Published online: 10 May 2012 Springer Science+Business Media, LLC 2012
Vladislav Chvála, Ludmila Trapková, David Skorunka
Vladislav Chvála, M.D., The Centre for Complex Therapy of Psychosomatic Disorders, The Institute of Family Therapy and Psychosomatic Medicine, Jáchymovská 385/25, 460 10 Liberec 10, Czech Republic, Europe, www.sktlib.cz, www.lirtaps.cz, email: chvala@sktlib.cz
Ludmila Trapková, MSc.,Clinical Psychology and Psychotherapy Outpatient Clinic, Ovenecká 34, Praha 7, 17000, Czech Republic, Europe, email: trapkova@mybox.cz
David Skorunka, M.D., PhD., Department of Social Medicine, Faculty of Medicine, Charles University, Šimkova 870, Hradec Králové, 50038, Czech Republic, Europe, email: skor@lfhk.cuni.cz
Abstract:
The article introduces a concept of social uterus as an integrative model of family development. The concept has been gradually developed in the last two decades of extensive clinical work with families with psychosomatic disorders and various chronic somatic diseases. It has proved its clinical validity particularly in the family therapy for the abovementioned problems presented by individuals and families. In the article, we first begin with a short description of our perspective on psychosomatic issues. We also give some information about broader context of psychosomatic medicine and family therapy in our country. Main part of the article is focused on the basic assumptions of the concept of social uterus. With regard to process of family therapy, both promising and controversial aspects of the concept are discussed. We conclude with some ideas concerning a need for collaborative health care in the treatment of psychosomatic disorders.
Keywords: social uterus, family, family therapy, psychosomatic disorders, separační proces, eating disorders
Introduction
It´s been more than thirty years ago when American psychiatrist George Engel (1977) called for a bio-psycho-social approach in medicine. In his opinion, narrow biomedical perspective was insufficient in both understanding and treatment of most diseases. He argued that psychological as well as social factors affected human health and thus had to be taken into account in the treatment. Emerging disciplines such as psycho-biology, psycho-neuro-immunology and affective neuroscience seemed to support Engel´s timely arguments. Knowledge coming from those new fields left no doubt about mutual connection between affective and cognitive processes and physiological processes in human body. On top of that, expanding psychotherapy research has been providing consistent evidence about efficacy and effectivenness of various “talking cures” for many health conditions (Lambert, 2004). However, knowledge built-up in such interdisciplinary fields has slowly been finding its way to clinical medicine and health care policy. At many health care institutitons, Engel´s claim is by no means less needed than three decades ago. Persistent reservation in academical medicine towards knowledge from psychological and social sciences is evident even after the first decade of the 21st century. Unfortunately, the consequences of fragmentarisation of knowledge and the emphasis on the biological perspective affect both patients and physician.
A good example demonstrating epistemological as well as clinical difficulties in medicine is a phenomenon of medically unexplained symptoms. This term has been used when a person attends a physician with physical symptoms that cannot be explained and/or objectified with various examinations. No adequate pathology with organic basis indicating a physical disease can be found. According to various studies about 20-50% of all patients seeking treatment in primary and/or secondary care who suffer from so called medically unexplained symptoms (Hotopf et al., 2001; Fink et al.1999; Reid et al., 2001). For those health problems other terms are used interchangeably; functional symptoms and somatisation. The latter is related to a category of somatoform disorders within ICD-10 and DSM-IV and rests on the assumption that emotional turmoil related to intrapersonal or interpersonal conflicts is manifested through somatic symptoms. No matter what term is preferred and used by clinicians, patients whose complaints are labeled by those terms are well known for an excessive use of health care both in primary and secondary care. Not only are numerous examinations, combinations of treatments and sometimes surgical interventions costly but they also result in iatrogenic harm. As McDaniel et al.(1989) point out, part of the problem is the process “whereby a physician and/or a patient or family focuses exclusively and inapproprietaly on the somatic aspects of complex problems”. The result is the frustration on both physician´s and patient´s side. Whereas the physician frequently deals with such frustration by detachment, labelling and referral to a psychiatrist, the patient very often gives up on mainstream medicine and seeks alternative treatment. These patients might feel like any other marginalised group in the society; alienated, rejected and abandoned by health care system they, in fact, are dependent upon (Griffith, Griffith, 1995).
