to administer all of the family's assets, and she
managed all of the investments of all of the members of the
family. Essentially, Luciano and his sister were simply stock­
holders. N o w the therapist began to investigate Luciano's deci­
sions about his inheritance more insistently. H e wanted to
know why Luciano didn't take care of this personally. We felt
that particularly in that family, one's management of one's
 SYSTEMIC THERAPY CASES 229

own money was the touchstone of maturity and independence.

Faced with this type of question, Luciano seemed more and
more uncomfortable, and he defended himself by emphasizing
the great trust that he had in his aunt and in her ability as an
administrator.

THERAPIST: You have this huge and, it seems, justified trust in your
aunt, and in exchange you get her love. Your aunt loves you
because her love is reciprocated, but it seems to me that the
price that you pay is remaining an adolescent and not growing
up.
LUCIANO: Yes, sometimes it seems that my aunt wants, at all costs,
to have me be the good little boy.
THERAPIST: If you would decide to become independent and ag­
gressive and plan your own life, is it possible that this would
ruin your relationship with your aunt? Is it possible that deep
down you have made this choice to remain a child in order to
continue being loved by your aunt?

The client did not accept these hypotheses. In fact, he fought

them quite actively. H e said that his aunt had always loved
him, that she had nothing against him, and so on. H e changed
the subject to his mother, criticizing her severely for not having
taken adequate care of her children. After a few more ex­
changes, the therapist left the therapy room to go and have a
discussion with the therapy team.
A female colleague who was present in the observation
room said that she felt uncomfortable because, once again, and,
in fact, more emphatically than ever, Luciano had attacked his
mother. The colleague had begun to feel a sort of solidarity
with Luciano's mother, who had never been accepted by the
powerful M . family because she had not conformed to the fam­
ily myth. In fact, she had always been more or less covertly
rejected, with the result that even her own son always took the
side of his aunt against his mother. In the team discussion,
there emerged the idea that Luciano was the sacrificial lamb
w h o m his mother had given up to the M . family clan, and that
she permitted the aunt and the clan to be the guardians and
followers of the myth of the Great Father.
230 CASES

It was decided that a third party would take part in the

session: the above-mentioned colleague would enter and give
her impressions directly to Luciano. The colleague entered and
said that she had felt the need to express her distress about
Luciano's mother's suffering at her exclusion by the women of
the powerful M . clan. This statement provoked animated pro­
tests from Luciano, who immediately proceeded to emphasize
how much his mother had been helped by his grandmother
and his aunt, although later he did agree that there had been
disagreements and misunderstandings.

COLLEAGUE [speaking to Luciano]: I think that your mother had no

choice, somehow she had to leave the clan. A n d for this reason,
she found another family. She was not a member of the M . clan
and she was considered a sinner, so she had to leave. The M .
name was precious and mythical, and it wasn't her name, so
therefore she was not necessary to the family. In the meantime,
your aunt, who had taken on the heavy responsibility of carry­
ing on this name, had convinced you children that she was
your mother. A n d so she became your mother, but, you,
Luciano, suffer because your real mother is another person.
THERAPIST: I think that, at a certain point, your mother had to
choose either to stay with the M . clan and be the underdog, at
the beck and call of the M . women, who would always be the
champions, or else to leave. Faced with this dilemma, your
mother, who was a woman with her own personality and a
feeling of self-worth, decided to not submit and to live her own
life. A n d , at this point, she rebelled, and she didn't end up out
on the street or living a miserable life because of her rebellion.
Instead, she showed that she was a great woman, because she
found herself a man who was even richer than her mythical
husband. I can understand, Luciano, that for you it is difficult,
in fact, right now, really impossible, to accept this idea, because
you are still too tied to the myth of your father's family. Thanks
to my colleague's intuition, what we see is that you came here
with a symptom, which is the symptom of panic about taking
trips. Well, we feel that you can't go away because you haven't
yet made the choice that your mother made, the choice of free­
dom. A n d also for this reason, you can't undertake another
 SYSTEMI C T H E R A P Y CASES 231

trip, that of embarking on a relationship with a woman, since

you have to obey and avoid taking on the responsibilities com­
mensurate with your age; and, for these reasons, even though
you say that you wish it, you cannot become involved with a
woman. A n d you have to remain dependent because, since
your father is dead and you think that your mother is a bad
mother, you have to stay tied to your aunt, and the price you
pay for this is to remain a child, maybe an adolescent.
COLLEAGUE: But right now you can't become an adult, because in
order to become an adolescent and then a man, you have to feel
accepted by a real mother, for whom you feel esteem, the es­
teem I feel when I think of your mother's life.
THERAPIST: First it was your grandmother and then later your aunt
who felt the obligation to bring you up, and to make you a real
M . Thus your aunt was both mother and father to you, but with
the expectation that you would become a proper heir of your
aunt's brother—or, at any rate, that's the expectation you've
sensed. This has created a crucial dilemma for you of either
being on a pedestal or falling into the dust.

After having heard these statements, Luciano first denied

that they could be true, and then he seemed doubtful, and
slowly began to agree, so much so that he helped the therapists
in their reframing. In the last few minutes of the session,
Luciano appeared emotionally very different from before as
well as more attentive and in harmony with the therapist and
his colleague. H e also seemed rather worked up. He continued
to take off and put on his eyeglasses. When the therapist's
colleague made her last statement, one could see that he had
tears in his eyes and that he was deeply moved.
The colleague's intervention recalls the words of Harold
Searles (1965), an analyst of schizophrenic persons. His clients
often gave totally negative judgements of their mothers, practi­
cally equating them with monsters. According to Searles, if the
analyst does not confront such views of his client and either
implicitly or explicitly endorses them, then the analysis can
enter an irreversible impasse. For this reason, it is important to
introduce positive versions, even if hypothetical, of the
mother-son or mother-daughter relationship. To develop a
232 CASES

sense of self-worth, it is necessary to feel accepted and loved by

at least one of one's parents. In this sense, it is significant that
Luciano was profoundly moved by the words of the colleague
who had expressed admiration for his mother.

LUCIANO: If I discover anything, anything done wrong, if I dis­

cover that my mother was sent away, I'm going to become
nasty. Even with my aunt.
THERAPIST: Listen . . .
LUCIANO: But do you think that it was premeditated?
COLLEAGUE: No, not premeditated. We think that this was a story
that arose by itself, and that you all have written together,
everyone his or her own part. It's out of place to look for where
to place the blame. It would be useless and wrong to get angry
with your aunt or with others, because everybody, including
you, has contributed and contributes to creating the story in
which all of you are involved.
THERAPIST: I think that it is necessary for you to hear the story that
we are creating and that you know how we see it, as one of the
possible stories or one of the possible ways to see the story of
your mother.

It is interesting that when Luciano listened to the colleague,

he was totally spellbound, much more interested than when he
listened to the therapist, who, after all, reiterated the same
ideas. It is another example of the power of every now and then
unexpectedly introducing a third party in the dyadic relation­
ship. Behind the one-way mirror, a psychodynamic version of
this story also emerged. If, before, Luciano had been alone with
a metaphoric father, now, at the session, he had both a mother
and a father, this pair of parents by whom he had felt aban­
doned, and who were now attempting to help him.
Actually, the story that we had narrated up to that time was
an all-male story, based on the father, on the other men of the
family, on the relationship with the (male) therapist, on the
masculine character of the aunt, and so on. In a sense, after
having dealt with the patrilinear dynasty of the family, we
discovered the matrilinear dynasty of the M . clan. We went
 SYSTEMIC T H E R A P Y C A S E S 233

from the masculine to the feminine, with the effect of an inver­

sion of figure-background. Thus the story of his deprivation of
affection, which, in therapy, was always the story of a boy
deprived of his father, suddenly became the story of a boy
deprived of his mother. The introduction of feminine figures
and a feminine reading of the same story was having a power­
ful effect. It was overcoming the impasse that we had perceived
in the last few sessions.
In the discussion after the session, we came to think that
quite probably the therapist, as a man, had identified with the
M . father and had begun to want a different Luciano, a Luciano
who could detach himself from the expectations of the women
of the family. A l l of the men of the team were in agreement
with this masculine view, which did not accept very well
Luciano's "feminine" side (according to the traditional idea of
"feminine"), i.e. his passivity, his delicacy, etc. It was a classical
case of bias due to the premises of the therapist, which was
overcome with the introduction of the third person who had
different premises.
We could also say that the earlier work of the therapist, all
based on the man-to-man relationship with Luciano and on the
proposition of being able to have him become a fulfilled per­
son, was not efficacious, because of the actual situation of the
family. This was a family in which the power was really in the
hands of the women, starting with the grandmother, while she
was alive, and continuing with the aunt. A l l of the men were
subordinate to them, including the mythical father. 9

From a narrative point of view, the work done in this session

reversed the punctuation, changing both the narrative style
and the connections in the story. So, why was it necessary to
have so many sessions to arrive at this new vision? Why had
we, for eight sessions, accepted the negative view of the
mother, whom, at this point we could (honestly) see as a posi­
tive and strong-willed woman? Maybe it was due to our biases,

9
Naturally, a psychoanalyst could easily read this whole story in terms of
phallic or castrating women, etc. A l l one needs to do is substitute "phallus" for
"power".
234 CASES

or maybe it was because the story (in therapy) had had its own
logic and its own time of maturation.
With regard to the effect of the intervention, another impor­
tant point was probably the dialogue between the therapists at
the moment of the introduction of the third party. This had
contributed to removing the therapist's aura of omnipotence
and had shown Luciano different possible worlds, which were
neither perfectly identical nor mutually exclusive.

CARLA V.: HER FEMININITY FOUND AGAIN

Carla was a 35-year-old paediatric dentist. She had been mar­
ried for ten years to an engineer and had a 5-year-old daughter.
She had been diagnosed as having Crohn's disease, a severe
form of hemorrhagic enteritis, and had been sent to our Centre
by her family doctor.
She had been asked to come with her husband, but at the
first session she arrived alone. She said that her husband was
scared of psychotherapy and therefore was not willing to par­
ticipate. In fact, even though he had brought her by car from
the city where they lived, which was quite far from Milan, he
had not even gone upstairs with her, for fear that he might be
induced to have therapy.
What immediately struck the therapist were Carla's vigor­
ous, masculine handshake and her somewhat ambiguous facial
expression, neither clearly masculine nor clearly feminine. Her
haircut and clothing (trousers and sports jacket) were very mas­
culine-looking. However, a casual observer would not have had
doubts about her being a woman.
During the first session, she said that she had come to
therapy because of the serious gastroenteritis from which she
had suffered for almost ten years, which caused her a great deal
of discomfort every day. She had even undergone an operation
of intestinal resection, but without resolving the symptoms. For
years she had been in the care of gastroenterologists and sur­
geons.
The therapist then began to look into Carla's relationships
with others.
 SYSTEMIC THERAPY CASES 235

Shortly after getting married, Carla had entered into an ex­

tramarital relationship with a former university classmate,
who was well known as a fascinating man, and in his university
days had been much sought after by the other women students.
The relationship was still going on at the time Carla started
therapy. A s far as her marriage was concerned, she felt that
there was much affection between her husband and her, but
that their relationship was more like a brother-sister relation­
ship, without passion.
Carla described herself as a meticulous and dutiful person
(especially with regard to her daughter) and very much a per­
fectionist. She said that her symptoms had appeared a few
months after she had begun her affair with her ex-classmate.
Her lover was a married man, who was well known in their city
and was also an acquaintance of her husband. Describing her
relationship with her lover, Carla said, " H e ' s in my blood", and
she couldn't do without him. She always felt a bit humiliated
when she telephoned him, because it was always she who
called him. They would meet in a secluded place and have
passionate sexual relations, in which she always reached or­
gasm. After this, they would part, and two or three months
would pass before Carla would again feel this overwhelming
need and telephone him again. (The therapist described this
need as "similar to a craving for heroin", an analogy that Carla
liked very much.) She said that, since she had felt that she
didn't know how to write good letters, she had even taken a
letter-writing course, just to be able to write letters to him, but
that he had never answered, even though he was always ready
for her when she called him.
Carla agreed to a contract for twenty sessions of therapy,
according to the programme for our research. A t the first ses­
sion, the therapist began to work on the theme of Carla's sexual
identity, a theme that was suggested by Carla's appearance
and by her story. She was born in a small town. Her father was
a well-known and highly esteemed artisan in this town. Carla
described her mother as a rather tiresome "little" woman who
thought of nothing but the house and the family. The client had
always admired her father, but she had always thought of her
236 CASES

mother with a vague feeling of irritation. Her brother was a few

years older than she, but not very highly regarded. H e was a
manual labourer, who had married an unimportant woman,
and had not ever done anything to put himself in the limelight.
In contrast, Carla was the darling of the family, in that she was
a successful woman, a university graduate, and was married to
a professional man.
According to what Carla had said during her evaluation of
therapy at the last session, what seemed to have most i m ­
pressed Carla and to have had an effect during the first few
sessions was that the therapist felt that inside her, there was a
splendid woman whom he wanted very much to see come out
into the light, and that he felt that she could not for fear of not
being accepted. For her, only men were first-class persons. For
this reason, she had, at first, felt legitimized by her father, and
then she had chosen as her lover the man who, when they were
students, had been the idol of all the other female students. In a
certain way, she was fascinated by whatever was considered
"the best". The therapist confronted Carla on this, emphasizing
that feminists would justifiably be horrified at the idea that in
this day and age there could still be a woman like her, who
could only feel legitimized by a man, as was the case in the past
when women even lost their own surnames when they were
married.
The therapist's challenge began to have an effect and to
bring about the discovery of one of the principal themes of
Carla's therapy. Since she had little respect for women, she had
chosen a masculine identity, dressing and acting like a man,
even if clear signs of her suffocated femininity did leak out.
This challenge began to make her have doubts about this iden­
tity, and after about ten sessions Carla began to change very
visibly. The exterior signs of masculinity disappeared (particu­
larly those of her mode of dressing), and a certain hardness of
character also abated. It must be mentioned that in the last
couple of sessions of this period, the main topic was her diffi­
culty in breaking off the relationship with her lover.
Before she could really get out of this relationship, she had to
go through a particularly difficult period of great suffering. A t
the time of the summer break she went into a deep depression
 SYSTEMIC THERAPY CASES 237

for two months. A t the first session after the vacation, she said
that the only reason that she had not committed suicide was
that she was very attached to her daughter.
After this break-up, the symptoms of Crohn's disease com­
pletely disappeared, and Carla also began to get rid of the guilt
feelings and anxiety that had tormented her for years. After
that, things changed rapidly. Carla began to let her hair grow
and to wear very feminine clothing. The change in her facial
expression was extraordinary; it became softer and more re­
laxed. Warm maternal feelings also emerged. According to
Carla, her daughter had developed enuresis and encopresis as
a protest against her lack of maternal warmth. A t the beginning
of therapy, Carla had asked about the possibility of her daugh­
ter participating in it, but the therapist had refused, convinced
that when Carla's problems were solved, her daughter's would
also be solved, as proved to be the case.
After the summer, she came to the fifteenth session, relaxed,
smiling, and elegant, wearing an airy silk dress. She had spent
the vacation abroad with her husband and some friends. She
said that everything had gone beautifully, and she thought that
this would be the last session of therapy. She added that during
the trip home in the car, she had had the idea of leaving " o n the
other side of the A l p s " the last dark point of her past, and she
decided to confess the whole story of her unfaithfulness to her
husband. It was a dangerous decision because of the time and
place when and where it took place.
Her husband was obviously infuriated, and he said that he
had also expected something of the kind. Then, in the heat of
the moment, he raised his hand as if to slap her in the face.
Seeing her husband's hand raised, Carla was assailed by the
vivid memory of one time when her father gave her mother a
violent slap in the face for a banal reason about which he was
mistaken. Carla's mother had taken this without protesting
because violence, even if unjustified, was a man's privilege.
Thinking of her humiliated and offended mother made her sick
at heart, and tears came to her eyes. Carla's husband, who was
under the impression that she was crying for him, had reacted
by saying, "Let's not make a tragedy of it. What has happened
has happened, and that's the end of it."
238 CASES

During this session, Carla also told about a dream, the sec­
ond of the whole course of therapy. A n analyst would have
described it as a classical "final dream" of therapy. In this
dream, Carla was invited to tea, along with other women, by
the wife of her former lover. A t first, she had felt embarrass­
ment with regard to her lover's wife, but she had been wel­
comed so warmly that she felt relieved of the sense of guilt that
she had had for many years towards this lady. Both the confes­
sion i n the car and this dream seem to demonstrate her redis­
covery of her femininity and maternal feelings and also show
her growth and recovered sense of worth.
It is interesting how, following the therapist's exploration,
Carla's past changed. From a past in which her mother (like
women i n general) was seen as a completely negative and sec­
ondary figure, a new past emerged in which her mother was
seen i n a different light as a woman who was the victim of the
familial and social circumstances of the time. The recovery of
that past was the recovery of a new reality, which up to that
time had been only a virtual reality, a reality i n which her
mother was subjugated and, at times, humiliated and offended
by Carla's father. Since the time of therapy was i n the present, it
was in the present that Carla's perception of the past changed,
and this, in turn, had an influence on the past and on the future.
This is an example of the concept of the reopening of the self­
reflexive loop of the past, present, and future, which is one of
the most important points of our model (Boscolo & Bertrando,
1993).
In his way, the therapist had created a possibility for Carla to
come in contact with another possible world—that of a mother
who, far from being a person of little account, was, instead, a
victim of the culture and of the social environment in which she
lived. After the deconstruction of the story that had come out
over time (a story heavily influenced by the biases of the cul­
tural environment in which Carla lived), the story about her
mother that Carla could now tell had become a different one
(an alternative story, as Michael White would say: White &
Epston, 1989).
Since the case was followed by a team, this was also a case in
which it was possible to use the presentification of the third
 SYSTEMIC THERAPY CASES 239

party in flesh and blood several times, by having a colleague

from the observation group come in at the end of the session, to
express her point of view (or, more specifically, a feminine
point of view). A t the end of therapy, the therapist asked Carla
which were the most significant moments of therapy. Carla
responded that the final interventions of the female colleagues
had impressed her most of all, and in particular that of one of
these colleagues. She added that she would very much like
personally to say good-bye to this colleague if she happened to
be behind the mirror at the time. When the colleague entered
the therapy room, Carla, clearly moved, gave her a big hug.
A t the end of therapy, Carla mentioned one of her husband's
fears that kept h i m from participating in therapy. It was that he
was somewhat afraid of discovering in himself a latent homo­
sexuality. If one considers sexuality from a relational point of
view instead of from an individual one, one would expect that
Carla's change might well have dispelled her husband's fears.

