practice

The Difference Bowen Theory Makes in Clinical Practice: Challenges and Choices

Victoria Harrison, MA
Ms. Harrison practices Bowen family systems based psychotherapy in Houston, Texas, where she also directs the Center for the Study of Natural Systems and the Family and is on the faculty at the Bowen Center for the Study of the Family. She can be reached at: vaharrison@sbcglobal.net.
The faculty case conference is held bi-monthly at the Bowen Center. Faculty members take turns presenting a case conference from their clinical practices. The conference is not intended
as supervision or as a meeting to arrive at a consensus about how to manage a specific case. It is intended as a learning experience for the faculty and to keep them aware of one another's general approach to clinical problems.

This clinical case was presented at a faculty case conference in October 2017 after two months of family systems psychotherapy with a couple. It is an example of the difference it makes for a therapist to draw upon Bowen family systems theory to define for herself decisions and directions involved in the challenges of therapy practice. This presentation illustrates ways that family history and a family diagram help to understand and interrupt a common emotional process that persists in individual therapy—focus on the other as the problem. Defining the focus of therapy as "working on self" offers an alternative perspective that facilitates a shift from blaming each other toward understanding patterns of reacting that each brings to problems in the marriage. It is a responsibility of the therapist to raise questions in the sessions that direct thinking toward differentiation of self in all family relationships, rather than continue to support the emotional process of focus on the other. This is one of the biggest differences between therapy based in Bowen theory and the more common relationship therapy approaches.

It is possible in the early months of therapy to hypothesize the difference it can make if either spouse is able to recognize his or her own reactions and their impact. Both husband and wife in this example show some ability to begin to make changes, based initially upon the clarity of the theoretical focus of the therapist.
Key words: marriage and family therapy, family history, differentiation of self, family systems psychotherapy, Bowen theory
Introduction

This interesting couple represents challenges for any therapist and therapy mode. Therapists based in Bowen theory are especially challenged to define what is different about this approach, about the thinking, and about how people make use of therapy. They also represent common challenges that couples face in marriage. It may be too early to say, but I believe this couple can illustrate ways that Bowen theory makes a difference in addressing these challenges. I look forward to the questions and thinking this will stir.

When I was a young therapist in the Georgetown Family Center Postgraduate Program (1976 -1980), I heard Dr. Bowen talk about all of the details in clinical practice as opportunities for the therapist to "define a self." These included decisions about fees, insurance and relating to insurance companies, interaction with referral sources, using first names or last names, working with family members who are in therapy elsewhere as well, cancellations, and more. An understanding of Bowen theory is the basis for the many decisions that therapists make. This presentation is an example of ways that I put theory into practice now, after over forty years of work with Bowen theory. One of the rich and challenging implications of Bowen family systems theory is that this is not the only way one might address these decisions, using the same theory.

Challenges begin with the first telephone call to schedule an appointment. What are the expectations of the caller, of their referral source? This couple found me on their Blue Cross Blue Shield insurance provider list and the husband (Mr. B) contacted me for "couples therapy." This is an illustration of what Murray Bowen described so well in the GAP Report that compared the premises and practices of therapy based in psychoanalytic theory with those of family systems theory. Conventional therapy defines techniques based upon whether the symptoms occur in individuals or in relationships. One family of four, for example, might see six therapists. Each parent and each child might have an individual therapist. The couple might also see a therapist as a couple and the whole family might meet together with another therapist. Training in individual therapy would emphasize the importance of seeing one individual in the family and referring others to other therapists.

Bowen family systems psychotherapy is based upon a radically different view. The family is an emotional unit that governs the biology and behavior of each member. Everyone plays a part when symptoms occur for any family member. Any symptom is a function of common factors. Levels of differentiation of self and degrees of chronic anxiety are central to development of symptoms in individuals and in relationship problems. Observing and interrupting anxiety reactions and working on differentiation of self are the basis for change in those symptoms. Any motivated individual can make use of this approach. It is not necessary for a family to work with six different therapists. In fact, it is a counterproductive though well-established convention. A therapist trained in Bowen theory faces many challenges and opportunities to define and maintain the differences in this approach in therapy.