Throughout our career, therapy with this group of patients constituted a significant part of clinical practice. In our community we are used to speak about psychosomatic patients and psychosomatic problems. Although we are aware of an ambivalent attitude towards the notion of “psychosomatic disorder” and its meanings in both public and professional community (Stone et al., 2004; von Schlippe, 2001), in preferring this term we relate to our local tradition and also to fruitful exchange with some colleagues from Germany, where psychosomatic medicine is well established. In our view, any health condition could be understood as psychosomatic for processes we used to attribute to either mind or body are actually intertwined, not separated like our disciplines, in which we usually study those phenomena out of context. On top of that, the course of an illness that fits well in classification of disorders like ICD-10 is affected by psychosocial factors too. This holds true particularly in case of long term health problems being coined by physicians as chronic that affect the quality of life of the person and usually also his/her family.
A consistent argument is being heard in psychotherapy community that people seeking psychotherapy most frequently present the therapist with problems in relationships, especially with significant people in their lives. As Barber and Wiseman (2004, p. 151) aptly say outside the realm of family therapy, „even when so-called presenting problem does not appear initially as an interpersonal one, much of what is recounted is in the form of relational stories.“ From our point of view, distress at developmental milestones and subtle changes in family dynamics during process of separation affect the course of not only elusive medically unexplained symptoms but alse diseases well established in classification systems like asthma, eating disorders, various algic syndromes and many others. We see the treatment of so called psychosomatic disorders as “treatment” of family relationships burdened by interpersonal dilemmas, attachment injuries and emotional traumas that occur inevitably during the development of family system. Studies unravelling the complexity of psycho-somatic mutuality (Kiecolt-Glaser et al., 2005) and growing body of research on family and health (Russel Crane, Marshall, 2006) provide us with encouraging support for what looks so obvious in the consulting room.
Broader context; psychotherapy and family therapy in the Czech Republic
Before we start to describe our integrative concept of family development, we would first like to give some information about broader context of both psychosomatic medicine and family therapy in our country. The situation of those disciplines may significantly differ from from the United States and some Western European countries, in which psychotherapy and family therapy has been firmly established. It may, on the other hand, be similar to other countries whose political regime is not based on democratic principles. Before 1989, development of humanities and social sciences including psychotherapy was curbed in the Czech Republic because of ideological reasons. Psychotherapy and family therapy were not accepted as activities having adequate scientific status. The idea of psychosomatic medicine that would be based on bio-psycho-social approach and application of psychological principles in medical treatment was considered similar to quackery. Only due to boldness and determined effort os some colleagues, important international connections were kept and at least limited access to proffessional resources was maintained literally behind the official authorities´ back.
After 1989, major political and social transformation of the country resulted in expanding civil liberties and emerging opportunities for a great deal of activities that were not possible before. Changes in society on various levels boosted development in many fields, including psychotherapy and family therapy. A new national organization called Society for family and systemic therapy (SOFT) was founded and it soon became a member of one of three chambers of European Family Therapy Association (EFTA). Coordination with development in European professional organisations led to institutionalisation of psychotherapy and family therapy. In this process, both training and supervision standards were adjusted to requirements that were established by and agreed upon by members of European Association of Psychotherapy (EAP) and EFTA. Fruitful communication with German colleagues from the psychosomatic medicine field encouraged development of professional psychosomatic community.
Despite apparent progress, several important steps have yet been made. At present, psychotherapy and family therapy is not regulated by a law as an independent profession. Only psychiatrists and clinical psychologists are eligible to provide psychotherapy and family therapy in health care, provided that they fulfill the qualification requirements. Limited budget remains the problem and so positions for psychotherapists as well as family therapists are scarce even though they are needed in units such as oncology, paediatrics and internal medicine. In psychiatry, family therapy is perceived as controversial and not considered as evidence based despite the compelling data available. The continuing global financial crisis brought about more economical cut-offs and increased uncertainty in public services. Consequently health insurance companies started to limit their reimbursement for psychotherapy and family therapy in health care.