OLGA M.; AN EXISTENTIAL DESERT

Olga M . , aged 35, had been sent to our Centre by the Headache
Clinic of her city's hospital. For many years she had been af­
flicted with a serious form of intractable cephalalgia, together
with severe masseteric muscle tension, which obliged her to go
to bed wearing a dental apparatus to protect her teeth. Accord­
ing to the client, over time the muscular tension had even
changed her physiognomy, sharpening the lower part of her
face. U p to that time, her headaches had responded very little
to pharmacological treatment.
Olga was a homemaker. Her husband was a specialized
metalworker. She was the only child of parents who lived in a
large northern Italian city, with whom she had never got along.
She described herself as a person who had always been a loner.
Before meeting the man who became her husband, she had had
a pseudo-relationship with a man who had been interested in
her but whom she had rejected. When this man had married
another woman, Olga started thinking of him as the only man
she had ever loved, even though she had never had any physical
contact with him!
240 CASES

In the past, Olga's 8-year-old daughter had had problems of

enuresis and anorexia. The daughter was very attached to both
her paternal grandmother and her father, in whose bed she
often slept, preferring h i m to her mother. The paternal grand­
mother was a widow, and she adored her only child and, of
course, his only daughter. Olga dutifully took care of her
daughter, but she was incapable of "feeling warmth" either for
her daughter or for anyone else. She said that she felt as though
there were a desert inside her and that she had never felt joy in
all of her life but, instead, only indifference or strong anger
towards everyone and everything. Naturally, her relationship
with her husband and her mother-in-law was very bad.
The first encounter took place in the presence of the whole
(nuclear) family. The client was a tall and attractive woman
who, however, appeared to be quite tense and constricted. She
had a tendency to avoid eye contact with the family members
and also with the therapist. Her answers were short, given in
fits and starts, and her movements were also jerky. Corning in
contact with another person caused her to become anxious and
sometimes get red in the face and, as she admitted, to make her
heart beat rapidly. Her husband, who was very different from
her, said that he had never been able to become close with her,
and the reason that he had not divorced her was because of
their daughter, fearing that after the separation his wife might
get custody of the child. In an almost explicit way, he spoke
about her as though she were mentally ill. The little girl became
stiff and motionless when near her mother, but she appeared at
ease, lively and smiling, with her father.
Olga's mother-in-law was also invited to the second session.
The husband refused to continue with family sessions after this
session, citing his work as the reason. However, it was quite
clear that both he and his mother felt that the person who
needed treatment was Olga. Thus, individual therapy of one
session every two weeks was agreed on. This therapy soon
took on the characteristics of support therapy rather than
therapy intended to change the client's view of the world and
have her buried emotions emerge from her existential desert,
Olga had come to the sessions because of the repeated urging
 SYSTEMIC THERAPY CASES 241

of the Headache Centre's specialists, and it seemed that her

only expectation was to be freed of her headaches. The diag­
nostic impression was that she had a serious personality disor­
der of a schizoid type, with the presence of an intractable
pessimistic, if not nihilistic, view of the world. A t the session,
she often seemed as if petrified, immobile, in a defensive atti­
tude. Yet she seemed to come to the sessions willingly since the
problems of headaches and muscle tensions gradually, but
quite noticeably, diminished. This fact added to her confidence
in the referring doctor who treated her pharmacologically and
who continually recommended her to persist in going to ther­
apy at our Centre.
During the course of the sessions, whenever the therapist
tried to open the conversation to certain subjects, Olga would
usually reply, "But that's just the way I am. That's the way I see
things . . ." and thus bring the conversation to a standstill. The
therapist, who desired very much to help Olga get out of her
desert, began, at a certain point, to fear that this wish of his
could have a destabilizing effect on his client and possibly con­
tribute towards a psychotic decompensation. This realization
prompted him to avoid using an argumentative tone. This
awareness also permitted him to respect and accept Olga's
inaccessibility. Since Olga was not very talkative, the therapist
often filled the silences with stories and anecdotes.
Even now, after eighteen sessions, the situation is more or
less the same. The very notable progress is limited to the prob­
lems of headaches and muscle tension. The current idea is to
continue after the twentieth session, possibly changing the fre­
quency of the sessions, as one does with chronic psychotic pa­
tients who need an endless relationship with one person they
can trust, who can contain their anxieties and reduce their soli­
tude. Cases like this, in our experience and in the professional
literature, are of persons who, in early childhood, had not been
able to develop sufficient security and trust in themselves and
in others. It is particularly in these cases that the aspecific as­
pects of therapy are most relevant.
242 CASES

SUSANNA G ; RELATIONAL DILEMMAS

Susanna was an attractive young woman of 25. She was an only

child and, at that time, lived in a small house adjacent to that of
her father and Luisa (the woman with whom Susanna's father
lived). Susanna had had a very sad life. Her parents had sepa­
rated when Susanna was only 5 years old. From that time on,
Susanna had lived either with her father or with friends of her
father in various cities all over Italy. In pursuing his artistic
career, Susanna's father had had to travel from one end of Italy
to the other. Susanna's mother had led an irregular life, domi­
nated by the use of hard drugs. Susanna's father's disdain for
his ex-wife had caused an almost complete break between
mother and daughter. In about ten years, they had seen each
other only four or five times. When Susanna was 15 years old,
her mother committed suicide.
Susanna had attended junior high school and humanities
high school in various cities. She had graduated from the Brera
Fine Arts Academy. A t the age of 20, after a broken love affair,
she became depressed and put on more than 10 kilos. A s a
result, her father brought her back to Treviso to live with him.
Susanna's maternal grandfather was an important person in
Susanna's life. He was a prestigious scholar who had lived in
Canada for many years. After the tragic death of his only child,
he had visited Susanna every now and then, when he made
trips to Europe. It was the grandfather who had contacted Dr.
Boscolo, asking him to take on his daughter as a patient and
offering to pay for the therapy.
After the first two sessions with Susanna, the therapist had
offered therapy consisting of no more than twenty sessions, but
with the condition that the client be the one to pay for it. Since
Susanna, at the time, was not able to pay, the therapist, at his
own risk, offered to defer payment until Susanna could afford
it. Susanna's case was thus made part of our research study on
individual therapy limited to twenty sessions.
Since Susanna's therapy offers a good view of the course of
the therapeutic relationship, we have decided to present two
moments in this therapy—the fourth session and the thir­
teenth—in a particularly detailed manner. The fourth session is
 SYSTEMIC THERAPY CASES 243

the one during which emerged the most important themes that
determined the course of therapy. The thirteenth session fea­
tures the use of the presentification of the third party by the
therapist in order to overcome a moment of impasse.

The fourth session

At the beginning of the fourth session, the client was serene

and spoke spontaneously and fluently of a few episodes re­
garding her father's friends, both male and female, and regard­
ing her grandfather. First she told about a trip to Spain that had
actually taken place and later about a trip to Canada that had
been planned but cancelled. 10

THERAPIST: Hello. What are you going to tell me about today?

SUSANNA [seems relaxed and in an unusually good mood]: Hello . . . I saw
again, for the first time in many years, this girl, Vittoria, who is
married and has a child who is a year-and-a-half old. I stayed
at her house and felt comfortable with her. I led a family life in
this big city full of chaos and everything [laughs]. It was very
different from the usual situation, even though I did have mo­
ments of [sighs] listlessness. When I left for Madrid, having
changed scene, I was elated. I hadn't been together with
Vittoria for a long time, for many years. I was able to talk about
everything with her. I got home about ten days ago—in this
new house that my folks had built for me near Treviso. I've told
you about it, but I don't know if you remember. Anyway, my
father and the down-to-earth woman he now lives with had
three separate houses built. They live in one house. The son of
my father's companion lives in another, and I live in the third.
In these two months that I've been away, I never phoned home.
I didn't feel much like calling. Even though we've never
phoned often during trips, this time in particular .. .
THERAPIST: IS this routine, or did you overdo it this time?
SUSANNA: N O , it's pretty normal. Well, yes, I have never really
phoned often, but the second month I began to , . . well, maybe,

She did, in fact, later make a brief visit to Canada, a short while before the
1 0

thirteenth session.
244 CASES

in a certain sense, I ought to have phoned because I had been

away for a long time . . . but no, I didn't call. A n d even when I
arrived here in Milan I didn't immediately go to Treviso. I went
to Bologna to see some friends. I was a bit . . . [sighs] . . . I tried
to postpone going home for a while. Then, returning home at
the last minute, I was a bit uneasy about . . . maybe because I
hadn't got in touch with my father...
THERAPIST: When you returned did you perhaps imagine that your
father might have disappeared or died or that he would have
punished you?

She had left for Spain euphoric and had had a pleasant time
with her Madrid friend, even though the thought of telephon­
ing home had bothered her quite a bit. Her evident ambiva­
lence about distance and nearness in her attachment to her
father was rebutted by the therapist with the suggestion that
she might have imagined that her father had disappeared or
died or that he might be waiting to punish her for her silence.
The therapist's unusual hypothesis introduces the idea that
there might be a reciprocal ambivalence on the part of
Susanna's father.

SUSANNA: As long as I was away, everything was normal as al­

ways, but after about, say, ten days, I began to feel oppressed
by the feeling that I should phone him. That is, I thought that
my father would have made the usual remarks, that I shouldn't
take two months of vacation when everybody else takes one
month. Well, I began to feel a bit anxious, but afterwards, as
time passed, at a certain point, I said to myself, "So what! What
does it matter whether or not he disapproves? I'm here, and I'll
go home . . . "
THERAPIST: To me those seem like two different emotions. One
might pertain to the age of fourteen or fifteen, and the other
might apply to a more mature age.

The description of two conflicting internal voices was trans­

lated by the therapist as two emotions, one pertaining to a
dependent state and the other associated with an independent
position. The client could thus reflect on this and be aware of
this in herself.
 SYSTEMIC THERAPY CASES 245

SUSANNA: Yes, yes, but . .. I've also thought that probably it is I

who has created these problems, and that now that I am living
in the new house, there should be a change from the past in
that we don't eat together any longer, and .. . well, nobody
would have to keep to a schedule any longer.
THERAPIST: It seems that you feel the kind of obligations to your
father that a child of twelve or thirteen might have—the duty
to arrive at home at a certain time.
SUSANNA: Yes, but it wasn't just the obligation to go home, but
also, since I no longer had last year's job, I had to return to get
organized. I couldn't rely on them, and if I were to be in diffi­
culty, not having any money, he would have said . . . or any­
way, I was afraid that he thought . . . yes, because two years
ago when I was away for a long time, he said that, after all,
normal people [laughs] don't take two months off for vacation,
and that I ought to shape up a bit. Instead, this time, when I got
back, there was no problem. I saw him just once, even though
we live just two steps away.
THERAPIST: Were you happily or unhappily surprised that he
didn't say to you what you had expected?

The dilemma introduced by the therapist made Susanna re­

flect on her " r e a l " emotions about her father. The client was full
of dilemmas pertaining to her unstable sense of identity. The
dilemmas introduced by the therapist could have helped
Susanna to see and clarify some of the basic aspects of her life:
regression and development, dependence and independence.

SUSANNA: Well, it wasn't that I expected him to be angry.

THERAPIST: H O W did you greet each other? Was there a n y . . .
SUSANNA [interrupting]: Well, I actually—he was seated—I actually
hugged him and I gave him an affectionate kiss. We chatted a
bit about this and that, and he was content—that's all.
THERAPIST: Did he ask you about your grandfather?
SUSANNA: N O , this time he didn't, because he knew that I hadn't
seen him.
THERAPIST: What do you mean by you hadn't seen him?
SUSANNA: Well, I hadn't seen my grandfather.
246 C A S E S

THERAPIST: But didn't you go to Canada?

SUSANNA: N O , no. I was supposed to g o . . .

THERAPIST: I thought you had said that your grandfather had in­
vited you to go to Canada.
SUSANNA: Yes. I was supposed to go in September, but my grand­
father came here in July, and he came to Treviso to see me
when he had some free time, and he told me that the trip was
off. I was upset. How strange . . . I think it was an excuse . . . .
maybe I'm wrong. Anyway, he said that it was better to post­
pone the trip. He said that it was cold in the winter—that it
didn't make sense to go now. He really trimmed down the
invitation, in the sense that he began to say that anyway, it was
only a trip and not a long-term stay there, while before
. . . maybe I didn't understand him r i g h t . . . we had spoken
about possible schools, looking into taking a course at the uni­
versity, and therefore it wasn't just a trip. I think that he did an
about-face.
THERAPIST: A n d you felt hurt, right?
SUSANNA: Yes. Yes. I went to pick him up here in Milan. We took
the train to Treviso, and he told me while we were on the train.
I said, "Yes, yes." and I didn't even bat an eyelid about any­
thing and uh . . . and he explained these things about the Cana­
dian climate, that it was better if I go there when it isn't cold
[laughs]. Humph, it all seemed so absurd that I wasn't even able
to . . . to react or say anything. Like last year, I spent entire days
with him from morning until night walking around the city,
seeing things, talking, always talking, with the unspoken hope
that he would invite me to his house to show that he was good,
that he wanted to help me, but on the other hand . . . it's some­
thing that embarrasses me, say, going around with h i m . . ,
THERAPIST: What do you talk about?
SUSANNA [seems a bit agitated and irritated]: U h , he talks a bit about his
doings, and I talk about . . . in fact, I don't know what . . . we
walk in silence a good part of the time. We hardly ever talk
about our personal affairs. Oh ., . y e s . . . I even told him a bit
about my difficult relationship with my father. He was in
Treviso on my birthday. There was a dinner party at the home
of one of my friends where he and my father chatted a bit. The
day after this dinner, he said some things to me about our
 SYSTEMIC THERAPY CASES 247

relationship—things he had observed. Usually when we're in

public, dining with friends, my father and I rarely speak with
each other. At this dinner, the only things we said . . . that, at a
certain point, I said to him were two somewhat ironic com­
ments about something that he had said. The next day, my
grandfather said to me, "Look, why do you have to attack him?
What need is there? Try to be a bit more discerning, because,
between the two of you, you're the more intelligent one, and
you shouldn't go down to this level and get mixed up in these
things that mean absolutely nothing." When he said this to me,
deep down inside I was hopping mad, really terribly angry
because I couldn't accept how he had made the excuse of the
cold weather, and after a l l . . .
THERAPIST: Living with a relative for several days with this
unexpressed protest must really be h e l l . . .
SUSANNA: Yes. I just wasn't able to speak. We walked around and I
wasn't able to think about anything else, but I couldn't make
myself bring up what he had said.
THERAPIST: What might have happened if you had brought it up?
SUSANNA: I don't know. Maybe a criticism, maybe a rebuttal...