The initial challenge often occurs with the first phone contact. My goal is to define the way I work while learning about what someone wants to accomplish. I did that in the initial conversation with the husband. I described that I do not divide up the work based on whether I see the individual or the couple. Whether I see the couple together or each individual separately, I talk with them about the dilemmas in their relationship, how those dilemmas are a product of their own reactivity, and what people can do to change those reactions.
This ninety-four page report was written in 1970 by The Group for the Advancement of Psychiatry's Committee on the Family, whose authors included Dr. Bowen and other pioneers in the development of family theory and family therapy. More information can be found on The Bowen Center's website, thebowencenter.org, on the publication page within the store section.
I may suggest that people look at my website or read about Bowen theory on the Bowen Center website.

After our phone conversation, Mr. B wanted to proceed with an appointment, and I scheduled to meet with them together. At the first appointment, I began to learn about difficulties in their marriage. I also learned that they had each been in individual psychotherapy with different therapists since 2012. For the past five years, the husband had seen his therapist and the wife had seen her therapist weekly. The husband had been off and on anti-anxiety medications and that produced side effects. He had also been in drug and alcohol rehab and experienced chronic gastro-intestinal symptoms along with exercise-related injuries. The couple separated in May of 2016 and have been stuck in a miserable limbo since then, unable to "live with each other or live without each other." They recently decided to add couples counseling.

Toward the end of that first session, I let them know that I would not see them as a couple as an add-on to therapy they were pursuing with others. If they wanted to work with me, it would involve wrapping up their therapy with other therapists. I could meet with them together and separately, depending on what seemed most useful. Mr. B asked good questions about this approach and about these operating principles. He asked to meet a second time to let me know more about their dilemma, their marriage, and the problems they faced as the basis for their decision. I agreed to meet with them a second time, to describe more about what people do when they work with me, and to learn more about their dilemma.

It was easy to begin to develop the family diagram and a timeline in that second meeting. A version went up on the board in front of them, where they could begin to see their symptoms in the context of facts about each family. I try to ask questions that help people think about their own reactions and how they developed. "How do the problems in your marriage compare to your parents?" "Which of your parents depends more upon the other?" or "How did you learn to take charge of others growing up?" "What kinds of symptoms did your parents develop?" and "How do you function now in your own family?".

This couple separated in May of 2016 after Mr. B reported an affair to his wife. He initially wanted to divorce and pursue this other relationship. Ms. B cooperated with that at first. Mr. B moved out of their home and began to live with his parents. As he took steps towards divorce, his wife reacted with dismay. He decided to break off the affair, which he did in December of 2016. He and his wife began to pursue a kind of reconciliation. This course was fraught with emotional reactions, leaving them stuck living apart and miserable, unable to decide to divorce or to stay together. My impression in the first and second meeting was that they hoped a couple's counselor would tell them that they were hopeless and make that decision for them, which I of course did not. As I talked with them about the history of the marriage and of each family, I communicated that this therapeutic approach could be useful if it helped either one of them make sense out of their own reactivity and the ways it was a challenge in the marriage and do something about it.
I said, "You all think about it. It's not a decision you have to make in this hour. Talk about it, think about it, and let me know what you decide."

It was a surprise that they decided to wrap up their individual psychotherapy and meet with me together and separately to see if that could lead to more clarity and a decision about the marriage over time. This was another opportunity to communicate that if either of them could take steps to see and change their part in reaction patterns, the future would be better. I conveyed that I am not invested in whether they stay together or divorce, but I am invested in seeing what difference it makes for people to work on differentiation in a situation like theirs. It is a challenge to effectively define oneself as a therapist when emotional reactions in a family are high.

As is often the case, people say that they want to focus on themselves and their own reactivity, but in fact they are really focused on the other person. This couple had been in individual therapy for five years, talking about how the other person is the problem, and how helpless each is if the other person doesn't change. That became clear in the third session. It was possible for them to also see how much their focus on the other one as a problem was part of the problem.

The focus on facts about the history of their marriage and events in the life of the family helped decrease the anxious focus on each other. The timeline of events in the life of each family made visible some of the powerful influences on the marriage. The therapist is often clearer than either spouse about how much the reactivity to their own families is central to the difficulties that they face with each other. Going over the timeline with questions is a part of each session.