Needless to say, the political and social changes affected demographic indicators and inevitably the family. The major changes are represented by decline of birth rate and marriage rate. In the 1990´, the birth rate in the Czech Republic dramatically dropped. The decline was caused by delay in constituting a family in the “demographically strong” generation that was born on th 1990´. It was this generation, that took advantage of new openning possibilities (study, career, travelling) after the fall of communist government in the 1989. Another decline was related to marriage rate. On one hand, people started to prefer living together and having children without getting married (cohabitating families on the increase). At the same time, the divorce rate has significantly increased in 1990-2010 (about 52% of all marriages) being it one of the highest among European countries. These changes may not surprise readers from Western Europe countries where they have been gradually occuring since the 1960´. However, in the Czech Republic some of these changes were hapenning suddenly and resulted in significant shifts in both family structure and quality of family relationships. The new possibilites in changing society emerged together with unforseen downsides. Increasing economical pressures, expectations related to new career opportunities and options for self-actualisation interferred with interpersonal procesess in the intimate space of family system. Mutual attunement among family members in particular seemed to be adversely affected with a consequence of both behavioral and health problems especially in childhood and adolescence.
We (VCH, LT) spent most of our careers as family therapists in this transformational social context. During the 1980´s a group of professionals from the County Hospital, the Psychosomatic Outpatient Clinic and the Centre for Counselling and Family Therapy started to meet. Their shared interest in the treatment of patients with so called medically unexplained symptoms resulted in the foundation of a team that in the beginning consisted of physicians with somatic specialities, psychologists and a sociologist. We found out that majority of those patients end up in primary care of their general practitioners usualy after a long and often unsuccessful journey through health care system for restoration of their health. In the 1989, a new institution was founded – The Centre for Complex Therapy of Psychosomatic Disorders – a rather unique workplace in the Czech context of transformation of health care. The treatment approach in the institution was primarily based on systemic family therapy but also integrated specific body oriented therapies and acupuncture. After a couple of years of team´s settling down and organisation of our services, the usual number of patients beginning therapy reached 800-1000 a year. In the beginning of our team work, a considerable proportion of patients were families with eating disorders. This specific clinical experience including unique family stories affected our professional career and shaped our ideas regarding health and family system. More than 20 years of clinical practice with more than 20.000 patients with a great variety of symptoms and health problems resulted in formulation of an original developmental concept. We named the concept social uterus and after several years it became well known on the national level in the psychotherapy and family therapy community.
Social uterus; a metafor for family development and guiding concept in family therapy
The concept of social uterus is a concept about individual and family development. Drawing on analogy with the intrauterine development of human being, we use a metaphor of uterus for the intimate space both mother and father constitute for the child in the family. The concept has evolved in the 1990´s. In this period of time our consulting rooms were literally flooded with families with eating disorders. We started noticing typical patterns in those families that were related to both development and symptom generation in the family system.
A great many analogies and metaphors for families´ troubles as well as possible solutions may emerge in conversations with families. A metaphor of social uterus ensued from the intensive “languaging” during the therapy process. It was certainly no coincidence. First of all, one of us (VCH) worked as a gynecologist and obstetrician for about 10 years before moving to psychosomatics and family therapy field. The other (LT) worked a long time as a child clinical psychologist. Both of us started to notice similarities between the intrauterine development of embryo/foetus in the mother´s body and later development from the childbirth to the period of gradual separation from the family of origin. The metaphor of social uterus resulted from a dialogue between a physician representing the medical knowledge and a psychologist representing the psychosocial knowledge. Our active role in conceptualising families´ difficulties was nevertheless based on careful observation and listening to stories of families´ we worked with. We can recall several occasions when we were surprised by hearing some family members´ commenting the relationship between another family members by the following way: “she/they act as if we/they were still connected through umbilical cord”.
After some time of fruitful exchange of ideas and then collaboration we came to a conclusion that those aspects of development well known in obstetrics seem to repeat again on a higher social level, in the family. During pregnancy, the embryo and then the foetus develop in the mother´s uterus through three distinctive terms – trimesters. In each trimester, various organs and physiological systems gradually develop until the pregnancy ends with delivery. The baby is not born immediately to the outside world with the ability to survive on its own. It is first born to both biologicaly and socially defined intimate space formed by mother and father. Similarly to uterus, which protects the human being in the first stages of development, the main purpose of the intimate space, the social uterus, is to protect the baby until it is mature enough to survive, understand and adapt to various life challenges. While the formation of vital organs and functions is enabled (or impaired) in the protective space of the uterus that is closely tied to the mother´s physiology, the development of so called “social functions” is enabled (or hindered) in the safe space of social uterus, the family.