Usually at the beginning of a session the therapist listens and

lets the client speak. A t the beginning of this session, also, the
therapist took on the role of listener and allowed the client to
choose what she wanted to talk about. The therapist followed
the flow of conversation, interrupting on occasion, but rarely
changing the subject. Occasionally, he interposed a statement
or a question, which, however, did not induce the client to
change the subject but helped her instead to clarify or enrich
her narrative.
The main principles of conducting the therapy session are
realizing the importance of listening to what the client is say­
ing, exercising the option of asking questions rather than giving
answers, and paying attention to timing. However, it is always
the client, in his uniqueness, and the attention of the therapist
for the changing context that induces the therapist to take spe­
cific decisions and actions. In the case of Susanna, there were
no specific symptoms. She had been prompted by her grandfa­
ther to go to therapy, and she herself said that she wouldn't
248 CASES

have decided on her own to do it. She was aware of living in a

chronic state of dissatisfaction, distress, and uncertainty and
also of having a tendency towards isolating herself. Even
though she had quite a number of acquaintances, she did not
enter into an intimate, trusting relationship with them. Occa­
sionally, she would close herself up in the house for two or
three days in the darkness, trying not to think, or else engaging
in vague, sad thoughts. She was not able to conceive of a future
for herself. She appeared to be a confused, solitary person,
defensive towards the outside world. It was important for her
to be able to tell her life story to an attentive and accessible
person whose participatory listening could give a sense to what
she said and which would, therefore, help foster the develop­
ment of a constructive therapeutic relationship. It is in this
sense that the therapist's brief questions and comments acted
as empathetic reinforcement. It was as if Susanna needed,
above all, a therapist who would give her a sense of self (before
trying to solve her concrete problems).
In a certain sense, Susanna was a person who did not have a
clear and connected life story. The impression of indecision and
tentativeness that emanated from her narrative can be attrib­
uted to her difficulty in talking about herself in a coherent
manner.
Her story does not tell who she is. It does not give her an
identity. Therefore, in having her speak, the therapist helped
her to create a story in which her life had a meaning. The
therapist's attentive listening was therefore particularly impor­
tant in that it implicitly communicated to her that he felt that
she was an interesting person, worthy of attention.
In this therapeutic conversation, the therapist behaved in a
particular way. A t the beginning, there was a long monologue
in which Susanna told about her trip to Madrid and the emo­
tions that this trip provoked in her. At the end of this mono­
logue, the therapist recapitulated briefly, in his words, what
Susanna had said. After this summary, without the therapist
having asked her to, Susanna changed the subject and started
talking about her everyday life. The therapist then began to
ask her brief, factual questions. Karl T o m m (1985) would call
these "linear questions". Their main function was to follow
 SYSTEMIC T H E R A P Y C A S E S 249

Susanna's discourse and to keep the subject open. Only at the

end of this segment d i d the therapist make a second brief reca­
pitulation. After this, when Susanna changed the subject to her
relationship with her grandfather, the therapist began to com­
ment on the events she described, calling the grandfather's
action an "about-face", and thus making a distinction through
reframing. The subsequent questions all arose from the defini­
tion of "about-face". This unified the whole discourse and fo­
cused it upon a definition of Susanna's relationship with her
grandfather. From this point on, the dialogue proceeded in a
more compelling manner and it concentrated on an interesting
theme.

***
This second segment is taken from about the middle of the
session (which lasted just over an hour). Susanna told about her
return home from her trip to Spain and about her relationship
with her friend. This friend had always been like a sister to her
because she was the daughter of one of Susanna's father's most
important partners. The money necessary for this trip had been
given to Susanna by her grandfather.

SUSANNA [has lost the smile that she had at the beginning of the session, when
she spoke about her trip to Spain]: I'm back at home in Treviso, but
when I'm there, it's like being in a sort of isolation cell, partly
because I don't have any deep friendships there in Treviso,
partly because I'm not working and therefore I have nothing to
do—this surely is a factor. I tried to organize my little house,
but, yes, right now, while waiting for .. . for nothing . . . and so,
I don't know . . .
THERAPIST: Waiting a bit too long?
SUSANNA: Yeah . .. hmm, maybe I ought to finally make up my
mind to leave.
THERAPIST: T O leave?
SUSANNA: It's exactly the feeling I had six years ago . . . it's actually
the feeling of , . . that made me feel really well. I had no room
for the usual problems, that is, they seemed to be all things that
I created, and probably that's what the situation is. In fact, I
said, " N o . I don't even want to think about these things. Look,
250 C A S E S

now I am really doing this, now I am actually doing that/' I

was actually doing things in a practical sense, feeling strong . . .
being with other people, especially being with others. A n d in
Spain I had moments like this. I was a tourist, but I was also in
contact with people who were friends. I didn't simply wander
around the city and do nothing else. Yes, I had moments of
difficulty, but also moments of relaxation. But, you know, I
came back home having done something concrete, and there­
fore life here wasn't my only life, the only kind of life I had.

This is the therapy session that best illustrates Susanna's

existential dilemma, her confusion, and her difficulty in finding
meaning i n life. The image of her in her small house, " a sort of
isolation cell . . . waiting for nothing", is reminiscent of the
theatre of the absurd—for instance, Waiting for Godot by Becket,
where, on the stage, there is only one person sitting in a chair,
who waits and waits, or The Scream by Munch, in which there is
a terrorized young woman who walks i n a desert.
The theme of the desert, loneliness, and lack of communica­
tion was often present i n Susanna's drawings that she had
shown the therapist at the beginning of therapy. The most
prevalent image was that of a sad young woman, dressed i n
black, sitting in the hollow of a crescent moon and dumb­
foundedly looking out into space. In her manner of speech and
behaviour, Susanna seemed strikingly devoid of rhetoric, role­
playing, and allurement (in the sense of trying to attract atten­
tion or elicit understanding or compassion). She gave the idea
of a bewildered person who was searching for significant h u ­
man relationships, which, however, d i d not materialize, and,
above all, of a person searching for her self. Her very hesitant
and inconstant manner of speaking was a reflection of her u n ­
certainty about her identity. The therapist intervened from
time to time, entering into her flow of words, to bring her back
to a more concrete world.

THERAPIST: When you were in Spain, did you have any romantic
attachments?
SUSANNA: N o .

THERAPIST: Did you want to?

 SYSTEMIC THERAPY CASES 251

SUSANNA: Not really. Oh, another thing. As soon as I returned

home, I had the feeling, again, that if only I were in love, then
everything would be easier. This is something that I've always
thought, but a situation, obviously such a rapid change . . . I
needed it in the sense that, even though I always wanted love,
in Madrid, it wasn't like that any more . . . I was content being
by myself, something that i s n ' t . . .
THERAPIST: Well, actually, you weren't really alone, because your
friend was there.
SUSANNA: Yes. In fact, she was warm towards me. She gave me
advice. She said to me, "You shouldn't live there in Treviso,
because you don't have anything there. You have your father,
but, anyway, it's not a good relationship. There isn't a mutual
understanding . . . "
THERAPIST: Would you like to live with your friend?
SUSANNA: Yes, except that, well, I'd have adjustment problems. It
seemed so hard to live there. Every now and then, I have the
wish to live in a tranquil place. Yes, it would be really hard,
with all the chaos there, and then, I don't know, I didn't feel a
strong desire to stay there. I don't know to what point I was
trying to convince myself of something, because really, it
would be the right thing to live there. M y relationship with the
city was sort of like saying, "Yes. No. I don't like it. No, I don't
like it because of this." You know, I almost paid more attention
to the things that I wouldn't have liked.
THERAPIST: If I understood right, when your friend said to you, "It
would be better if you were to leave your father. Come here to
live", she was advising you against living near your father.
SUSANNA: Yes.

THERAPIST: Do you think that this was good advice?

SUSANNA: She has a very negative relationship with my father. She
grew up living with him, so therefore . . .
THERAPIST: She knows him well.
SUSANNA: Yeah, even though they haven't lived together for many
years, every now and then they speak on the phone when she
calls me—but it's limited to that.
THERAPIST: If I remember right, she's the daughter of one of your
father's woman companions—is that correct?
252 CASES

SUSANNA: Yes, but her mother was the only one who stayed with
him for many years.
THERAPIST: Did he have the same kind of sentimental relationship
with your friend as he had with her mother?
SUSANNA: What kind of relationship? One of affection?
THERAPIST: Yes. A love relationship, also sexual.
SUSANNA: Uh, well, I don't know. Sincerely I couldn't, I couldn't
. .. Well, maybe on the part of my father for her, but I don't
think on her part. Anyway, she has very negative memories . . ,
I don't know . . . like for instance, she remembers that my fa­
ther, who never really hit her, even if maybe once he gave her a
smack, instead really hit me hard many times, and she remem­
bers these scenes [laughs] like scenes from . . . I don't know, like
scenes from a film. A n d because of that, she says that he is a
violent person, a sort of authoritarian father. I don't see him
only that way, also because it's been years since I have seen
him do anything violent, at least not to me. Instead, she re­
members him as a kind of monster, almost...
THERAPIST: A n d if you were to learn that there had been a sexual
relationship between your friend and your father, how would
you feel?

Here the therapist asked an unexpected question, pregnant

with possible anxiety-laden meanings. Elements of the client's
history suggested this question to him. She had lived mostly
with her father, who had had love affairs with many women.
Her friend-sister had recommended that Susanna leave her
father because of the negative influence he had had on her,
both before and at that time. In particular, her general psycho­
logical state was suggestive of possible sexual abuse in child­
hood. The question about a possible sexual relationship
between her father and her friend was an indirect way of bring­
ing to the surface potential feelings of embarrassment, shame,
or guilt, that might conceivably be signs of having been in­
volved in an incestuous relationship. While Susanna was quite
struck by the question of whether her friend might have had a
love affair with her father, her emotional reactions were not
such as to confirm the above-mentioned hypothesis. The reader
 SYSTEMIC THERAPY CASES 253

will note that the therapist showed great respect for his client's
feelings in that he merely touched lightly on the subject in an
oblique way without insisting when Susanna showed that she
had no desire to continue talking about this subject.

SUSANNA: . . . I would be totally . . . shocked, that is, I would feel,

uh, I don't know, I would hardly be able to believe it . . . or else,
maybe I could believe it, b u t . . .
THERAPIST: Would you be angry?
SUSANNA: . . . I don't know. No. That is, it's like this .. . instinc­
tively, I can't say that I'd be angry. I would feel . .. yes, maybe
I would be angry also because . . . I would be so upset that I
hadn't known that, that I would be angry, for this reason,
yes . . .
THERAPIST: Would you be more surprised about your friend or
about your father?
SUSANNA: More about my friend.
THERAPIST: About your friend?
SUSANNA: Yes, but also about my father, that is . . . I don't know . ..
I should say something about this friend who seems so strong
and solid to me. Even though she's younger than I, she's al­
ready embarked on her own life. She is an actress and is mar­
ried with a child and a house—she has everything, and she's
also very intelligent, very acute in a lot of things. At the begin­
ning, when I had just arrived, I felt very mtirnidated by her. It
was hard for me to have a normal conversation with her, even
though she gave me free rein. She didn't say much—for the
most part she listened to me. But there was one day, when she
spoke about this thing and . . . I don't know, she began by
saying that she felt that I simply was no longer capable of
exercising good judgement . . . She felt that I was so . .. con­
fused, that she actually said to me, " Y o u know, you are no
longer capable of exercising good judgement. If you think that
going to Treviso is a good thing, and even if you feel like doing
it, I think you're wrong. That is, I think that what you think and
especially what you feel is no longer . . .", it doesn't correspond
to what she thinks is right for me to do.
254 CASES

The therapist spoke more in this part of the session than in

the preceding part, and he also intervened more often. H e at­
tempted to make Susanna speak more concretely by asking
more incisive questions.
In addition to becoming more active at this time, the thera­
pist also delineated a theme for the session. Although this
theme derived from Susanna's words, it was the therapist who
helped to make it take form. The theme was still—but more
emphatically—Susanna's identity. Here it was connected to the
subject of where to live. In this session, it came out that Susanna
had no homeland, no place of belonging. A l l of the answers to
the therapist's questions confirmed this impression. Spain was
not the place where she wanted to live, which was Italy—or,
more precisely, Susanna's city, Treviso. However, in Treviso
Susanna was not happy. This theme of belonging (to a place)
was closely connected with her problems of attachment (to her
father). Susanna felt the necessity of living close to her father,
but when she was near him, she was unhappy. Her sense of not
belonging derived from this. In this way, the identification and
delimitation of a theme moved the attention from a question of
space to one of belonging and attachment. It changed from a
physical place (living in a specific city) to an emotional place
(Susanna's relationship with her father).
The theme arises from and is created by the give-and-take
between the client and the therapist. It does not result solely
from the client's words, but rather from the interaction in
which the therapist is an active participant who points out
connections and relationships between events, emotions, and
people in the client's life.
During the course of the session, there was a significant
change in Susanna's posture. A t the very beginning, Susanna
was sitting back in her chair, in the relaxed manner of one
taking part in a serene, undemanding conversation. A s time
went by, as she became more and more involved in the dia­
logue, she leaned forward, towards the therapist, and showed
that she was paying particular attention to the conversation.

THERAPIST: What was your state of mind when you came here?
 SYSTEMIC THERAPY CASES 255

SUSANNA [pensively]: Oh . . . [sighs] . . . I didn't know what I was

coming for . . . I absolutely didn't know . . . but, it's different
from a few days ago, when I felt so different that I said to
myself, "Why am I going there? If I feel fine .. ."
THERAPIST: Maybe you have a feeling of uselessness, a certain
sense of uselessness in coming here.

In this part of the session, Susanna's conversation became

more rambling and vague. She seemed to have lost the vivacity
that she had at the beginning of the session, when she described
her trip to Madrid. Sighing, she revealed that she didn't know
what she was coming for. The therapist carried to the limit the
content of this statement, hypothesizing that she might have
had a feeling of uselessness in coming to therapy. This was
done to stimulate her to reflect upon her therapy.

SUSANNA: N O . N O . I felt this when I felt strong, and then I said to

myself, "If I'm feeling fine, what am I going to talk about? That
is, uh, what do we talk about if I don't have anything to com­
plain about?" A n d today, instead, I don't know what to say . . .
the other day, I actually made a list of things to talk about
because there are various things that I observe in myself . . . I
don't know, on the train, I spent the whole time thinking about
something that I often do, that I've often done for years, I don't
know . . . For example, I think about last year, when I was in
love or . . . well, I don't know if I was really in love. Anyway, I
very much liked a fellow who didn't care for me and whom I
chased after for months and months . . . A n d when I have mo­
ments like this, in which I want to escape from reality, then I
think about various possibilities. For example, I haven't yet
seen him, and I spend hours thinking about when I'll see him
or about possible encounters, like in a film, you know what I
mean? I think about possible encounters in this way . . . and
then there are also moments in which I realize that I am fanta­
sizing again. . .
THERAPIST: Have you spoken about this young man before?

Susanna's reflections about going to therapy brought her to

identify a frame of mind in which she felt "strong" (as a result
256 CASES

of her trip abroad). In this state, she neither felt the need for
psychological help nor did she have the visual feeling of dis­
comfort which would give her something "to complain about".
The use of this expression signified a negative view of herself, a
certain dis-esteem, in that she did not feel justified in seeking
help for herself. A t a certain point, she went into her trips into a
world of fantasy—or, rather, into her daydreams, which cause
her to withdraw from the real world for long periods of time.
She thus touched on a relationship with a young man, but she
was not sure whether this was a relationship of love. This un­
certainty about her thoughts and emotions was pervasive. It is
shown by her frequent use of expressions like, "no, I don't
k n o w " , "well, maybe" . The therapist got her to speak of con­
crete things by asking her to talk about this young man.

SUSANNA: I've mentioned him.