Mr. and Ms. B were both born in 1981, she in Texas and he in northern Louisiana. Mr. B was the only child of a second marriage for his father and a first marriage for his mother. He grew up in a more obviously tumultuous family, where his father's drinking and wild lifestyle and his mother's tendencies towards hoarding and reclusiveness created the lifestyle of that family. They moved to Houston when Mr. B was five. Mr. B's father worked as an airline employee who flew internationally and continued his wild lifestyle. In his teens, Mr. B began to travel and party with his dad. He became more distant, critical, and tentative with his mother, who ran the household strictly. She was in charge of everything in her domain and rarely left the home. Mr. B left for college and describes that as a time when he began to function more for himself. He did his own laundry and cooking and discovered that he was really a pretty capable young man. Although continuing to drink and party, he earned his degree in business.

Ms. B is the first daughter and middle child for her parents who were married until her father died in 2010. She is definitely not a "wild and party" person. She was studious, serious minded, and stable while earning her doctorate in pharmacy. She describes her own family as stable but fun loving, a version of the ideal family. The functioning of her siblings held clues to ways in which her family was more similar to her husband's family than she realized and also illustrates how she learned to focus on others and to take responsibility for the problems of others.
Ms. B's older brother, who is married and has two children, is anxious but functions well at work and at a distance from the family. He waits for others to take charge and cooperates with them. Ms. B's younger sister is the most symptomatic sibling. She is "wild and crazy" and has alcohol and drug problems. Ms. B watched her parents take care of her younger sister and encourage the sister's dependence on the family. It is the younger sister who functions in this family more like her husband, which is something Ms. B had not seen on her own. Mr. and Ms. B met at college and began to live together in 2006. They were both pretty capable for a time. They finished college and moved to Houston where each began to work. Two things happened in their families after they become a couple. The first family event came into play in 2009. Mr. B's maternal grandmother begins to develop dementia and depends more on her children. As this happens, Mr. B's mother discovers that her oldest sister's son has been embezzling funds from the estate. Animosity and explosive confrontations occur between his mother, her older sister, and their mother over the two years until Mr. B's grandmother dies. Mr. B develops acute and debilitating hearing loss during this time. His symptoms are diagnosed as stress-related and remedied with medication. He recognizes that he was reacting to the family conflict but does not see any connection between his own family turmoil and his symptoms and functioning in the marriage. He also does not yet see relationships in his family as avenues for change.

Around the same time, six months before Mr. and Ms. B marry, her father receives a cancer diagnosis and begins to fail. The cancer progresses quickly. In the face of the diagnosis and in the aftermath of the turmoil in Mr. B's family, they marry in July of 2010. Within two weeks of marriage, Ms. B's father's cancer symptoms worsen, and Ms. B's parents briefly move in with the couple. After only a few weeks, her parents return home where her father dies in hospice care. This is a huge disruption for Ms. B's family, and Ms. B spends a lot of time traveling to be with her newly widowed mother. Although Ms. B can appreciate the impact of her father's death on the family, it is difficult for her to recognize her own reactions and how they played a part in the marital problems that occur.

After her husband's death, Ms. B's mother lives alone for a time and the younger sister is somewhat stable independently. It is interesting that Ms. B's younger sister had stabilized and moved out on her own in 2010, at about the same time the couple married and the dad's cancer accelerated to his death. She began to flounder in early 2011, resulting in her moving in with Ms. B and Mr. B for about six months in 2012. During this time, Mr. B focused on helping his sister-in-law, but his own drinking and drug use accelerated. He entered rehab in 2013 for drugs and alcohol. Ms. B's younger sister moved back with their mother and has remained there As they reviewed the history of the families, both Ms. B and Mr. B were able to begin to consider the impact on their marriage of events in each of their families. They were able to think about how the reactivity stirred for each of them related to the family, not to personality flaws or problems they encountered with each other. They sketched a basic pattern in the marriage in which Mr. B would drink more, stay out longer, and be less available after her father's death and her sister moved in. Ms. B alternated between being more critical of her husband or feeling sorry for him and taking care of him. Mr. B distanced into his own work projects and problems, which were significant. He described the marriage "shutting down for him." He "shut down" in the marriage, had no more feelings for his wife, and was not interested in intimacy, sex, or closeness with her. He started a long-distance affair on one of his work trips in April 2016. They separated for the first time in May of 2016.
Ms. B described her reactions to the affair and threat of divorce. She wanted to reconcile after he broke off the affair, but found herself critical, negative, furious, always focusing on what he was doing wrong and could do better, and what he should do to reassure or bolster her. Mr. B moved back to their home for a time. During this time, he experienced a serious injury that required surgery and prolonged recovery. Both Mr. and Ms. B were miserable, and he moved back to his parent's home in May 2016.