The importance of the primary bond between mother and the baby is well known partly due to impressive body of knowledge about attachment(Cassidy, Shaver, 2008). At the same time, we have observed that the relationship between mother and baby is, at least partly, dependent on quality of other relationships. Mother´s own childhood experiences with her parents become a sort of foundation for her future parenting capabilities. On top of that, it is particularly the well balanced and emotionally satisfying relationship between both parents, the man and the woman, that we found essential for the emotional and social development of the child. The child both receives and respond to stimuli from the parents separately and so their contribution to the child´s development is equally important. At the same time, the child and then the adolescent is sensitive to the quality of the parent´s relationship. We see the relationship/partnership of the parents analogically like a “social placenta” of the family system. While in the intrauterine development the placenta provides the embryo/foetus with oxygen and the essential substances, the “social placenta” provides emotional “nutrition” that is absolutely necessary for healthy development. Not only is the emotional “nutrition” essential for development of various psychological functions, but it apparently affects the bodily processes (Schore, 2001).
When the baby is born, it initiates changes in the intimate space of the family through its development and through progressively expanding its affective, cognitive and relational capacities. In the sequence of developmental stages, some tasks must be accomplished before others in both individual and systemic (family) development (Erickson, 1993;Carter, McGoldrick, 1980). Emphasizing both individual and systemic (family) dimensions we mean that it is not only the child who goes through developmental stages but also the parents and thus the overall intimate space of the family. Here comes the analogy with the uterus again; the organ must grow accordingly to the growth of the embryo/foetus and the same counts for the social uterus. The quality of the parents´ relationship and mutual attunement to growing maturity of the child is an essential part of the adjustment of the social uterus to the expanding capacities of the child. Some aspects of this process could be best described in terms of oscilation theory (Breunlin, 1989). During the development, the child seem to continuously oscilate in-between of developmental trajectories of both father and mother. In some stages of development, the child moves closer to mother´s relational zone while in other stages to the father´s relational zone. Each approaching includes specific experiences and developmental tasks. For the healthy development of the child it seems necessary that child have a chance to experience the differences between the mother (woman) and the father (man) in affective, cognitive and interactional dimensions. Being with both mother and father provides the child with complexity of experiences based on polarities both biologically and socially determined. We see the differences in unique experiences with the mother (woman) world and the father (man) world absolutely essential with regard to the process of separation, which we call metaphorically as a social birth. After the social birth, if everything goes well, the young adult is able to function as emotionally secure, socially skilled person with clear sexual identity and propensity to care for the progeny.
In the end of pregnancy several indications inform about the more and more constraining conditions for further development of the foetus in uterus. Like contractions announcing forthcoming birth, more frequent conflicts between adolescent and his/her parents could be analogically understood as “social contractions” signaling the forthcoming “social birth”. However, specific relational conditions including emotional climate in the social uterus may hinder the spontaneous process of separation that eventually lead to social birth. During our work with families with eating disorders we first witnessed how those, metaphorically speaking “physiological” processes, may go awry. From the developmental perspective, eating disorder appeared as signals of difficulties in the process of separation with its culmination during adolescence. We have noticed that symptoms of eating disorder were often occuring simultanously with difficulties in a particular relationship in the family. For instance, in case of mental anorexia problems in the relationship between adolescent and the mother were observed whereas in case of mental bulimia the relationship between adolescent and the father was predominantly tense. If we were able to identify the particular relationship difficulties which the symptom seemed to be mostly “connected to” in the intricate family situation, we would focus on that relationship in the first place. Then we would try to encourage the approchement of those two family members (for example the mother-daughter relationship) so that the appropriate emotional “nurturance” sharing of important experiences would be possible. Improving the emotional quality and mutual attunement in the particular relationship during the therapy process made the treatment of the “disorder” more effective (Trapková, Chvála, 2000).
