By Dr Kate Owen
Clinical Family Therapist & Clinical Psychologist
What language do you use to describe hypothesizing?
Do you say “hypothesis”, “conceptualization”, “formulation”, or simply your best guess at what is happening for the client and family?
Hypothesizing is a central part of the family therapy process. Without a hypothesis, a therapist is placed in a passive role with no direction.
Can you remember your original training in formulation? I would guess that you were taught the biopsychosocial model for understanding and explaining a client’s symptoms and presenting problems: Predisposing, Precipitating, Perpetuating, and Protective Factors contributing to the Presenting Problem. This is a great way of organizing your thoughts.
Did you know that you can give the biopsychosocial model a “systemic twist” to capture the client and family within their context, see the bigger picture, appreciate the interconnectedness of relationships, and assist clients to see the circularity of their challenges?
If this concept feels new to you and you are finding it challenging to break away from linear thinking, then read on to learn and practice some clinical tips and strategies to enhance your systemic hypothesizing skills.
View the “Identified Patient” as the barometer and thermometer for family life.
In Family Therapy there is the concept of the "Identified Patient". This is the person who is seen as "having problems" or "being a problem". This could be a teenager who is self-harming, a child who is school refusing, or an adult who is drinking heavily. They are usually the person seeking therapy, being dragged into therapy, or consistently being told that "you need help".
Family Therapists stay away from pathologizing people, instead looking at the bigger picture of family life and trying to hypothesize how this person's "symptoms" actually tells a story about what is happening in the family.
Some helpful questions to assist with your hypothesizing might include:
(1) What anxiety or tensions might be occurring in the family? And not just with the person bought to therapy.
(2) Are these symptoms an expression of anxiety and tensions in the family - now or linked to the past?
(3) Do these symptoms somehow protect the family from having to address other challenges? For example, if the family was not focused on this particular problem, then what other areas of family life would they need to address?
(4) When these symptoms started, what other events occurred around the same time? And not just related to the person brought into therapy. A common example is the "naughty child" but upon exploration is only naughty and troublesome when mum and dad are not getting along due to conflict.
So the next time that you are hypothesizing, what would happen if you thought of the client's symptoms as telling you a story? What if you considered their presentation as being a barometer and thermometer for family life?
The hypothesis must be systemic and relational.
In Systemic Family Therapy a hypothesis is only useful if it suggests interventions that will target the system rather than an individual, and which helps clients and families reach their goals.
This is often initially challenging for therapists to learn as most counselling and mental health training involves linear thinking - i.e. when “A” leads to “B” which leads to “C” for "John".
One small exercise to get you started with systemic hypothesizing is to think of the behavioural sequences around the problem.
How you do this is to be curious about "When John is upset, what happens next?", "What effect does this have on others in the family?", and "Who does what and when?"
For example, when John is upset his partner usually becomes worried which sees her increase her attention and focus on his needs.
This then allows for further exploration.
And when John's partner is worried about him and she increases her attention and focuses on him, what happens after this? And what effect does this have on the family? And who does what and when?
This curiosity continues until the client, family, and therapist start to appreciate the effect of "the problem" on the family system.
Give it a try and see what news of difference is created for you and those you are supporting. But remember....hypotheses about what is maintaining the problem is only useful if it suggests a useful intervention.
“Never marry an hypothesis – just flirt with it” (Ceccin, 1985).
Our brain has an amazing ability to "find" information that fits with our worldview and where we are focusing our attention. This is why Systemic Family Therapists hold their ideas tentatively and with curiosity.
Curiosity and holding ideas “lightly” provides the therapist with an openness to news of difference that may be more, or less, useful when working with clients.
How open are you to reviewing and revising your ideas in therapy? What mechanisms and processes can you put in place to hold this principle in mind?
Frame the hypothesis in positive terms for the client and family.
"If framed in negative terms, blame and lineal causal attribution may be introduced” (MacKinnon & James, 1987).
This is not to justify unhelpful behaviours and patterns, but rather highlights how you use language and describe your ideas.
For example, if you hypothesized that a coalition exists between a mother and teenage daughter against the husband/father, the systemic family therapist might frame this hypothesis as "It is a special bond that exists between mothers and daughters, and at the same time, when two people share such a strong connection it might not leave room for the other parent to share in the same delightful relationship with their child. I wonder if there is room for other strong connections to grow in the family? Between father and daughter? And perhaps husband and wife? This would make things feel more equal perhaps?"
Although the hypothesis relates to a family coalition, this language is too pathologizing and this jargon would not be used in contemporary systemic practice
How do you frame your hypotheses to your clients and families you work with? What style of language do you use?
To share or not to share....that is the question.
Historically, around 50 years ago, Family Therapists did not share their hypotheses with families. The prevailing framework at the time was for clinicians to hypothesize together and then instruct the family to do something different.
With the evolution of Family Therapy and the rise in social-political movements (e.g., Feminism), there has been a shift away from therapists being "experts" towards a collaborative and dialogical approach.
What does this mean?
This means that it is ethically and professionally responsible for the Family Therapist to share their hypotheses with their clients, and to seek feedback from the family about these ideas.
Engaging in this collaborative process is useful for strengthening the alliance, gauging if the therapist and family have a shared understanding, invites the family to shape the hypothesis further, and provides an opportunity for families to view “the problem" through a systemic lens.
How open are you about your ideas and hypotheses with your clients? What processes do you have in place that allows sharing of ideas?
Are you a practitioner that enjoys linking theory to practice? Are you interested in knowing who originally influenced systemic hypothesizing ideas and practices?
A key contributor was the Milan Systemic Family Therapy team.
The original Milan team was made up of four Italian Psychiatrists who greatly influenced the field of systems thinking and practice with key ideas related to circularity, context, hypothesizing, curiosity and neutrality.
Another key Milan Systemic influence was the use of a "team" in helping clients and families. This would involve therapists sitting behind a one-way mirror and observing sessions, being one step removed from the family emotional process so that they might offer ideas or suggestions to the therapist in the room or the family.
In contemporary practice it is challenging to resource multiple therapists, however, the idea of "holding a team in mind" is still valuable and can assist the systemic therapist to stay open to different ideas that may be useful to their clients.
Q: Have you ever had a mid-session break to gather your thoughts - as if you were consulting with a team?
Q: Which supervisor or colleague could you hold in mind when conducting a session?
Q: Have you ever said to a client and family "If there were a team of therapists here today, I wonder what reflections they would have about what we have discussed?"
Give It A Go
Give systemic hypothesizing a try and observe the impact this has on your clinical thinking, practice and work with clients and families.
By Dr Kate Owen
Clinical Family Therapist & Clinical Psychologist
Please note that this article is educational in nature and does not constitute professional advice.