Since the B's began to meet with me in August of 2017, there have been seven sessions with Mr. B, three with Ms. B, and five meetings together. I cannot report any "giant steps" or dramatic progress. Everyone is learning more about reactivity and its impact. There have been some surprises and further challenges for the therapist.

In early September of 2017, Ms. B got mad at her husband because he went out of the country on a getaway that was innocent and did not involve affairs or irresponsibility. Later, he flew to Europe for a weekend when she was away on a work trip. She got upset with him for doing that without her, and Ms. B had a one-night stand during her business trip. She immediately told her husband, and they discussed this in the next session together. She described feeling closer to her husband in the aftermath, relieved that he blamed himself for upsetting her. This comforted her. It was only later in an individual session that Ms. B was able to consider how her own immaturity, drinking too much, and reactivity were all at play. She was not pleased with herself.

Mr. B went into a couple of binge episodes with drinking. Ms. B comforted him. It was possible to talk and think with each of them about their sensitivity to each other, the way their "emotional fusion" appeared to operate, such that they were depending more on each other and less on self for managing anxiety. It was possible for them to entertain some thinking about the reactivity that each brings to the marriage and the dependence on each other.

It was also possible for Mr. B to begin to think about how the cutoff between his mother and her siblings has also been a cutoff for him from his cousins and aunts. He considered the way in which this cutoff plays a part in his mother's isolation and his own anxiety. He was able to make contact with his aunts and to respond to their contact with him. It has become obvious that he is someone who exaggerates his shortcomings and failures. His aunts and cousins provide a different perspective, which is very different than the one he has about himself. He saw himself blowing up with them at his grandmother's funeral as if it were outrageous, irresponsible, and unforgivable. They have almost forgotten his blow up. As he begins to make contact, he begins to realize that his view of himself is one of exaggerated negativity. He takes more blame than is his due. He is beginning to think about that and about how to have a more realistic view of what he is accomplishing, what he needs to accomplish, and how to represent himself better in his relationship with his wife.

They are still living separately. Ms. B struggles with seeing her husband as the problem and—as the well-behaved one in her family—has difficulty seeing the part she plays. Her onenight stand, however, alerted her to her own immaturity. She struggles to see the versions of immaturity that are present in her own family. But she can entertain the idea that there are connections between her father's cancer and anxious reactions in the family, between her parents and with her younger sister.

This is definitely a work in progress, with challenges for the therapist and for the couple with each other. I'm very interested in what thoughts and questions you have about these interesting people. While I wait for you to organize your thinking, let me give you an example from one of my individual sessions with Mr. B.
This session is a good example of the challenge to "think systems" for him and for the therapist. During each session, Mr. B does talk and think and train his brain on the Zengar neurofeedback equipment. He almost always starts a session talking about everything he has done wrong, about what a mess his life has become, and how he does not know what to do about it. This session began the same way, talking about everything he has done wrong.

Mr. B talked about getting drunk the night before this session and that it was his birthday. He felt sorry for himself and got drunk on his birthday and was hung over. I asked him if he heard from anybody on his birthday, and he said, "Well, yes." He showed me text messages he had received. He was interacting with the aunt from whom he had been estranged since his grandmother's funeral in 2011. He had exchanged emails with her on his birthday while he was drunk. His comments and responses to his aunt were open and engaging. I told Mr. B that I thought the message here was not that he should get drunk more often so that he could interact with extended family better. The message was that he is probably doing better more of the time than he realizes. It certainly was useful to me to see the texts and wonder out loud if he was not as drunk as he thought he was? "Are there other examples of this kind of thing?" I asked him. I also asked what else he had done since the last session.

Mr. B had gone into the office every day. He works for himself as an independent consultant. He was in contact with a number of colleagues involved in a current project. He described the process in the household where he is living with his parents now. There were clear examples of how the triangle with his parents trains him to under-function and see himself as the problem in his marriage. By the end of the session, he began to think about how he could stand up for himself, be more responsible for himself, and represent himself better with his family.