THERAPIST: But why did you chase after him for months? Was it
because he refused you?
SUSANNA: Oh, because some years previously, I went with him for
a short while, and then I broke off the relationship in a very
brusque manner. At that time, I was living in Bologna, and I
didn't speak to him any more. I dumped him brutally, in si­
lence, without talking about it. Because of this, I felt stronger
and very sure of myself.
THERAPIST: But why did you break off this brief relationship ...?
SUSANNA: Well, for two or three years, every time he saw me, he
would tell me that he was in love with me. At first, I didn't
want any part of it, but after a long time, I finally decided to
give in. However, I treated him very badly. I kept my distance.
I didn't let him enter into my life completely. Things went on
like this until finally he got fed up and, at a certain point, he
told me that he was no longer in love.
THERAPIST: A n d who reopened the story?
SUSANNA: I did. After a long time had passed, I felt lonely, and I
called him up and asked him to go out with me, but, to my
surprise, he turned me down. Last year, for six months, I
phoned him often. We would even talk for an hour. He was
ambiguous—he wanted to and he didn't want to. . . . In the
 SYSTEMIC THERAPY CASES 257

beginning, I felt very sure of myself, and then, little by little, I

was less and less . . .
THERAPIST: Did you really want to see him or was it just a game to
see who would give in?
SUSANNA: Yes, I did want to have a relationship with him. I even
began to go around with his friends, and, consequently, some­
times he was there, too . .. but, no, it was nothing doing.
THERAPIST: You don't fall in love very easily, so what is so special
about this gentleman? He must certainly have something very
special about him!
SUSANNA: M m m . . . He's a person who absolutely doesn't want
anybody [laughs], absolutely anybody. He wants no woman
close to him. I don't know, maybe it was the fact that it was so
hard to conquer him that . , . that attracted me . . . he's very
playful.
THERAPIST: D O you think he likes women?
SUSANNA: Well, at this point, I don't know, also because after six
months of being chased by me, one evening he finally gave
in—that is, in the sense that he said, "Okay, listen, come to my
house to watch the sun come up." We were with friends, and I
was rather tipsy because we had passed the night in a place
drinking. I was very happy and I felt victorious. I was euphoric
about this, and I think that it was for this reason that I had an
accident with my motorbike. I don't know if you remember
when I came here with a black eye [points to her left eye]. I was in
the emergency room until seven in the morning, and I went to
his house just the same, and I stayed with him, but. . .
THERAPIST: SO did the two of you make love?
SUSANNA: Yes, we did.

THERAPIST: Did you sort of force the situation?

SUSANNA: Oh, no. That is, I was very happy at the moment.
THERAPIST: Did he have difficulty in making love?
SUSANNA: N O . N O , . . but afterwards he didn't want anything
more to do with me just the same.
THERAPIST: Was it because he was a mysterious person who was
difficult to win over that you were so impassioned, that you
pursued him?
258 CASES

SUSANNA: Yes. Yes, also for this reason . . . Yes. Yes, he's a person
who . . . I don't know, who is happy by himself, a person who
doesn't do anything but drink and go to ruin. That's all that he
does.
THERAPIST: Did you feel that he was a bit similar to you?
SUSANNA: Very much so . . . He's very much like me, that's true.
But now I'm sick of this affair. I've had enough. It lasted for
eight years in my head.
THERAPIST: Didn't your father also have difficult relations with
women? Did he make them suffer?

The story of Susanna's relationship with the "difficult" boy­

friend was characteristic. It revealed her need of the Other and,
simultaneously, her flight from the Other, or, in other words,
her desire and her fear of intimacy. It is striking that she sought
out a difficult partner, who, in the end, turned out to be similar
to her. It was as if she could only fall in love with her "double".
At this point, the therapist decided to explore the relationship
of Susanna's father with his women to see if he could find any
indications that could illuminate Susanna's difficulties in her
love life.

SUSANNA: I think so, because he is very dornineering.

THERAPIST: A n d also very fickle?
SUSANNA: Yes, He's fickle.
THERAPIST: IS he a kind of person who treats them as . . . I don't
know . . . sort of disposable objects?
SUSANNA: No, not like that. I don't think so, because he didn't have
a huge number of women. Well, yes, he did have plenty, but
with all of those whom I've seen, he had fairly long-lasting
relationships.
THERAPIST: Was it the women who fell in love with him?
SUSANNA: No. I think he, too, loved them.
THERAPIST: Were there any women who showed a particularly
great passion for him?
SUSANNA: Yes, there were.
THERAPIST: Did he break many hearts, as they say?
 SYSTEMIC THERAPY CASES 259

SUSANNA: Yes, I'd say so. Uh, I don't know if you could say that he
broke an awful lot of them, but yes, quite a few. That is, a few
women were very much in love with him . .. and I think he
was also very much in love with them as well, I don't know .. .
THERAPIST: A n d some of them even sort of chased after him?
SUSANNA: Yes . . . uh, for example, there's the affair that he had
with my mother. He was always rather dominated by my
mother, I think, unlike many other women of his. But, from
what I've heard, my mother left him because of various prob­
lems between them. However, when the mother of Victoria
(the friend with whom I have a sister-like sort of relationship)
became his lover, my mother, when she became aware that he
was no longer her man . . . that he was no longer in love with
her, she really kicked up a row.
THERAPIST: She made him sweat blood, huh?
SUSANNA: Yes. There was even one time when my mother became
hysterical. She broke a glass door to pieces, because he didn't
want to let her come into the apartment where he was already
living with this woman and her daughter. A n d there were also
other affairs between them that had to do with other people .. .
THERAPIST: N O W please excuse me. I would like to go to consult
with my colleagues.
[The therapist re-enters after afairly long interval]
THERAPIST: I was struck by the fluctuations that took place during
the summer. When you were in Spain and afterwards when
you returned to Treviso, you felt strong and well. Feeling
strong and well, the idea of "Why am I going there?" occurred
to you. It is natural that when one feels like this, one does not
feel the need of any help. I spoke of fluctuation because of
this: the period in which you felt strong was followed by an­
other period in which you felt, say, weak. You felt strong dur­
ing your trip, and you felt like this from the time you set off up
until when you returned. Then you began to feel differently.
This, to us, seems a bit like the description of your life. This
situation, that is, the trip going and returning, seems to me like
an oscillation that, on the whole, reflects your life and also that
of your parents. From the story of your mother, who was a
woman who had travelled quite a lot, going from place to place
260 CASES

and from person to person, readily and perpetually, I'd say . . .

Your father, too, was always moving in life, regarding places as
well as the many relationships (especially love affairs) that he
has had with various people. A n d it seems to us that from what
you told us today, your history also reflects this style of life.
This is what you've communicated to us. We've taken this into
consideration, and at this point, we've begun to think about
your future—a future that is difficult for us to imagine. What
direction will your life take? That is, will you become settled in
the place that you choose to live in? Will you also, in effect, be
relatively stable in that you will choose a place and you will
choose one or more persons with whom you will establish a
meaningful and lasting relationship? Or will you become a
migratory being, a person who has no roots—a nomad? Basi­
cally, I'm speaking metaphorically, but also concretely. You
continue to go from place to place, like your parents. It seems
that you don't find roots of any kind. With regard to relation­
ships, it seems that you are perpetually searching and that you
establish very few stable and lasting relationships. What
strikes us is that, at a certain point, your mother's wandering,
somehow, tragically came to an end. It came to an end with
her suicide. Lately, it seems that your father, too, has stopped
wandering. He's found an earthy, solid, and unsophisticated
woman, who, as you've said, has changed him, making him
appreciate the simple pleasures of the house in the country,
gardening, using various tools. We see connections between
your parents' life style and yours. We feel that also in your
relationship with us. You've said that when you feel strong,
you don't need us, and you've implicitly stated that when you
feel weak, you need us. In a certain sense, this echoes the oscil­
lation that I spoke about a few moments ago: " A m I nomadic
or rooted?" This is more or less the picture that we have got
and that portrays the story of your life, as seen from outside,
from our point of view. Does what we've said make sense to
you?

A s in the preceding sessions, Susanna began with a similar

dilemma: " D o I need these sessions or not? Will I let myself go
or not . . . ? "
 SYSTEMIC T H E R A P Y C A S E S 261

SUSANNA: What you say makes a lot of sense. What I don't under­
stand is: does it make sense for me to continue to come to
therapy?

Susanna's answer, which repeats the theme described above,

is significant. She seemed to need the Other (e.g. her grandfa­
ther or the therapist) to decide for her in order to feel reassured
that she was accepted.

THERAPIST: You should ask yourself this and decide by yourself.

SUSANNA: Yes, I am afraid that I'll go on for a year talking about
these things .. .
[The therapist tells her the date of the next session.]

According to narrative theory, the therapeutic session pro­

duces a de-construction of the story that the client tells, while
the intervention or final comment may have the function of
11

reconstructing a (new) story. The therapist does this recon­

struction (either by himself or else with the help of the thera­
peutic team) by using the fragments of the client's story and
finding unifying elements such that they make up a theme that
seems to connect the most significant elements (see Boscolo et
al., 1993).
In this session, Susanna spoke of her trip to Spain and of the
emotions she felt. She introduced the personages of her father,
her grandfather, her woman friend, and her boyfriend and de­
scribed the ambivalent emotions she had about them.
In this intervention at the end of the session, the therapist
made a reconstruction using a metaphor that drew on many
elements that had emerged during the course of the session.
A l l of these were put into a reorganized story. The metaphor,
which has an anthropological feeling to it, introduced a distinc­
tion: the distinction between rooted and nomadic. This distinc­

11
Usually the individual therapy session is held without the use of the one­
way mirror and without an observation team. In that case, instead of making an
intervention or final comment, the therapist might, from time to time, make a
reframing of whatever has come out during the session.
262 CASES

tion was created from the story of Susanna's family. During

their lives, both mother and father had been "nomads", with
regard to the multiplicity of places they had visited as well as
with regard to the many persons with whom they had come
into contact. A t a certain point, both had become "rooted": the
mother through her death, the father through formed a rela­
tionship with an "earthy" woman. (The use of this word
"earthy" made Susanna laugh, indicating that the word was
appropriate.) However, it seemed that, in Susanna, what was
prevalent was restlessness and oscillation between people and
places. This restlessness was felt as distress and as a search for
her identity. Susanna seemed to be unable to choose between a
stationary, stable life and a nomadic one. It was in this sense
that her future was still vague and hazy. The metaphor
summed up the session's themes and elements, and it offered a
story that was open to the future. Its solution could be decided
by Susanna, as an active protagonist. She could make her own
choices, which would be suggested by the new connections that
would emerge from the therapeutic dialogue. The intervention
could be seen as a reconstructive intervention, in that it gave a
narrative coherence to the elements that emerged during the
session and connected them in a coherent and logical vision.
Obviously, this reconstruction reflected the therapist's own
biases and theories, which guided him in connecting the data in
a story that, in the first place, made sense to him and, he
hoped, also to his client. One of the most important biases of the
therapist was that of the temporal-spatial frame that encloses
events and the meanings that a client attributes to these events.
The metaphor of "stationary" and "nomadic" was a reflection
of this frame. Often in the interventions or comments at the end
of the session, the therapist connects events and meanings of
the present time with those of the past and then turns to possi­
ble future scenarios. Susanna's temporal horizon (see Boscolo &
Bertrando, 1993) was limited to the past and the present. The
future appeared only as a hazy mist in the distance. While it is
important that the therapist take the role of listener, it is just as
important that he accept, within certain limits, the client's tem­
poral horizon. In this initial period of Susanna's therapy, there
 SYSTEMIC THERAPY CASES 263

were mostly elements of the past and present. Later on, once the
client had become more sure of herself and had developed more
self-esteem, it would become possible to explore possible future
itineraries.
Some therapeutic approaches (e.g. that of Watzlawick,
Weakland, & Fisch, 1974; Haley, 1963; or de Shazer, 1985) ig­
nore the client's past and deal only with the present and the
future. We feel that this could be appropriate in a therapeutic
view of "problem solving", i.e. in solving specific problems, but
not in more complex cases, such as in a borderline personality
disorder. In these more complex cases, the most important
therapeutic work is that which relates to the person and not so
much (or only) that which relates to the client's problems and
their solutions.
The therapist passed from the role of listener, at the begin­
ning, to a more and more active exploratory stage, and finally
to a phase of reconstruction of the data that had emerged. In
this last phase, the therapist, with the help of the therapeutic
team, invented a story that was centred on the metaphor of
oscillation. The session passed from the focusing of attention
on the past to the future, thus permitting the opening of the
recursive loop of the past, present, and future that we consider
a characteristic of our model. In this way, the intervention gave
the initiative back to the client, putting her in an active position
of choosing among the future possibilities. It also favoured her
escape from a world that she had constructed, that was, at the
same time, both fluctuating and ultra-stable.

The thirteenth session

The themes that were dealt with in the fourth session may
also be found in the thirteenth: the choice of a place to live and
to work, and the relationship with the Other (especially that
with her father). In the first part of the session, Susanna seemed
interested in the dialogue, but she was lacking in "passion",
which appeared only at the moment when the therapist
touched on the theme of Susanna's father and her relationship
with him.
264 CASES

A t this point, to arouse Susanna to a higher degree of emo­

tional intensity, the therapist decided to resort to the
presentification of the third party. H e began with a series of
questions that had Susanna and her father as themes. Susanna
appeared to be much aroused emotionally by the theme of
"father". The therapist worked on emotions, concentrating at­
tention on a word that Susanna had proposed: "anger", d i ­
rected towards her father. H e proposed, in its stead, a much
stronger word: " f u r y " .
When the therapist introduced questions, about the future,
that dealt with Susanna's relationship with her father and that
postulated a possible clearing of the air between Susanna and
her father, Susanna appeared to experience a great deal of diffi­
culty i n following the therapist. It seemed that she could not
imagine herself in the act of clarifying her relationship with her
father. A t this point, the therapist directly brought the third
party on the scene by taking on the role of Susanna's father,
who was not present at the session.

THERAPIST [indicates an empty chair]: If today your father had hap­

pened to be here and had heard what we have said, what do
you think he would think of what Susanna was saying just
now?
SUSANNA: If he were here right now?
THERAPIST: Yes.

SUSANNA: Y O U know that it is actually . . . I really don't know,

because it has been more or less three months that I haven't
talked at all with him. I don't know—maybe he'd be a bit
irritated, because, anyway, he's always felt like that towards
me, and therefore he can't understand why it is that one can be
without a plan . . . well, I think that he just wouldn't be able to
understand it, at. . .
THERAPIST: Would you be curious to hear what he would say and
what he thinks?
SUSANNA [very hesitantly]: Yes. We're in a strange phase, because
from that time when I came back from Canada, I've seen him a
couple of times. In effect, I ran into him by coincidence. We
hadn't agreed to meet, or anything. He had a really hostile
 SYSTEMIC THERAPY CASES 265

attitude, I have to say, and it didn't even have anything to do

with the usual question of my not . . . I don't know, maybe . . .
that it might have been that this trip annoyed him, this thing
about me going to my grandfather and . . . well, I think that
maybe it might have been that this trip annoyed him—the fact
that it turned out so well, the fact that I stayed longer than I
should have, just because of a kind of jealousy towards this
grandfather who paid for my trip but had never done anything
for his own daughter nor for me. I think that he has a grudge
against him. Anyway, I don't know the reasons, but he was
really hostile, and I actually h a d . ..
THERAPIST: But was there something that he said that made you
think this?
SUSANNA: N O . N O , he didn't say absolutely anything. But after a
month t h a t . . .
THERAPIST: . . . or is it just your expectation that he would be hos­
tile?
SUSANNA: N O . N O . I was aware that he was angry . . . even though
we have never had a good relationship, that is, we haven't had
a good relationship for the past ten years, I felt that he was
really mad, when, after he had spoken with a woman who had
telephoned him, I asked him, "What's the matter?" and he said,
"Nothing, I just have a touch of bronchitis." Well then, an an­
swer of this sort . . . Later on we saw each other at a party with
common friends, and we didn't even say a word to each other.
Then, the second time that I saw him, I called out to him from
the window and asked for a ride into town from my house, and
he didn't even answer me. I remember that morning, when I
asked him for a ride, he made a face . . . as if I had asked him
for heaven knows what. I don't know, I was taken aback by this
hostility. I just couldn't understand i t . . .

The communication and definition of the relationship be­

tween father and daughter were really very strange. They
seemed to reflect the inner confusion of Susanna. Naturally,
this statement has to take into account the observer, i.e.
Susanna, who had described her own experience and her way
of seeing things; had the father described the same things, we
would have had another account. If we had seen them together,
266 CASES

we would have become aware of the difficulty that they had i n

mutually defining their relationship and in exchanging clear
and complete information. It seemed that i n their communica­
tion, body language prevailed to a great extent over verbal
communication. It also seemed that negative emotions pre­
vailed over positive ones, even though we perceived a strong
tie between the two. It is significant that Susanna, at a certain
point, had said that the two of them had not had a functional
relationship for ten years. Ten years previously, she was 16
years old and in adolescence (and it was only a year since her
mother's death). A s a therapist of the psychodynamic school
might say, it is possible that incestuous impulses might have
led to the development of avoidance behaviour as a defence,
and that this defence was only partially successful in that the
conflict, like a fire covered by ashes, was still smouldering.
One could also formulate a very different hypothesis.
Susanna's parents d i d not take care of her. Her father, like
many artists, might have been in love with himself and much
taken with female charms, and thus may have had other people
(his friends) care for his daughter. H e might have felt that
Susanna was an impediment for him, and his frequent urging
that she be independent might have been a way to get rid of
her, a way for h i m to be liberated of any residual guilt feelings
he might have had. This hypothesis of Susanna's being an un­
wanted daughter could explain her disorientation, her inner
confusion, and also her peculiar involvement with her father
(from whom she was looking for what he could not give!).