My guess is that his thinking will wipe out between now and the next session, but it is certainly a better basis for moving forward than just to focus on how helpless he is with his wife. That was such an interesting session. It is important for the therapist to remember to ask factual questions and engage thinking when faced with the emotional reactions and feelings someone exhibits.
Discussion

Amie Post, MA: I've been thinking and wondering how marriages look at different levels of differentiation, and what happens in a marriage as a person begins to work on differentiation?

How can you begin to see where the family is in terms of differentiation without getting focused on the presentation of symptoms as defining differentiation? (that is, conflict or illness or an affair = low levels of differentiation) Those things can occur across the whole range of differentiation. How they get managed and the flexibility in the family varies. How do you learn about that?

One way I try to get at differentiation is to wonder how the individuals were moving toward the marriage—what did they hope to get out of it? In my experience people can tell you this pretty clearly: "I was looking for the perfect mate, he/she was it; I wanted someone who completed me, they did that; I knew I needed to find a person who had these particular talents, strengths, as I moved toward my own goals." It is most telling when neither has any idea of what they were moving toward. They just describe that they "knew" or it "felt like the right fit." It sounds like these folks were moving toward one another more from the togetherness drive than from an integration of togetherness and individuality.

Really, what is the purpose of a marriage? Biologically the purpose of mating is to provide stability to the procreative process and next generation. Marriage as an institution in society is about providing financial stability, cultural/societal stability, and support to previous generations and the next generations.

How would this couple see their purpose in being married? And what do they hope to accomplish by being married? I think that asking these kinds of questions of people gives them a way to think about how to be responsible to their goal. If you want this kind of marriage and want to meet these kind of goals, then what parts of you do you want to work on to ensure that you get there? If you wait for the other to drive the effort you may well be waiting a long, long time. How would these individuals describe the goal of being married? What are they hoping to achieve by forming a partnership, and how does that shift as they start to look at the other less dependently and start to look at their own goals?
Ms. Harrison: I haven't asked them that in that way. I asked what drew them together, what was it that attracted them to each other in the beginning? Ms. B commented that he was fun, charming, social, and that she was more reclusive, and less social, less fun. He was spontaneous. She couldn't do anything without planning it down to the nth degree. Plus, she said he was sexy. Mr. B said that she was adorable, beautiful, that he was immediately taken by her charms, and that he also learned that she was a good stable family member. That is what they say, but I think, as with most couples, what draws them together and keeps them together is an emotional process that is in her family, and that is in his family. That makes them a match. It is remarkable to see how both families have a branch of cutoff that occurred around the death of a grandparent.
They are such a great match in terms of her programing to focus on the problem of another and take responsibility for it, and his programming to be the problem that people can focus on. That's a marriage made in heaven, if not evolution. So I haven't asked the question the way you asked it, Ms. Post. They are both able to begin to reflect upon the reactivity that makes it difficult for them to stay married or separate. I personally believe that they will stay together if either one of them is able to begin to work on the reactivity part of it. Do you want to say more about the questions you posed, and what you think would be valuable about posing them to this couple at this point?
Ms. Post: This marriage emerges from family emotional processes that reflect an incredible sensitivity to and dependence on one another. It makes sense that those processes get recreated in this marriage. The pseudo selves are molded and formed in a dependent fusion. The process you describe demonstrates how the reactivity gets stirred and symptoms emerge when one or the other stops functioning for the other. I heard you describe the emergence of the drinking in the husband as a response to the wife's shift in focus from the marriage to a focus on helping her family of origin. I was thinking that the husband's dependence on his wife reflects the distance he has with his own family of origin. Each person's continued entanglement with their family of origin fuels their sensitivities and interactions to each other. It is striking to hear how the husband is able to have a tiny bit more room for thinking as he is able to engage his aunts.

I wonder what happens as an individual is able to begin to rise up out of the togetherness and take that microscopic step toward a better level of differentiation. Does that person begin to see a different way of organizing oneself toward the marriage? Do the goals the person begins to develop for self translate into ways of thinking about a coordinated response in the marriage? How does that process unfold?