THERAPIST: But how come you never asked him, "What do you
think of my trip to Canada?" How come you never made an
attempt to talk about it?
SUSANNA [talking at the same time]: But the question is this: I don't
know if I've told you, but we always . . . I think it must be at
least ten years that just the two of us have eaten together. The
two of us never even spend ten minutes together by ourselves.
The few times that it has happened that we were together by
ourselves in the car, both of us were embarrassed. I don't
know, he spoke to me about the things he was doing, or he said
things like, "I painted a beautiful picture", or "Luisa and I have
 SYSTEMIC THERAPY CASES 267

fixed up the house", or "The house is coming along beauti­

fully". He is always very enthusiastic about his own affairs,
and that's all. No, I don't know how to explain it. Anyway—to
give you an idea—just now he came down to the seaside,
where I was staying with some mutual friends of ours. A n d I
knew that he was there for a few days, but I hoped that I
wouldn't run into him, not because I'm particularly angry with
him, but because I would first like to get clear in my mind what
I want to say to him. I know that we're both mad at each other.
I'm angry at him because he doesn't give me what I want, and
he's angry with me because I don't give him what he wants. It's
like this: I've always been angry at him because it seemed that
he was never interested in me and never cared for me, or at
least, he never showed affection, because, well . . . I need to get
clear in my mind everything that I want to say, the feelings that
I have here . .. [she puts her hand over her heart].
THERAPIST: Today you said, "I'm not particularly angry with h i m " .
Isn't it possible that, instead, you are absolutely furious, that
there is, inside you, a feeling of fury about him that is so enor­
mous that you try to cover it up, maybe because you feel that if
this fury were to come out, who knows what might happen.
SUSANNA [amused at first, then becoming serious and intense]: Yes, in a
way it is like that . .. Yes, it's true. It might well be that I am
furious. I have a thousand things to accuse him of, only, I know
that he, too, has just as many things to say to me, so, at this
point, it seems to me that we're never going to arrive at a
conclusion if we continue being so angry. I don't know, I really
would prefer to avoid encountering him, that is, if encounter­
ing him means making small talk and not looking for a solution
for this relationship that doesn't work; in that case, I'd prefer to
wait. It seems to me that his way of doing things just makes
things more difficult for me . .. this expectation to see my plans
carried out, to see me manage by myself . . . It seems to me that
the fact that he expects this and demands this keeps me from
. . . from doing it.

Susanna continued to repeat the same ideas for several min­

utes. She spoke about an episode that seemed to reveal a veiled
jealousy on the part of Susanna towards Luisa, her father's
companion. Susanna claimed to have arrived at a certain dis­
268 CASES

tance from her father. She said, "It seems to me that I no longer
need his approval, but rather his understanding." However,
she demonstrated a deep ambivalence about this. She seemed
to be tormented by a relational dilemma (whether or not her
father would accept her for what she was) until the therapist
introduced the theme of the death of Susanna's father.

SUSANNA [apparently in anguish]: This has occurred to me a number of

times. If something were suddenly to happen to him, I would
remain with this matter unresolved and . . . and it would be a
terrible thing . . . I don't know.
THERAPIST: What would be terrible?
SUSANNA: The fact of never having cleared the air, never having
spoken, never having been able to enjoy ourselves together in
any way at all.
THERAPIST: A n d what would happen if one or the other of you—or
even both of you—were to decide to clear the air right now?
SUSANNA [silent for a long time, then sighs]: But, but. ..
THERAPIST: Let's imagine your father to be here, sitting in this
chair. [He points to an empty chair and then makes a gesture with his
hand as if somebody were seated there.] Now let's imagine that your
father were seated there and that today we had come together
to "clear the air". Let's make believe that you had requested
this encounter, so that the two of you could finally clarify your
relationship, as you said before, to avoid the tragedy of never
having done it, were your father to die suddenly. Now, try to
speak with your father. [Again he points to the chair.]

One might ask why, right at this time, it had occurred to the
therapist to change roles and personify Susanna's father. It is
probable that the theme of "death" and Susanna's consequent
despair (or possible breakdown) stirred the therapist to take
the father's place and attempt to "clear the air" during the
session. This is reminiscent of the final chess game with death
in Ingmar Bergman's film The Seventh Seal.

SUSANNA [smiling]: As I said before, now I'm trying to avoid him

because it seems to me . . . as I said . . , [appears confused and
embarrassed].
 SYSTEMIC THERAPY CASES 269

THERAPIST [pointing to the empty chair]: I presume that your father

would also be interested in speaking with you. Now, what is it
that you would like to tell him here, right now? Your father is
waiting to hear what it is that you want to clear up, that is,
what it is that bothers you about your relationship. How do
you see the situation?
SUSANNA [turns towards the therapist]: Well, as I said before, both of
us expect things that.. .
THERAPIST [insistent]: If you could conjure up the vision of your
father right now and speak directly to the chair as though he
were seated there, what is it that you would want to say to
him?
SUSANNA: But I . . . I d o n ' t . . .

THERAPIST: Why don't you say what's on your mind now? I think
that you've confirmed the impression that I have. You said,
"I'm not particularly angry". However, I think that you are
fending off an enormous feeling of fury towards your father
and that you have a great fear of losing control and letting the
fury come out, perhaps bringing on an all-out break in your
relationship. This is my impression. Today you have the possi­
bility of clearing this all up with him, so speak. Speak to him
and try to get it all off your chest. . .
SUSANNA [embarrassed and silent for quite a while]: No, I can't . . . I
don't.
THERAPIST: I could try something else now. I'll go sit there [points to
the empty chair] and I'll be your father. Afterwards, when you
and I as your father have cleared things up, then I'll come back
to my seat here, and I'll be Dr. Luigi Boscolo again. Okay?
SUSANNA: Okay. Let's try.
THERAPIST [changes his seat and nods towards the chair that he has just left—
now speaking as father]: I was called here today by Dr. Boscolo,
who said that somehow or other it might be helpful if the two
of us could manage to clear things up. He said that you need to
clear the air with me, and I was pleased to come, especially to
make an effort to talk together. What is it that bothers you
about our relationship?
SUSANNA [leaning forward towards the therapist]: The main thing that
bothers me is the fact that . . . [takes out a cigarette and lights it in
silence] . . . this . . . Oh God, I just can't do it! [Silence.]
270 CASES

THERAPIST [FATHER]: I understand that it's difficult for you to talk

with me just as it's difficult for me to talk with you. It's always
been hard for me. Now and then I tell Luisa that I don't know
how to talk with you and that I don't understand you. As your
father, I feel . . . you're my only child, and it would give me
great pleasure if you were happy and satisfied and if you were
to become independent and find a job. Instead, I find you con­
fused and uncommunicative . . . I just can't understand you.
What do you think about this?
SUSANNA [thinks about this for a while]: It's the same problem that I
have . . . I think. A n d I just can't understand this hostile atti­
tude that you have towards me, besides . . . yes, I can under­
stand the reasons behind it, but it seems to me that there's
nothing else other than this hostility, always the same .. . [In an
anguished tone, she lets loose.] But why don't you ever try to have a
relationship, in spite of these problems and all of these disap­
pointed expectations? A relationship . . . a kind of friendship,
besides, I want you to know, I have relationships with other
people who don't expect so much of me. They don't insist on
having something in exchange for their friendship.
THERAPIST [FATHER]: Yes, I understand, but to have this friendship,
first certain problems have to be resolved. Maybe I see things
only partially, because maybe I'm partially responsible. But
what I see is that the years pass, and still I see you at a stand­
still, you seem confused, and you don't think about your fu­
ture . . .
SUSANNA [becoming animated]: Yes, but why does this worry you?
THERAPIST [FATHER]: It's because of this that I, as your father, feel
angry. I want so much to see you satisfied and serene, to see
you moving on . . . having plans for the future . . . but I see
absolutely nothing of any of this. This worries me and it also
makes me angry.
SUSANNA [silentfor a while; all of a sudden, she moves her body as far back as
possible in her chair, as if wishing to distance herself]: And you're not
able to make an attempt to do anything other than be mad?
[Now she is almost in tears.] Aren't you able to hold back this
anger? That is, do you mean that there can't be any relationship
until I show you what I'm capable of doing?
 SYSTEMIC THERAPY CASES 271

THERAPIST [FATHER, in a voice full of emotion]: But don't you see? You're
my only child. Your mother is dead, you have a grandfather
who's not here because he lives in Canada, and the two of us,
we could say, are the sole surviving members of the family.
And, at this point, I see . . . well . . . as your father, I'm also
afraid that if we are too close, it will be more difficult for you to
break away and seek out your own path. You might have
noted that, after having spent years travelling all over for work,
at a certain point, I've settled down and made my home with
Luisa. We've had three houses made, one for us, and, just be­
cause of my love for you, a house for you and as well as another
one for Luisa's son. Now I don't know, but I have the feeling
that I've done my duty as a father. I'm happy with Luisa, but
there is something that continually eats me up inside—it's that
my only child, the daughter to whom I'm so very attached . . .
let me say it . . . I see her adrift,
SUSANNA [appears to enter into this escalation]: Yes, but the fact is that
. . . I also have something that eats me up inside, which, in fact,
may explain why I haven't developed these future plans and
all the rest, and another thing that disturbs me is the fact of not
having a . . . decent relationship with you, a relationship that
gives me something, that eats me up.
THERAPIST [FATHER]: But why are you so distressed when you speak
of your relationship with me? I don't know, but it seems to me
that young people of your age, at a certain point, have relation­
ships outside the family . . .
SUSANNA: But I do have outside relationships!
THERAPIST [FATHER]: However, it seems that that's not sufficient.
SUSANNA: N O , in fact, it isn't. I get along very well with men and
women of my age, but I have many women friends of my age
who have good, communicative relationships with their fathers
.. . both sides make an effort to speak together. However, I've
got to admit that I, too, don't try very hard. I'm aware of it, but I
just let it be.
THERAPIST [FATHER]: Well, I have the impression that what you're
telling me now is going to make your separation from me more
difficult. It will also make it more difficult for you to fall in love
and to make a career for yourself.
272 CASES

SUSANNA: That's just your impression, because we've never tried

to change things. On what evidence do you make this judge­
ment . . . I don't know, it's clear to me that our way of doing
things doesn't help me.
THERAPIST [FATHER]: I often think about you. I also try to help you
financially . . . at this point, I think I do what a father ought to
do. Then again, I, too, have my own life. There's Luisa and
projects to do with her, like the house in the mountains that
we're building. Do you think that Luisa's son also complains
like this about his mother?
SUSANNA: Yes, I'm sure of it.
THERAPIST [FATHER]: D O you speak together?
SUSANNA: Sometimes . . . and he, just like me, doesn't have that
confidence, that drive, that inner force . . . well, I don't agree
that affection and being close can keep people from doing what
they can do on their own.
THERAPIST [FATHER, glancing at the empty chair]: Now you're in
therapy. Don't you have Dr. Boscolo to help you?
SUSANNA [after a long pause]: . . . Yes, I think that he helps me. I
think that they help me in many . . . I don't know how I'd feel
now if I hadn't had any therapy. I think that I wouldn't ever be
able to overcome the situation of confusion and loneliness that
I'm in.
THERAPIST [gets up and returns to the seat he was in before]: Now I'm
leaving this role and I'm Dr. Boscolo again. [Glancing at the chair
that he has just left] Your father is still there. Right now, I'm
thinking about the conversation that the two of you have just
had. M y impression is that the two of you are both in the same
boat. I think that there's a strong bond between you, due to
what's happened to you in the past: the death of your mother,
when you, Susanna, were still a child and the lack of relatives
near you caused you to live with your father, or, more often,
with friends of your father. Your relationship is strong but
erratic. You, Susanna, say that in the past ten years, you've
rarely eaten together even though you are next-door neigh­
bours, and you also say that you rarely speak together, but
your father is very much present in your thoughts. [Turns to­
wards the empty chair] I would imagine that you, too, often think
 SYSTEMIC THERAPY CASES 273

about your daughter. [Susanna nods in agreement.] Because of the

past between the two of you, there is a risk that if you did get
together, you would never leave each other. For this reason,
you frustrate each other—to keep yourselves at a distance!
[Susanna nods again.] Therefore, try to separate from each other
somehow. I think that Luisa has also helped you to detach
yourselves. For some time, Susanna, you've been saying that
you've been distancing yourself from the past and from your
father, and I've commented that you are in midstream. You've
added that you feel directed towards the future, but right now
you don't yet have a passion, a depth of feeling about it. There
isn't a drive to do things and make plans and to fully immerse
yourself in life. Even today, after having said that you've left
the past, you talked a lot about your father, thus showing that
this past is still very much present.
SUSANNA: There's a question that I want to ask. In this metaphor of
crossing the stream, could it be that my father is on one side
and that I'm going to the opposite side? Isn't that what you
mean?
THERAPIST [rising]: I'll put this question to my colleagues .. .
SUSANNA: Would it be better if I could convince my father to come
here?
THERAPIST: I'll also put this question to them. I'll be back very soon.
[Leaves the therapy room.]

Part of the discussion between the therapist and his col­

leagues that took place after the session is cited here, with some
of the points of view of the therapy team members and the
therapist (in a fragmentary and incomplete manner), in the
order in which they were put forward.

1: I get the impression of an unaccepted and unloved daughter,

who has had neither a mother nor a father. She was accepted
for the first time by you. [The team member points to the therapist.]
When Susanna speaks of the necessity of a stimulus, maybe
only her father can give it. The therapist can only fill a bit of
this emptiness. What she is waiting for is acceptance from her
father.
274 CASES

2: I think that if Susanna's father had been here in person today,

both she and her father would probably have found points of
contact and their relationship could have started in a new di­
rection. However, I think that, in the end, Susanna will get
from the therapist the approval that she is lacking. The thera­
pist's acceptance and empathy will kindle the "passion" for life
and will foster the development of a feeling of self-worth.
3: But she already has "passion", and this is revealed by her
anger. [Looks at the therapist] I rather expected you to give a
positive connotation to this anger, but you didn't do so.
4: The client has gone for therapy, and now she finds herself in
midstream. She's beginning to see herself and to see the world
around her, while before, it was as if she were blind and she
couldn't see anything. Now, however, she has to take another
step. She has to say good-bye to her father, for it is she who has
to abandon him.
5: The metaphor of the crossing of the stream is interesting. It
refers to Susanna's wish to be closer to her father as well as her
wish to leave him. I think this reflects her relationship with
therapy. She is facing the subject of separation from the thera­
pist, and she is saying, "I'm at midstream, that is, at the mid­
point of my therapy. How am I doing? A m I getting lost or will
I make it to the other side?"
6: I would like to return to the subject of Susanna's relationship
with her father. Even though it is hard for him, he's been the
person who's always been present in her life, he's helped her
financially, he even had her house built next to his, and so on.
Probably it is the negative spectre of her mother—that is, the
fear of being seen by her father the way he saw her mother, and
thus being rejected—that makes Susanna seek the approval of
her father. If he doesn't give her this, then she can't separate
from him or become independent. It's possible that she became
more agitated after her father met Luisa, the person to whom
he feels very close and who has changed his turbulent life.
Susanna's anger might be in part an expression of envy and
jealousy of her rival, Luisa. Anyway, I think that the client can
get out of this ambivalent bond with her father through the
relationship with the therapist.
7. I was impressed by the therapist's decision to presentify
 SYSTEMIC THERAPY CASES 275

Susanna's father and take on his role. It was a nice move. At

first, Susanna expressed only the usual thoughts and usual
rationalizations devoid of emotion. Presentification heated
things up and stimulated her to express her thoughts and emo­
tions concretely and with pathos in answer to specific conten­
tions of her "father". I think that this is a very effective
technique, which could allow her to realize her eventual sepa­
ration from her father. This might take place spontaneously, or
else this experience might bring her to a confrontation with her
real father, in which she might be able to use the ideas that
came out in this session. The therapist's non-acceptance of the
12

client's request that he call in her real father makes it possible

for her to resolve her case with her father without the thera­
pist's direct help.
8. [THERAPIST]: In the role game, I was the masculine chauvinist
father who told her to find a job and a husband. This is the kind
of father that I imagine she might have. She confirmed that her
father was just like that, adding that he would like to get rid of
her and let it be Dr. Boscolo who takes care of her. I think that
her fear of expressing her anger is due to her fear of provoking a
definitive rejection. If that were to happen, she would lose her
only significant bond. Her father's love is a conditional love,
and, as such, it is paralysing. Even if she were to do what he
expects of her—for example, get married and have a fixed job—
she could still never be sure of being really loved for herself. The
therapist, instead, is a symbolic father, and by accepting her
empathically, primarily as a person and only secondarily for
what she can do in her life, he can foster the development of a
positive sense of self and therefore also of a sense of security,
which was missing. When Susanna asks about the metaphor of
crossing the stream—if this means that she leaves her father on
one side and goes to the other—it indicates that this is probably
the direction in which she is moving, even if she is still full of
doubts. Her doubts might well disappear once she has found
the acceptance that I've spoken about.... Why is Susanna so
blocked? We know that it is impossible to leave one's family if

T h i s second possibility d i d occur, as w e illustrated earlier i n the chapter, i n

1 2

the case of L u c i a n o M .
276 CASES

one doesn't receive some clear approval. Looking at this from a

temporal point of view, I could say that Susanna is looking for

what she didn't receive in the past, and she is still stuck at that

period. One could call it being out of phase with time. She

speaks with her father as if she were still a little girl, while her

father speaks with her as to an adult. It's as if they were on two

different wave-lengths. At this point, one could postulate that

therapy may help her to find approval that will permit her to

complete her crossing—that is, to find herself and become an

adult. As an adult, then, she will be able to see her father in a

new light and redefine the relationship. This could be consid­

ered the central theme of the entire course of therapy.

9: The moment in which Susanna alludes to the possibility of her

father dying seems very significant to me. She already had the
tragedy of her mother dying when she was still a child, and the
possibility of her father's death seems to evoke an intolerable
anxiety, the anxiety of being alone in the world, the anxiety of
nothingness. It's as if the anchor that holds her to reality had
been cut off.

A t a certain point, the group created a simple intervention

that the therapist communicated to the client.

THERAPIST [re-enters the therapy room]: We think that things are devel­
oping in a constructive way and that this period is one in which
there are beneficial changes going on. [Susanna nods with convic­
tion.] We've talked a lot about your anger towards your father.
We feel that it is a very important emotion and, in a certain
sense, positive, because in time it may change into that "pas­
sion" that will be able to connect your inner world with real­
13

ity, without your usual doubts and fears. When this happens,
your plans for the future will come on their own. With regard
to your two questions, we will answer you next time. [He stands
up and tells Susanna the date of the next session. Susanna thanks him and
says good bye. She seems very relieved.]

"Throughout the entire session, the therapist used this as a keyword, so as

to emphasize Susanna's lack of expression of passion when she spoke.
 SYSTEMIC THERAPY CASES 277

The continuation of the therapy

It is significant that, from the thirteenth session on, Susanna

hardly ever spoke about her father, her mother, or her past any
longer. During the course of therapy, Susanna had frequently
talked about her father but avoided talking about her mother
because the subject was too painful. Susanna's father, who had
taken her to live with him after separating from his wife when
Susanna was 5 years old, looked down on Susanna's mother.
H e viewed her as an irresponsible person, who was forever
taking drugs and prostituting herself to get money to buy
them. Susanna had tried, without success, not to think about
her mother, because she was afraid that she might be similar to
her. However, i n the first few sessions, the therapist had en­
couraged her to talk about her mother, trying to construct with
her positive stories that contrasted with her prevalently nega­
tive ones about her life, (see, once again, Searles, 1965).
Her life now became more active and oriented towards more
concrete goals. She no longer spent periods of two or three
days shut up i n her room i n darkness, meditating—or, rather,
brooding and trying not to think. During this period, she de­
cided to leave Treviso and move to Milan, into an apartment a
friend of hers had vacated. A n obvious association to make
would be that she had left her father's town for her therapist's.
Susanna immediately found two part-time jobs i n Milan. These
jobs took up all of her time, and even though she was tired, for
the first time i n her life, she applied herself continuously to
work. This allowed her to be independent financially.
Another unusual situation for her was that she was i n ­
volved, both sentimentally and sexually, with two men. Even
her looks had begun to change. She had discarded her usual
black tunic and pants, which she always used to wear, and
started dressing in lighter colours and different clothes. Her
interests had shifted to everyday life and to her future near at
hand. She reported, at times with pleasurable surprise, the i n ­
ner changes that she felt.
A s the advent of the twentieth session approached, she be­
gan to show signs of increasing anxiety. A t the seventeenth
session, i n an unusually worried tone of voice, she spoke about
278 CASES

a dream she had had, in which she was walking on the crest of a
mountain that connected Treviso to Milan. About midway, she
stopped, stricken by fear of falling into the precipice to the right
or the left, and she was assailed by a sudden doubt about
whether she had done the right thing by setting out on this
journey. Below are the final exchanges of the session.

THERAPIST [remarks unexpectedly]: Do you know which session it is

today?
SUSANNA: U h . . . I don't remember . . . I think it's the fifteenth or
the sixteenth . . . I don't know . . . is it?
THERAPIST: Which session would you like it to be?
SUSANNA [after a pause]: The twelfth.
THERAPIST: Okay, then, today we have just finished the twelfth
session. But, from the next session on, you will keep count of
the sessions.

The evident reaction of relief and the smile about the under­
standing with the therapist (alluding to the modification of
the therapeutic contract) confirmed the hypothesis that the cli­
ent needed more time than had been agreed on. In the subse­
quent sessions, Susanna continued the journey towards her
autonomy.

FRANCESCA T: AN INEXTINGUISHABLE HUNGER

Francesca was a 28-year-old southern Italian woman. Her

brother, who was 26, had been a heroin addict for eight years,
and for the past six he had been living in a therapeutic commu­
nity in the region of Campania. Her father had died of cancer
when Francesca was 10 years old. Her mother had later mar­
ried an antique dealer, but had not had any other children.
According to Francesca, this was because her mother was too
busy dealing with the problems of the two children she already
had.
Francesca had come to our Centre because of a severe case of
bulimia. Ten years previously, she had begun with anorexia,
which after three years had become bulimia. The symptoms
 SYSTEMIC THERAPY CASES 279

were very serious. For quite some time, she had been taking up
to 20 diuretic tablets a day and 40 doses of laxatives. The use of
these medicines had debilitated her, and she had had a number
of emergency hospitalizations for hypopotassiemia. A t the time
she began therapy, she was being seen periodically by an
internist and was taking potassium pills.
Francesca was very beautiful: slim, but not gaunt, elegant
and dark-skinned. She worked for a very important fashion
house, where she was so highly thought of that the manage­
ment paid for her therapy and medical bills.
A t the first session, Francesca had been accompanied by her
mother, but she refused to speak in her mother's presence, and
thus she forced the therapist to see her alone. A t the end of the
first session, it was decided to have the case be part of the
research study of individual therapy limited to twenty ses­
sions, according to the conditions already described.
The reasons for Francesca's refusal to speak in her mother's
presence became clearer during the second session, when the
therapist inquired into her past. With a great deal of difficulty,
the story about her incestuous relationship with her brother
came out. Sexual relations between them had begun when
Francesca was 10 years old and her brother 8, continuing until
Francesca was 15. The client remembered having had guilt feel­
ings about her relationship with her brother. A t the age of 15,
she had had sexual relations with a boy and had made sure that
she would be discovered by her mother, so as to divert any
possible suspicions her mother might have had and also to give
a clear signal to her brother about her desire to end their rela­
tionship.
Francesca described her mother as bigoted and punitive, es­
pecially after her discovery of her daughter with the boy. After
the first three sessions, the accounts of and the emotions re­
garding the incestuous relationship had come to occupy the
central position in therapy. The client related that she always
felt dirty, both internally and externally. To clean herself inter­
nally, she used vomiting, laxatives and diuretics, externally she
used frequent showers and baths, and often even felt forced to
scratch her skin. A t a certain point, the therapist suggested that
Francesca reveal her secret to her mother. Francesca agreed so
280 CASES

hesitantly that the therapist had to reassure her that her disclo­
sure was to take place in his presence, so that he act as the
container for their emotions.
Francesca's mother was invited to the seventh session, so
that the disclosure could take place. When, at the request of the
therapist, Francesca told her story, her mother, surprisingly,
did not reveal any emotion. She remained almost impassive
while Francesca, visibly upset, told her story. The therapist,
bewildered and burning with curiosity, suddenly turned to
Francesca's mother to find out what was going on.

THERAPIST: Mrs. T., did you know about these things—or are they
news to you?
MOTHER: N o . . . I didn't know.
THERAPIST: But what is it that you felt when your daughter told of
these things? Were you surprised?
MOTHER: N O . Not surprised.

THERAPIST: How come you weren't surprised?

Mother: Because at that period my younger sister was living with
us. She was 18 at the time, and I suspected that something was
going on between her and my husband. So then one day I came
home from work early without having told them beforehand,
and I found them in bed together . . . [to her daughter] Do you
remember?
FRANCESCA: No, I didn't know .. .
MOTHER: How can that be—it was you who told me that you saw
your father in your aunt's arms .,.?
FRANCESCA: I don't remember . . .
MOTHER: Anyway, I found them like this, but I couldn't send my
sister away because I had legal custody of her. A n d she tried to
put my children against me. After a while she left on her own,
becoming a drug addict and a prostitute. It may be that I then
became too protective of my son, as if he were the favourite,
and maybe for this reason the two of them are always in com­
petition . . .

After this disclosure, which followed considerable work on

her past, Francesca gave clear signs of getting better, particu­
 SYSTEMIC THERAPY CASES 281

larly with regard to her use of diuretics and laxatives, which

had ceased, although her bulimic attacks and vomiting contin­
ued. She made even more progress psychologically: she
emerged from the state of dejection and depressive mood in
which she had been lately, and she opened up more to the
outside world. This fact was noted and much appreciated at
work.
It also came out that Francesca's social life was rather poor.
She was living with a man, but this man did not seem to occupy
an important place in Francesca's emotional life, which was
completely occupied with her mother and her brother.
Francesca's relationship with her mother seemed to be very
ambivalent, with frequent fights and sulking as well as long
periods of not speaking to each other, which were then fol­
lowed by making up.
After the disclosure session, the therapist thought of asking
the brother to come to a session as well, so that there might be a
chance for all three of them to clear the air. However, this
turned out to be impossible. The mother resisted because she
felt that this might have a negative effect on the rehabilitation
programme that her son was involved in, and the therapeutic
community also felt that this was not a good idea. Thus the
sessions continued to be individual sessions with just Fran­
cesca, who showed a growing awareness of her problems and
continuous progress. During the tenth session, Francesca indi­
cated her intention of continuing with another therapist at the
end of this therapy, because she felt that for her therapy was a
necessity of life. A t the end of the session, the therapist made the
following comment.

THERAPIST: Our impression is that things are progressing nicely, in

that you are looking inside yourself and perceiving signs that
you are moving, that you've set out on a rather long path, so
long that you yourself said that when you are finished here,
you think that you'll need more therapy, maybe analysis, with
another person. We find this very unusual.
FRANCESCA: I would advise everybody to have therapy. It's very
good for me.
THERAPIST: It's unusual that a client would have the idea of never
282 CASES

fimshing, and we've also talked about your idea that therapy
would not ever finish, and so it is possible that in your past you
had the feeling of not having had much devotion or love . . .
and that you have a great vacuum inside you.
FRANCESCA [nodding in assent]: Yes.
THERAPIST: . . . and that at this point there is a great hunger inside
you, mixed with anger, because very often there is anger in
hunger.
[Francesca smiles.]

The reader will note the use of the keyword " h u n g e r " — a
metaphor for Francesca's symptom—and its coupling with the
word "anger". Thus a double theme was created, hunger/an­
ger that the therapist juxtaposes with the client's premises,
which seem to presuppose a possible interminable therapy.

THERAPIST: You also have a great hunger for your mother, and it is
somehow so huge that you think you'll need a whole lifetime to
appease your hunger.
FRANCESCA: Yes. I need this.
THERAPIST: Satisfying your hunger. This is the idea that came to
our mind to explain to ourselves this very odd fact, because it is
rare that a client feels that therapy has to go on forever.
FRANCESCA: Yes, I think that this is a first step . . .
THERAPIST: A n d this is very strange.
FRANCESCA: I think that it is strange that nobody else has ever
requested it. I don't understand this.
THERAPIST: The very fact that you think that this is strange some­
how makes us think of your having a very deep dissatisfaction.
And we think that somehow there wasn't sufficient attention
and protection, also for what happened with your brother, and
that you felt neglected, like someone who doesn't have enough
to eat. At a certain point, maybe an inextinguishable hunger
was created.
FRANCESCA: That's exactly right. I've always said that I have a
great need for love.
THERAPIST: A hunger for affection that somehow is so great that
even a lifetime may not be sufficient.
 SYSTEMIC THERAPY CASES 283

FRANCESCA: N O .

THERAPIST: We read your state of mind this way. It's clear that you
think you need a lifetime to get over this phase and finally feel
satisfied, which means being serene, sure of yourself, and so
on. What we are telling you is that usually changes don't come
in the way you feel, that is, that you need a lifetime, but in­
stead, often changes in one's life come when one least expects
them, and in your case, your hunger could suddenly disap­
pear.
FRANCESCA: Oh, I know that it will disappear all of a sudden.
THERAPIST: At a certain point, you'll feel satisfied both physically
and spiritually,
FRANCESCA: Tranquillity, to feel at peace, is the main thing.
THERAPIST: Your hunger for approval from others will disappear.
We're telling you this. However, we think that, for quite some
time, you'll still have the feeling that your hunger will be inex­
tinguishable. Maybe you'll need another three or four years or
more.
FRANCESCA: Let's hope not.

Francesca's problems came back again when her brother

was discharged from the therapeutic community where he had
stayed for six years. When he returned home, he was wel­
comed by his mother and by his step-father like the prodigal
son. In fact, his step-father created a place for him in his work­
shop as an apprentice restorer, and this worked out well. A l l of
this had a negative impact on Francesca. A t the twelfth session,
she appeared visibly irritated and tense, on account of her
mother's devoting herself to the brother. She complained about
this to the therapist so much that the latter decided to have both
mother and daughter come together for a session.
A dramatic encounter ensued, in which the mother main­
tained that she was being unjustly accused. She asserted that
she devoted her attentions to her son because he had neither a
home nor a job and that she felt incapable of understanding her
daughter, who always retreated into her accusations. A t this
point, the therapist considered utilizing the therapeutic rela­
tionship, i.e. the faith that Francesca and her mother had in
284 CASES

him, to get out of this endless game of slaughter and to resolve

the impasse created by the unresolved jealousy that was being
expressed in action through the mother. He proposed to
mother and daughter a pact for a period of four months, during
which time there was not to be any kind of communication
between the two of them, except through the therapist.
In prescribing this, the therapist had the intention of utilizing
their trust in him to loosen the negative ties between mother
and daughter. Unfortunately, things did not go the way they
had been intended. Three weeks later, Francesca's mother tele­
phoned him to say that, for several days, Francesca had been
telephoning her. A t first she telephoned anonymously and did
not speak, but later on she called and screamed and shouted
insults. She said that she couldn't stand it any longer and that
she was desperate.
Alarmed, the therapist telephoned Francesca, who answered
in the broken and slurred voice of a person who has ingested
neuroleptic medicines or mind-altering drugs. Francesca ad­
mitted that she felt very depressed and that for the past week
she had stopped going to work. She also said that she had not
been going to her medical check-ups, which were indispensa­
ble because her immoderation in eating and diuretic use had
caused kidney problems. The therapist immediately decided to
stake everything on the therapeutic relationship. He cancelled
the pact and ordered Francesca to go to have a medical check­
up. The next day he received a telephone call from the endo­
crinologist. The latter had found Francesca very debilitated,
and thus she asked his permission to prescribe anti-depres­
sives. The therapist also advised a brief hospitalization, but this
was impossible. Contemporaneously, the therapist had tried to
have a dinner organized for Christmas, which was soon to
arrive, for the whole family. This should have had the effect of
being a ritual occasion in which the whole family would be
reunited, and it should have offered Francesca a new occasion
to communicate with her mother and her brother. Both Fran­
cesca and her mother had readily agreed to this request.
A t the fifteenth session, which was held after Christmas and
thus after the presumed reconciliation dinner, Francesca ap­
peared thinner and more upset than ever. Unfortunately, once
 SYSTEMIC THERAPY CASES 285

more the therapist's hopes had been dashed. The dinner had
been a disaster because Francesca had become angry and had
argued with everybody. A t that session, she appeared to be
playing up (or at least that was the therapist's perception) a
gloomy and suicidal mood. She repeated several times that
there was no longer anything that one could do for her and that
suicide was the inevitable solution.
A t this point, the therapist decided to deal with the situation,
and, as in Ingmar Bergman's film The Seventh Seal, to play chess
with death. Suddenly, halfway through the session, he got up
from his chair and said that, since the task of therapy was to
help the living, and it seemed that she had chosen death for
once and for all, in this case therapy no longer made any sense.
She was told that her therapy would be considered terminated
unless she decided to go on living. In that case she could tele­
phone the therapist within a week to continue with therapy.
Francesca telephoned a few hours after the end of that week,
asking for an appointment in a peremptory and self-assured
tone of voice.
After these events, therapy continued to the satisfaction of
both parties for a couple of sessions. It was agreed in advance
that the eighteenth session was to be the last one. However,
Francesca stuck to her idea that she would need further thera­
peutic support, and thus she decided, with the therapist's bene­
diction, to go to Dr. Bruni, another therapist. We will go into
the details of this last session also to show the particular pro­
cess at work in the concluding moments of therapy.
Francesca came to the session elegant and well-groomed and
in a rather good mood. She immediately dealt with the subject
of bulimia, the problem that had brought her to therapy. The
bulimic ritual had not yet disappeared completely; however, it
was very much reduced. She had not yet returned to her job,
but she said that she felt fine in the present situation and that
she even managed to enjoy herself, which had not been the case
previously.
Shortly afterwards, Francesca began to speak about the new
therapist. There emerged very quickly some characteristics of
the latter, of which the client seemed to disapprove secretly.
First of all, Dr. Bruni had proposed a hypothesis about
286 CASES

Francesca's incestuous relationship with her brother as a " s i n " ,

which was not at all to her liking. Besides, she had the impres­
sion that more than wanting to propose hypotheses, he wished
to instil ideas in her mind, among them the idea that there had
to be more of a relationship of friendship between them rather
than simply a professional relationship. Francesca seemed to
imply that she preferred the style of her first therapist. Looking
at these statements in relation to the events of the preceding
sessions, it would seem that Francesca was having difficulty in
parting from her first therapist. In fact, a bit later Francesca
confirmed this impression quite clearly.