How would this couple begin to think about the purpose of their marriage beyond the function of being for one another— a focus on the relationship? Would there be a move from the goal of a happy or even functional marriage to thinking more about responsibilities? How am I responsible for self? Would there be shifts toward a focus on self rather than on the relationship? How does defining ways that the individual will be responsible to the other for self influence how the marriage gets organized? How does the energy that would have been invested in regulating for the other get reallocated, and what does the function of the marriage look like? Does that thinking provide a regulatory mechanism for the anxiety? Clinically, how does the question about what a couple wishes to accomplish provide a way for thinking about and managing self that is different than working on being for another?
Ms. Harrison: Thank you. Those are important questions and I certainly do not have answers to all of them. I am clear with people that the most productive focus is on seeing one's own reactivity and its impact as the basis for changing one's part in a problem. Often people are "programmed" to take all the responsibility and not see the part others play or they are conversely programmed to only see the other's part and blame them. That plays out in marriage. Really, seeing both is necessary and develops over time. The family diagram and a factual timeline are helpful for everyone.
I am going to stop because there are only a few more minutes for discussion. If there is time at the end I certainly have some comments about estimating the level of differentiation present and seeing the self in others at all levels of differentiation.
Robert J. Noone, PhD: These are such interesting kinds of cases. It is interesting that they were both willing to wrap up their individual therapy. That often isn't the case. There is something, a real draw for them to try and figure out what's going on and this annoying attachment that they have.
Ms. Harrison: I also think that their therapists were tired of working with them and glad to see them go. Both therapists had referred them to couple's counseling and I think that the therapists were probably both fed up with how long and drawn out this had been and yet they were still miserable. That's part of what I think came into play.
Dr. Noone: It is also interesting that you described her as being the "well behaved one" in her family and in the marriage, and his being the "misbehaving one." His father was the misbehaving one, and you know his mother focused on him. Generally, it's very difficult for the well behaved one to not focus on the misbehaving one, and for the misbehaving one to not stay focused on their own deficits and assuming responsibility for the problems and the reactivity. It is very early in the process of meeting with you, but do you have a sense that Ms. B has begun to look at her own reactivity and see some part she plays in the process?
Ms. Harrison: Well, it is interesting. I think that when the therapist, aiming toward a more factual view and toward neutrality, can introduce the concept of the triangle to the couple and show that each plays an equal part, it will give each one a chance to develop that perspective. There is evidence that Ms. B is trying to do that. Introducing that does not turn the process into an ideal one however. Ms. B's one-night stand is an interesting shift, for example.

That forced her, in some ways, to recognize her own immaturity. That would not be an ideal, higher-level version of differentiation for recognizing one's own immaturity. It is a pretty reaction-charged way of recognizing one's immaturity. She did recognize that she was mad at Mr. B for going on a trip without her. Her own reactions became available for observation. This is also an example of the difference it makes for a therapist to use Bowen theory and to work on their own reactivity in a session. Some therapists might have "supported or reflected" a tendency to justify one's immaturity by blaming it on the other. It is a challenge to communicate that both partners are reacting to each other in equal and reciprocal fashion.
It is really useful to know that emotional fusion is operating at physiological and biological levels as well as in behavior, where it may not be so obviously reciprocal. In the next session Ms. B was able to talk about how much she assumes responsibility for her younger sister and for her mother's distress. She began to talk and think about how her reactions look in her own family and how they can play out in her marriage. There are inklings of that for her too, certainly not in any kind of ideal fashion, but she has inklings. When she looks back to her growing up years prior to meeting Mr. B, she can see ways that she would operate to support her mother and do her mother's job in relation to her fatherå and her younger sibling. Does that address some of what you were raising?
Dr. Noone: Yes, thank you.

Ms. Harrison:That is how it works so far. It is early on, which I keep reminding them of. They have no idea what they can do yet with this approach. That is understandable. It is also so different from the therapy that they have been in for five years. They do comment on that.
Joan Jurkowski, MS: I thought you had an interesting way of starting the relationship with the couple. The way you defined a position made me think about my own work. I wonder if defining your role so clearly had anything to do with how quickly they were able to shift from focus on the other to focus on self.

I was also impressed by the understanding you have of the family relationship system. Perhaps they knew many of the facts already about the extended family. I don't think I am always able to have as clear a view of the family emotional system as early on in my sessions. I think that having the facts is an advantage in helping individuals to see the part they play.
Ms. Harrison: Let me address your first comment about shifting the focus. Do I think that defining myself early on plays a part in how quickly they were able to shift focus?

Yes. Defining myself and describing the process early on are just basic. That is what I believe is my responsibility for representing a focus on differentiation and Bowen theory in clinical practice. This is not the only way to use Bowen theory or define oneself as a therapist. Earlier in my history of practice, I tried to simply ask questions aimed at engaging thinking and watch to see if and how that thinking led to changes in their functioning in the family. There are some remarkable examples of steps people took on their own, without guidelines or suggestions on my part. Perhaps that is still the better way to practice.

At this point, I do not have time in my current practice to see everyone who is referred. Now I try to be very clear with people what the benefits of this approach involve on their part. The work can be slow going, and it can take them whatever time it takes, but this approach is what I know can be most useful to them. I am very direct about that now. I am not a supportive, listen for the hour, relationship therapist anymore. For better or for worse, I don't have time to work with people who just want to talk without taking steps toward making changes in their own life and family. I still have to recognize and manage my own reactivity in clinical practice. Impatience, for example, is different than being clear.

However, I don't think the Bs have shifted quickly to a focus on self. Part of the challenge for them and part of the challenge for the therapist is that they are still quite focused on each other and view each other as the problem. It is a challenge in each session to flip the focus back, broaden the focus, comment on, ask questions, such as "And the part you play is? And how do you react when… . " It involves going over and over and over those lines on the family diagram that put the focus back on one's own part in patterns of reacting and in problems that develop. Then they go away, and it slips. And they come back and it is back. The shift toward seeing the part one plays in reciprocal reacting does not happen quickly. That is part of the challenge. They are beginning to appreciate that the focus on the other is part of the challenge they face, part of the emotional fusion in their marriage. I just keep working it. I don't think that there's any other way. They decided to work with me because they really want to get a move on. So I can say, "Well, how long do you want to take? This is the only way I know to get out of the bind you're in!" So I just keep saying that. What was your second question or point?
Ms. Jurkowski: It was about the advantage of seeing them together. Is that an advantage?

Ms. Harrison: It is an enormous advantage to the therapist in establishing a neutral outside angle, in being clear about the focus on the part each plays without blaming either one. It is an advantage for each person to be able to hear the other think out loud about his or her own family and reactivity. It can be a disadvantage as well. Seeing a couple together can bring differentiation to a halt. If the reactivity is high in the marriage, as it is for this couple, it is more difficult for each to think in the presence of the other. It is harder to think about one's own family patterns if one's spouse is describing them (and you) as the problem.

When each spouse can listen to the work of the other and also describe his or her own efforts, it is productive. In his collected papers, Family Therapy in Clinical Practice, Dr. Bowen writes extensively about working with individuals and working with couples. I go back and read them so often that my copy is falling apart. There is still a great deal to learn about how a therapist can further the process of differentiation of self in marriage or get in the way.
Anne McKnight, MSW, EdD: I thought this was such a useful case, less about the family and more about the coach in terms of demonstrating number one, the clarity that a coach can present to a family and, number two, the difference it can make for people to be exposed to Bowen theory. In what way does it make a difference for the couple to come together and be able to address reciprocity rather than listen to what the reactivity is to the other? I was also actually a little amazed that the husband was willing to make contact with his aunts. You have seen them for a total of fifteen times altogether and he could already begin to use that as a stepping-stone to gain additional perspective about his functioning. It speaks in part to your clarity as a therapist, about what you do and how you do it. The larger frame of reference, how you think about their marriage as part of the larger system, the connections between events in the family ,and the emotional process that affects them both are all related to his willingness to talk to his aunts. It is a good illustration of how theory is actually lived out in the consultation process.
Ms. Harrison: This is a pretty realistic view of what happens when it is possible to be clearer and to stay on track, theoretically, in the triangle with a couple. It doesn't result in an ideal process, but I think it does illustrate something about the emergence of self in the midst of emotional fusion in the marriage. In one of the early chapters of Family Therapy in Clinical Practice, Dr. Bowen writes about being able to see the self at all levels of differentiation, being able to see and relate to what is self in the other, even in the midst of intense emotional fusion. That is one of the things that can make a difference with a couple like this. The levels of self are clouded, I think, by the impact of the anxiety this couple experienced since they married in 2010. This is a good example, I think, of how the process of change is not ideal but can move in a productive direction when the therapist can keep on track theoretically and work on self as well. Often what occurs is unexpected and operates beyond any instruction on the part of the therapist. Thank you for the comments and questions. They will be useful as I continue to work with this couple.
Editor's note: There were seven individual sessions with Mr. B, three individual sessions with Ms. B, and five sessions with the couple together.