FRANCESCA: Dr. Brum goes on and on saying that I should tele­

phone him if I need to, that I've got to open up, that I have to
have faith in myself . . . A l l in all, I feel closer to you, even
though at a certain point I did have a moment of rejection from
you. I would say that aesthetically I feel closer to y o u . . .
THERAPIST: Between Dr. Bruni and me, who do you think most
resembles your mother?
FRANCESCA: Oh . . . neither one of you.
THERAPIST: A n d your father?
FRANCESCA: Neither of you. You are Boscolo and he is Bruni, and
you two don't resemble anybody else.

A t this time, the therapist did an odd thing (maybe an error),

although he did manage to find the way out. In fact, at the
moment at which the client emphasized her ties to him, he
changed the subject and took refuge in a psychodynamic past­
present. It was the client who got him to return to the current
relationship. If, at this point, the therapist had persisted in his
idea that Francesca's relationship with him was connected with
her past relationship with her parents (transference), he would
then have become rigid and, thus, predictable. His strategy
would have been clear to the client, and the latter would
merely have had the choice of going along with him to please
him or defying him. It would have diminished the possibility of
creating scenarios or new meanings. In such a case, the thera­
pist would have been trying to instil his ideas into the client's
 SYSTEMIC THERAPY CASES 287

mind. We feel that the therapist ought to keep the discourse

open to various possibilities in order to avoid being predict­
able. It is also useful and opportune to leave due space to the
client and follow up on the indications that he gives about the
meaningfulness and sense of the therapist's hypotheses.
The secret of doing this is stating one's hypotheses as ques­
tions. This permits the client to decide on the meanings to
assign and to become the protagonist of one's own story. The
therapist does not directly furnish hypotheses but, rather, fur­
nishes them in the form of a question. The last word is the
client's. Otherwise (as in psychoeducational interventions), i.e.
when the therapist instils his own ideas into the client's mind,
the client will not change. He will simply follow the more or
less explicit instructions, but without gaining a sufficient
amount of autonomy.
Also, in this last session, although it is a conclusive one, for
the most part the therapist used questions, especially in the
opening remarks of the session. In particular, these questions
concentrated on the exploration of present and future sce­
narios.

THERAPIST: What emotions do you feel now on leaving me and

going to live with him? Naturally, I'm speaking metaphori­
cally. It's been a year that we've been together. What effect
does it have on you to move and go to him?
FRANCESCA: Well, for example, yesterday, I felt a bit embarrassed
at the idea of coming to this appointment . .. almost as if it
were a bit like . . . being unfaithful.
THERAPIST: D O you feel guilty, as if you were unfaithful to me?
FRANCESCA: I feel guilty as if I had done you wrong. If I were free
of this tie with you, I think I would feel okay . . . I would feel
fine.
THERAPIST: So what's the embarrassment about?
FRANCESCA: Because I have to tell you about the other therapist.
THERAPIST: H O W come you said earlier that you felt closer to me
from an "aesthetic" point of view? You emphasized and re­
peated several times that you felt closer to me in many ways.
288 CASES

FRANCESCA: It's true that I feel more instinctive liking for you. But
maybe I've repeated it many times mostly to give you a compli­
ment and to absolve myself.

At this point the therapist introduced a new subject, al­

though it had been present in the background since the begin­
ning of the session: the subject of leaving one another, of
separation. Repeating that this was the last session, the last
session according to the therapeutic contract, meant impeding
Francesca from nullifying this experience of separation. A s the
reader will see shortly, the client had a marked tendency to do
this.

THERAPIST: Today we are about to take leave of each other. When

two persons leave each other, it is beautiful to part with a nice
memory of one another. Most of the people we meet do not
leave any traces in our lives, but some leave a positive trace.
When it happens that they leave a positive trace, we carry
these persons inside us forever.

With this comment, the therapist put himself and the client
exactly on the same level. Each one was leaving something to
the other, each one bore something of the other inside. In a
certain sense, reasoning like this is the height of acceptance and
positiveness in the relationship between therapist and client.
At this point, Francesca made a comment that showed what
kind of a risk there was that she might negate the separation.

FRANCESCA: Then . . . maybe . . . is this the time to finish therapy?

[The conclusion of therapy had been explicitly agreed upon in the session of
the preceding month.] Actually, I've tried to not think about this
session, because I didn't know what to do. I tried to run away
from the idea, because I couldn't manage to be objective and
think whether to tenninate or not.
THERAPIST: But we had already decided to terminate therapy with
this session, and I think that if you want to try another therapy
with another person, who can also give you a different view of
things . . .
FRANCESCA: Yes, because, I confess that I've begun to be a bit tired
of doctors and therapies. They are all good, Dr. Bruni, the
 SYSTEMIC THERAPY CASES 289

endocrinologist, the nurses, but I'm . . . tired. At first I felt the

need. I felt I had to get: treatment. The doctors and everything
were necessary. But today I ask myself when will this nuisance
finally come to an end.
Another thing that you might get tired of is depending
THERAPIST:

on medicines . . .
FRANCESCA: Yes, I'm sick and tired of all this.
THERAPIST: A n d tired of depending on persons or medicines that
put you in a passive position.
FRANCESCA: Yes .. . This is a positive thing. Before, when people
said I looked as though I had lost weight, I was pleased, but no
longer.

Here the therapist openly allied himself with the new heal­
ing forces of the client. H e implicitly communicated that
Francesca might no longer need either medicines or specialists.
The therapist then proceeded to give a final panorama of
Francesca's situation and some future options, as well as the
still crucial relationship of Francesca and her family.

THERAPIST: What would you say if I were to ask you about your
relationship with your family today?
FRANCESCA: Well, my mother seems to me less spiteful than she
used to be and a bit calmer. Now I manage to do without
calling her every day like I used to. Nowadays, I don't even
think about my brother, but if I do think about him at all, it
seems that I can do so with a certain amount of serenity.
THERAPIST: T O me it seems that you and your brother have gone

through a parallel development. You are freed of a part of your

symptoms, but not all. He is finally freed of needing drugs, but
he's still dependent on the family. It is possible that your paral­
lel development will continue, and that at the end both of you
will be freed of your ties.
FRANCESCA: In part, this has already happened. The ties that there
were before between my brother and me were a bit sick. There
was a rather unhealthy relationship of envy. Now that there
aren't any more of these things, I think that this tie, in whatever
it had of unhealthiness, is disappearing.
290 CASES

THERAPIST: A t this point, you know that you leave a trace in other
persons—for example, in me. Now you can free yourself of
doctors, of medicines, and, also, in a certain sense, of your
family. If you free yourself of all of this, you'll be left with a
vacuum. But this will be a vacuum that can be filled on your
initiative with persons from outside the family, other relation­
ships, and so on.
FRANCESCA: But is this something that I've got to decide right
away?
THERAPIST: No. It is something that will happen by itself, little by
little.
FRANCESCA: Y O U know, I already don't feel like I did before, even if

there are still symptoms, because now I do things with pleas­

ure, wanting to do them. Before I used to have to be the most
scrupulous. I had to arrive at work early, even a half hour or
forty-five minutes earlier than the others. For me it was a duty.
Now I could even arrive late. But not because I don't enjoy my
work. O n the contrary, maybe just now I'm really starting to
like it.

A t this point in the session, the client's situation had been

made clear, and prospects for the future had also emerged.
N o w the therapist was able to further the closing of the rela­
tionship with the client with a simple end-of-therapy ritual,
freeing both of them of their respective roles of therapist and
patient. .

THERAPIST: Generally, when therapy is finished, I dedicate a few

minutes to looking together and seeing if, in the period we
have spent together, there were any special moments that had
a particular effect on and meaning for the client. What about
your case?

This question explicitly puts the client i n a position of obser­

vation of and metacommunication about the therapeutic proc­
ess. Our client's comments are often of great interest. Hearing
what the client perceives at the moment when he is beginning

Similar information is also obtained through catamnestic inquiries.

 SYSTEMIC THERAPY CASES 291

to change is a new aspect of the therapeutic process. One of 14

our clients summarized it, saying, "What was important to me

was that the therapist had faith in me." Another client said,
"What surprised me and helped me was that I never knew
what the therapist was aiming at with his questions."
The use of diagnostic statements and clinical explanations
creates negative realities. These realities may become reified,
and this would then emphasize what is wrong. If the therapist
avoids doing this and, instead, helps the client to break loose
from his rigid, linear explanations by extending the context of
inquiry from a positive viewpoint, then the client can thus inde­
pendently find his own way to change.
Francesca's comments were quite interesting.

FRANCESCA: Well . . . I would say that at almost every session im­

portant things emerged. Actually, almost every time, when I
left the session I didn't remember anything, but later on vari­
ous memories came to mind, and when I thought about these
things by myself, I felt that they had an effect on me.

One could hypothesize that long intervals between sessions

allow the client to remember and re-examine the events of each
session on his own, so that the meanings and emotions of each
encounter take on a greater importance and have a greater
effect.

THERAPIST: Were there any moments that stand out in particular?

FRANCESCA: Yes, when you said that my mother was right and I
wasn't, while my internist had said that I was right. I liked that.
Finally I felt that I was understood. Maybe that was the first
time that I felt really well.
THERAPIST: Negative moments or moments of anger ...?
FRANCESCA: When you terminated the session, saying that you
were willing to treat only persons who really wanted to live
rather than to die. I was furious. I didn't want to come any
longer, a bit because I was sad because I felt abandoned, but
also because I hated you. I thought that you had decided to
abandon me because my suicide would have been a blot on
your career.
292 CASES

THERAPIST: A n d what made you change your mind?

FRANCESCA: Your attitude towards me when I called you back on
the phone. If you had answered in a different way, I would
have quit. You know, what you did was risky, but it worked for
me. Maybe it was all calculated, I don't know, but, anyway, it
was the right thing for me.

The last ten minutes of the session (or rather, post-session)

passed in a pleasant emotional atmosphere—almost one of
friendship. Having left their roles of therapy, both therapist
and client were now on a level of equality, and they observed
together the relationship that they had had and the effect of this
relationship. Francesca's final comment was a sort of proposal
of restitution to the therapist for what he had given her.

THERAPIST: Before finishing, do you have anything you want to ask

me?
FRANCESCA: If someday I wish to call you because I have some­
thing to tell you, may I? Like . . . probably, if I would want to
call you, it would mean that I was cured, because otherwise I
could only speak about doctors, and it wouldn't make any
sense to call you for that. May I? I would like to come here
someday and tell you that I no longer had problems with food.
I would like to do this because I respect you, and also to give
you recognition for what you have done. Even though you
haven't finished the work, you were the one who started it.
Without you, I would have been a goner.
THERAPIST: Okay. Now, I wish you well.
FRANCESCA: The same to you, Dr. Boscolo.
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Schafer, R. (1976). A New Language for Psychoanalysis. New Haven,
CT: Yale University Press.
Schafer R. (1983), The Analytic Attitude. New York: Basic Books.
Scharff, D., & Scharff, J. (1987). Object Relations Family Therapy. New
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Searles, H . (1965). Collected Papers on Schizophrenia and Related Subjects.
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Segal, L. (1991). Brief therapy: the MRI model. In. A . S. Gurman &
D. P. Kniskern (Eds.), Handbook of Family Therapy, Vol. II. New
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Selvini Palazzoli, M . , Boscolo L., Cecchin G., & Prata, G . (1978a).
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Selvini Palazzoli M . , Boscolo L., Cecchin G., & Prata, G. (1978b). A
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Stagoll, B. (1987). Insight-outsight. Australian & New Zealand Journal
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INDEX

abuse, 94,143,175,187
brief-long therapy, 53,58,62

addiction, 46
case studies, 167-292

Alexander, R, 205
general methodology, 91-153

Alexander, J. R, 45
process of, 128-134

A n d e r s e n , X , 21-27,31,49, 92,146
see also therapy

A n d e r s o n , H . , 21,25,31,38,48,49,
brief p s y c h o d y n a m i c therapy, 53,63

54,72, 74,76,79,83,85,86,92,
brief strategic therapy, 53

114,124,126
brief therapy, 12,56,59,61

A n d o i f i , M . , 123
Broderick, C B., 27

assessment, 46-52,62,129,130,132
Bruner, J., 25

attachment, as reference point i n

Bruno K., 43,98,112,116,132,152,

therapy, 100
192-223

A u s t i n , J. L . , 108
B u d m a n , S. H , , 56

Balint, M , 53
Cacciari, C , 150

Balint, E . , 53
C a d e , B., 59

Barilli, R., 138

C a m p b e l l , D . , 94

Bateson, G . , 3 , 5 , 9 , 1 1 , 1 3 , 1 4 , 1 6 , 1 7 ,
Carla V., 44,234-239

18,20, 23,24,25,30,32,33,38,
catamnestic analysis, 45,129,290

39,42,54,60,67,68,69,71,72,
causality:

78,79,83,93,102,103,105,106,
circular, 6,102

121,122,143,151
linear and circular, 24, 83,142

behavioural therapy, 45,46,53, 74

Cecchin, G . , 4, 2 7 , 3 2 , 3 7 , 3 9 , 5 0 , 9 5 ,

belonging, as reference point i n

96,116,121

therapy, 101
Ceruti, M . , 22,35

Bertrando, R, 5,9, 24,25, 56,57,59,

change

61,81,93,96,97,109,117,119,
of client's epistemological premises,

128,131,136,175,238,262
59

" b l a c k b o x " theory, 13,19, 25,108

epistemological, 22

Bocchi, G . , 22,35
by leaps and bounds, avoiding, 35,

B o r g e s J . L . , 69
60

Borwick, B 107
v process, spontaneous, 64

Boscolo, L . , 4, 5,9, 24, 25,49,50,56,

of symptomatic behaviours, 59

57,59,60,61,71,73,81,93,96,
see also epigenetic evolution

97,109,114,116,117,119,125,
circular questions, 1,91,92,105-115,

128,131,135,136,146,147,148,
139, 202,206

157,162,175,177,238, 242,261,
in individual therapy:, 110

263,270, 273,276,287,292
reciprocal nature of, 105

Boss, R 83
triadic, 106,110

B o w e n , M . , 89
circular-causal epistemology, 83

Bowlby,J.,100
circularity, 9,91,93,105,122

Breunlin, D . C , 14,16,19
Clarfield, L . E . , 76

302
 INDEX 303

client:
de Shazer, S., 21,49, 263

goals of, 53
deterministic explanations, linear­
inner and external worlds of, 13-17
causal, 25

manipulation of by therapist, 84
deutero-learning, 10,54,68,75,113,

motivation of, 80,120

114,143

premises of, 68
diachronic perspective, 99

see also dialogue; therapy

diagnosis, 46-52

clinical explanations, need to avoid,

specific, sensitive approach to

291
corrimunicating, 48

cognitive therapy, 46
diagnostic statements, need to avoid,

cognitivism, 24,30
291

communication, 6,108
dialogic model, 27

non-verbal, 48, 77, 93,122,123,145,

dialogue, 91-117

146, 201
of client, internal and external, 121

theory, 78
depathologizing, 52, 62, 111, 139

conducting session, principles

internal, 114

employed in, 9,92-96

three-party, 221

confrontation, between client and

Diamond, D. D., 100

therapist, 214
dichotomies, overcoming, 51

constructionism, 3,16,40,46,49,80,
differences, highlighting, 105

106
discourse, analysis and

constructivism, 3,10,16,18, 20, 22,

deconstruction of, 104

23,24,33,34,40,44,48,67,76,
distance, 70

80,135
Doane, J. A., 100

consultation, 3,10,44,56,110,120,
Doherty, W, J., 83

129,132,146,192,201,212
dominant discourse (Foucault), 49

individual, 192-223
"dormitive principles" (Bateson), 16

conversational analysis, 10
Draper, R., 94

conversational theory, 117

DSM psychiatric diagnosis, 47,51

conversational therapy (Anderson &

Goolishian), 75
Eco, U . , 141,150,151

"conversationalism" (Lai), 31
Efran, J. S., 76

Crutchley, E , 94
emotional bonds, 100

cybernetic epistemology (Bateson), 3,

emotionally focused therapy, 46

9,17,42
empathy, 8,11, 55,69, 76-83,85,123,

cybernetics, 78
274

first-order, 17, 48, 67

empirical perspective, negation of,

second-order, 3,18, 22, 33, 44, 48,

140

67, 135
end-of-therapy ritual, 290-292

Engel, G . L., 36

deconstruction and reconstruction

Enrica S., 162-163

during session, 115-117, 238

epigenetic evolution, 3,16,29,33,35

process, 27
Epston, D., 22,25,112, 238

deconstructionism, 31
Erickson, M . H . , 8,12,89

Deissler, K, G., 107

ethical issues, in therapy, 83-87

Dell, R E , 30,83,103
ethnicity, 40

denotation and and connotation,

experiential therapy (Whittaker), 90

150-153
extremism, 35

Derrida, J., 22

de Saussure, E , 25
Falloon, I. R. H., 74

304 INDEX

"family game", pathological, 48

Haley, J., 38,39,74-76,85,86,118,

family myth, dissolving, 117

151,152,163,164,187,217,263

feedback, 122
happiness, 121

verbal and non-verbal, 93

concept of (Lai), 80

feminist movement, 30
Hare-Mustin, R., 83

and ethical issues, 83

Harlow, H . F , 100

and power, 102

hermeneutic framework, 31

Fiocco, P. M . , 24
hermeneutic position, definition of,

Fisch,R., 104,233
139

Fleuridas, C , 107
hermeneutics, 3,10,21,139-145

flexibility, 99,132
Hoffman, L., 21, 22, 25,31, 49,92,107,

Fliess, R., 77
114

follow-up studies, 56
Hofstadter, D. R., 34

Foucault, M , 22,49,51,75,103
Holmes, J., 73,75,78,84,124

Francesca T., 148,278-292

Holzworth-Monroe, A . , 45

French, F ML, 205

Hoyt, M . F , 65,66,112,133

Freud, S., 4, 53
human relationships, epigenetic

cases of hysteria, 173

model of (Wynne), 100

clinical cases of, 184

hypotheses, 30,50,76,125,146

concept of drives, 14
reference points for, 96-105

length of analyses, 63
stated as questions, 287

on the unconscious, 67
hypothesis, 91,92,93,140

Freudian libido, 31
-making, avoiding, 38

Freudian psychoanalysis, 89
and creating possible intervention, 4

Freudian typologies, 27
ownership of, 93

Fromm, E., 99
hypothesizing, 9, 50,52,115,136

Fruggeri, L., 22,27,104

F r y e , N 87-89

v
"identified patient", 43,129

future, see past-present-future impasse, 5,33,34,39,45,48,57,70,

118,121,128,206,207,208,209,

Gadamer, H . G., 144

214,216,231,233,243, 284

gender, 104-105
individual therapy:

as reference point of therapy, 104

indications for, 41-46

differences, 102
psychodynamic, 60

issues, 40
process of, 91

roles, evolution of, 104

and family therapy, 41

general systems theory, 78

see also therapy

genetic epistemology, 35
"inner voices" (Minuchin), 17,39, 205

Giat Roberto, L., 90

"insight" (Stagoll), 22

Gibney, P., 58, 63

insubordination (Viaro & Leonardi),

Giorgio B., 43,160-162

118,119

Giuliana T., 132,141,148,167-192

"integration", concept of, 39

Goldner, V , 92,114
internalization, 15

Goldstein, A . P., 76
internalized family (Laing), 190

Goolishian, H . , 21,25,31,38,48,49,
interpretation, 26,136,137,140-144,

75,82,92,114,124
152,161,185,200,208

Goudsmit, A., 11
intervention, 96

Guidano, V , 27
paradoxical, 159

Gurman, A . S*, 45,56

perceptive, 125

 INDEX 305

reconstructive, 262
MacKune-Karrer, B., 14

of third party, 70
Malan, D. H . , 53,63

intrapsychic processes, 19,34

Maruyama, M . , 18

Marzocchi, G., 136,198

Jameson, P., 45
Matthews, W. J., 137,152

Jervis, G 26,50,74

v Maturana, H . , 22,48, 79,103,135

Jones, E., 103,104

McDaniel, S. H . , 56

"justificationism", 83,102
McLuhan, M . , 138

McNamee, S., 106

keywords, 138
Mental Research Institute (MRI), 3,

avoiding moralistic tone with, 150

18, 20, 21,46,60, 80, 89,120

and change, 145-150

metacommunication, 79

used to create new systems of

meta-language, 36

meaning, 148
Michaels, G . Y , 76

redefining power of, 147

Milan Systemic Approach, 3,4,9, 29,

Kniskern, D. P., 45
41,43,48,64

Kohut, H . , 26, 77
Minsky, M . , 16

and narcissism, 31
Minuchin, S., 39,61,75,126

mirror, imaginary one-way, 70

Lai, G., 31,80,115,121,208

Morin, E., 35

Laing, R., 14,15,16,52,190

morphogenesis, 18

Lane, G., 32,37

motif (Lai), 208

language, 33,49,152
myth, family, 224-234

and change, 24,145,150

digital and analogic, 151

Nardone, G., 18, 85

lens of, 136

narrative, 33,91

metaphoric, 152
theory 22

paying attention to, 82

shared, 27

polysemic, 139
narrative-constructivist approach, 92

and systems of meanings, 49

narrative-conversational model, 38

and therapeutic process, 135-153

narrativism, 3,10,24-28,46,49

used in team discussions, 81

Nelson, X S., 107

Lankton, C. H . , 137,152
neutrality, 9,94-96,177

Lankton, S. R., 137,152

Nichols, M . P., 14,22, 84

Laplanche, J., 94
Nietzsche, F. W., 87,88

Leonardi, P., 86, 93,107,108,116,117,

normality, principle of, 86

118
"not-knowing" position (Anderson &

life context, 77
Goolishian), 38,75

lineal-causal view, 30,61

Novelletto, A . , 26

"linear questions" (Tomm), 248

number of sessions, limiting, 63

linguistic games, 21,49,136

theory of (Wittgenstein), 153

object relations, 31

linguistics, 10,21
O'Hanlon, W., 31,59

listening stance, 121,123

Olga M., 98,120,124,239-241

adoption of, 120

Ornstein, P. H . , 53

"lonely crowd" (Riesman), 98

"outsight" (Stagoll), 22

Luciano M . , 16,96,100,103,223-234,

275
Palvarini, R. M . , 24

Macarov, D 76,77

v paradigm, biopsychosocial, 36

306 I N D E X

paradox, 5,18,137,213, 214

problem-determined system, 49,82

past and present, relationship

pseudocomplementary, 38,75, 217

between, 12
psychoanalysis, narrative view of, 26

past-present-future, 10,11,
psychoanalytic model, 29

hypothetical questions on, 109

psychoanalytic treatment, 45, 75

mutually interconnected, 109,

psychodynamic model, 6,30

recursive loop of, 25, 27, 61, 97, 98,

-experiential model, 65

116, 126, 191, 238, 262, 263

psychodynamic therapy, 4,5,208

relationship, 12
psychotherapy, client-centred, 75

pathogenesis, 48

pathologizing system:
questions:

danger of, 51
client's views on, 73

"dis-solving", 82
in end-of-therapy ritual, 290

"pattern that connects" (Bateson),

hypothetical, use of, 109

69
rhetorical, 204

Penn, P., 107

stating hypotheses, 287

Pereira, J., 24
and themes, 109

Perry, R., 73
use of preferred to answers, 75, 85,

Piaget,J.,35
247

polysemia, 139,145-147,151-153
see also circular questions

Pontalis, J.-B 94

positive connotation, 80,81

radical constructivism, 22

positive reframing, 80
Ray, W, L., 32,37

positive view, 62,80

re-story ing, 26

post-modernism, 22, 31
reality, 49,50, 67, 71,135,136, 223

post-structuralism, 21
emerging in language through

power, 40,83
consensus, 48

connection of to knowledge, 103

lineal and causal views of, 72

as epistemological error, 83,103

multiple versions of, 138

as reference point in therapy,

punctuations of, 50

102-104
view of, changing client's, 153

and responsibility, relationship

reflexive loop, 61

between, 104
reframing, 5,18,115-116,159,209,

in therapeutic relationship, 74r-76

249

sensitivity towards, 104

macro-, 116

of therapist, 74
micro-, 115

Prata, G., 4,9, 50

reification, avoiding, 48,49,51,68, 93,

pre-knowing, 124
128,291

prejudices, and sensibility of thera­

relational circuits, of individual, 34,

pist, 40
114

prescriptions, 117,137,165,284
relationship:

ritualized or behavioural, 116

avoiding reification of, 68

presentification of third party,

client-therapist, reversal of, 221

110-115,130,155,202, 238, 243,

dyadic, 110

274,275
paradoxical, 214

and use of empty chair, 112, 202,

symmetrical, 214

206, 217, 218, 220, 264, 268, 269,

symbiotic, 44

272
resistance, formation of, 119

presenting problem, 60,54,81

reticence, principle of, 87

 INDEX 307

rhetoric, 137-139
supervision, 4 4 , 6 7 , 7 0 , 7 2

and hermeneutics, 136-137

Susanna C , 65,112,116,133,134,

a n d systemic therapy 138

242-278

as means to create context, 138

symbiotic couples, 98

"rhetoric of unpredictability", 139

s y m p t o m prescription, 137

Ricoeur, R, 26
synchronic v i e w (de Saussure), 25

rigidity, 56,69,113,132
systemic epistemology, 33

role-play, 71,112,219
systemic hypotheses, 30,50

Rosenthal, M . , 107
systemic i n d i v i d u a l therapy, 57

m o d e l of, 62

Schafer, R., 26-28, 7 7 , 8 7 , 8 8 , 8 9 , 9 0

systemic v i e w of d y a d i c relationship,

Scharff, D . , 14
79

Scharff, J 14

v
systemic-cybernetic m o d e l , 60

Schrader, S. S., 27
systemic-cybernetic theory, 19,36

Schwartz, R. C , 14,16
systemic-strategic m o d e l , 43

Searles, H . , 78, 231,278

systemic therapy, evolution of, 17-22

second-order cybernetics, 18, 22,33,

systems of meanings, 49

44,48,67,135

Segal, L . , 120
team, supervisory, 69

self-observation, 78
temporal coordination, 126

self-questioning, 142
Teresa S., 98,157-159

self-reflexivity, 14,67
Terry, L . L . , 113

Selvini Palazzoli, M . , 4 , 1 8 , 3 9 , 4 1 , 5 0 ,
textual analysis, 140-141

52,64,82, 92,93,106,114,116,
therapeutic alliance, 119

117
therapeutic context, 119-122

separation, 133-134
co-creating with client, 54

a n d individuation, 81,191
creating, 119

anxiety, 65, 66, 277-278

and requisites of therapist, 120

session:
therapeutic contract, 62,131-132, 222

conducting, 122-128
therapeutic dance, 115,126

interval between, 64-65

(Mmuchin), 72

silence, importance of, 123-124

therapeutic dialogue, 92, i l 4

S l u z k i , C , 22, 25,136
therapeutic m o d e l , 45

social constructionism, 10,16,21,22,

therapeutic paradox, 81

31,33, 34,38, 44,49

therapeutic process, meta­
social constructivism, 91
c o m m u n i c a t i o n i n , 290

space, as reference point i n therapy,

therapeutic relationship, 70, 80,123

98-100
linguistic analysis of, 146

Spence, D . R, 26,137
a n d power a n d gender, 122

Stagoll, B., 22
reversal of roles in, 219

story:
therapeutic team, internalized, 72

client's, joint exploration of, 60

therapist:

deconstruction of, 238, 261

awareness of o w n premises, 68

strategic m o d e l , 30, 74,75

-client relationship, 32

strategic-systemic therapy, 3 , 6 , 5 , 4 7 ,
curiosity of, 121

55, 67,157-165
directivity of, 117,118

structural family therapy, 46

gender bias of, 233

structural m o d e l (Minuchin), 75
goals of, 8

Sullivan, H . S., I l l
omniscience of, 27

308 INDEX

openness or closure of, 84

introduction of, 81

personality characteristics of, 45

lack of coordination with, 126

prescriptions of, 162-163

lineal-causal view of, 109

professional background of, 124

as reference point in therapy, 96

and risk of rigidity, 56, 69,113,132,

and rhythms of therapist and client,

286
126-128

Self, 67-74
synchronic and diachronic, 97

therapy:
time-closed therapy, 62

aspecific aspects of, 121, 241

time-limited psychotherapy

breaking off, 55
(Mann), 65

client's expectations of length of, 56

time-open therapy, 66

co-evolutionary conception of, 122

timelessness, 49

context of, 77
timing, 127,175

widening, 128
importance of, 247

drop-out from, 56
Tomm, K., 16,17,94,95,107,108,248

ethical obligations in, 143

transformation-externalization, 15

focus of, on person, 11

trust, between client and therapist,

goals of, 53-58

120,122

here-and-now of, 27, 31, 63, 69, 71,

truth, avoiding trap of, 125

72, 124,125, 126

twenty-session rule, exception to, 134

"humanistic", 46

hybrid, 160-162, 222

Ugo B., 164-165

interruption of, in cases of abuse,

"unconscious, the" (Bateson), 67

143
"unspoken, the", 5,16, 20,28-33,76,

long-term, time-open, 61
86

philosophy of, 87-89

previously undertaken, 169

Varela, E , 16, 22,135
problem-solving, 46
Viaro, M . , 86,93,107,108,116,117,
protracted, 59
118

short-term, MRI model of, 4

Villegas,M.,18,20

spatio-temporal coordinates, 98
von Foerster, H . , 22,85,124

therapy of absurd, 90
von Glasersfeld, E., 21,22

third party, introduction of, to

unblock impasse, 70,230,232,

Watzlawick, P., 4,13,18,22,39,48,70,
234
84,85,94,118,121,137,263

time, 8,33, 96-98

Weakland, J. H . , 104,233

and change, 58-66, 119

Weber, X T., 56

correlation between, 58
White, M . , 22,24, 25,49,112, 238

coordination of, in therapy, 61,69,

Wiener, N . , 17

72,126,127
Winderman, L., 49

importance of, in human relation­

Wittgenstein, L., 21,49,136,153

ships, 96
Wynne, L., 28,35,56,100

Systemic Therapy with Individuals

b y L u i g i Boscolo and Paolo Bertrando

Until recently systemic therapy has been identified with family therapy. This
no longer applies; the systemic approach and its techniques can now be used
with profit in therapy with individuals. This book introduces and describes
the first adaptation of the systemic model in the individual context.

Boscolo and Betrando describe the work they are doing with individual
clients in Milan. Locating themselves clearly within the tradition of the Milan
approach and more recent social constructionist and narrative influences,
and articulating continually a broad systemic framework emphasising
meaning problems in context and relationship, they introduce a range of
ideas taken from psychoanalysis, strategic therapy, Gestalt therapy and
narrative work. They describe the therapy as Brief/Long-term therapy and
introduce new interviewing techniques, such as connecting the past, present
and future in a way that releases clients and helps them construct new
narratives for the future; inviting the patient to speak to the therapist as an
absent family member; and working with the client to monitor their own
therapy.

The book is written with a freshness that suggests Boscolo and Bertrando are
describing "work in progress", and the reader is privy to the authors' own
thoughts and reactions as they comment on the process of their therapy
cases. This is a demystifying book, for it allows the reader to understand why
one particular technique was preferred over another.

The book is timely in several ways. As proponents of different models

increasingly exchange their ideas, there is greater mutual influence and
breaking down of traditional barriers. This book demonstrates the value of
applying a range of techniques to therapy. Also the book addresses the need
for practitioners, and increasingly clients, to justify their expenditure of time.
This model makes the most efficient use of the therapist's resources and also
the client's pace for therapeutic change.
From the Foreword by David Campbell & Ros Draper, Series Editors

Karnac Books, Cover Design by

58, Gloucester Road, Malcolm Smith
London S W 7 4 Q Y ISBN 1 85575 094 5