Initially, we thought of eating disorder as typical manifestation of separation difficulties occuring in the basic triangle mother, adolescent and father. After some time, we began to realize that the proces we observed was not specific to problems like anorexia or bulimia. The same conceptual “lens” could be used in family therapy not only for the treatment of eating disorders but for any psychosomatic symptom presented by individuals or families. This may appear as rather bold general conclusion but it should be clear that as family therapists we work on a systemically different logical level. In adopting systemic perspective we focus on symptom´s meanings in the psychosocial context of the family. In the treatment we do not join an individual family member but rather a subsystem of two members (or more) in the family who are in a mutual relationship. At the same time we focus on developmental dynamics in the basic triangle: mother – child – father. Not only eating disorder but any symptom like various algic syndromes including migraine, chronic fatigue syndrome, conduct disorders, addictions and so forth may be understood as signals of conflicts and emotional tensions during the process of separation in the family triangle. Anyone in the family can become a designated patient because of health problems related to separation difficulties or to any transitional period that increases both distress and demands for adaption for all family members.
We are aware that speaking about focusing on the basic triangle mother-child-father may appear oversimplistic in the light of a great variety of family forms we see these days. In the acceptance of and respect towards diversities in family structure that may as well be result of unintentional and unwanted events, we should not overlook problematic consequences certain family structures and dynamics may result to. Families we meet with are too often disrupted or the boundaries between relationships are blurred. Family members themselves are confused about who belongs to the particular family system and who does not. Combined with rejection of some family members or their disengagement from the family, the confusion and related emotional climate generate various problems particularly in childhood and adolescence. In medicine, the relational context is rarely taken into account in both assessment and treatment. In behavioral and social sciences, however, the data speaks quite clearly. Some surveys show evidence about the negative impact of less stable family structure (cohabitating step families) on the well being of adolescents (Brown, 2004). The trend towards less stable and more complex family structures has long been on the increase and consequences for children are striking: by the time a child is 10 years old, 8% of married parents and 43 % of cohabitating parents will have split up with following consequences: children not brought up by both parents have more educational problems, substance abuse, later debt and unemployment (Etherton et al., 2007; Wilson and Oswald, 2005). We would add, that health problems are among the consequences of those trends as they usually complicate the developmental processes including the separation.
In spite of a great variety of families, we cannot overlook certain natural relations that hold true across various cultures. For instance, it is the mother who gives the birth to a baby after conceiving him/her with the father. While the relationship between the father and the mother is acquired one, their relationship to their baby is a natural, biological bond. We tend to understand this as a basic axiom of all families that goes through generations. When the trend of growing split-ups, divorce and cohabitation becomes a norm, those aspects are frequently forgotten if not denied. Because of those family disruptions and reconstituations, the previously only centre of the family of origin has become diversified into multi-centered families with confusion between biological and “acquired” relationships. In work with these families consisting of confusing systems of stable and unstable triangles (Hoffman, 1980), we witness long-lasting emotional turmoil and distress with consequences on both psychosomatic and social level. Emotional distress and misatribution of meanings is likely to increase during the transitional points between various stages of family life cycle. Because of distress and new challenges the system generates various “symptoms” at moments of difficulties or developmental impasse.
With the biological analogy in mind again, we can call some of these difficulties metaphorically as “social miscarriages”, untimely “social births” and the like with all the possible consequences similar to those phenomena in the pregnancy, which can be fraught with many complications too. This could be rather daring hypothesis if we did not witness these processes through listening to trans-generational narratives of families we have been working with in more than past two decades. In some of those cases, we frequently had to assist in therapy to “social births” in two generations simultaneously when the parents were unable to fulfill their role for their children because they themselves struggled with emotional traumas experienced in relationships with their parents long time ago. Those traumatic attachment experiences are evoked again in time when the person, now adult and parent herself, has got a child. We have given a detailed account of those narratives in our monography (Trapková, Chvála, 2004). Having done that we follow those family therapists who in the past formulated the principles of transmission of emotional deficits and traumas through generations (Bowen, Kerr, 1988; Wirsching, Stierlin, 1982).
Being limited with the scope of this article, we would like to mention few ideas regarding our clinical work with the concept in mind. When talking about the process of separation and the social birth, we could easily see the family therapy process similar to delivery. During delivery, the role of the obstetrician and other professionals is not to stifle contractions but to attend to the woman and to intervene only then, when there are complications that could endanger mother and/or baby or both. If we understand the process of separation as the social birth then we see our role as mere guiding the family in the spontaneously occuring process. It means that sometimes, our role is only to support the frustrated an exhausted parents and give them both reassurance and ecouragement at moments that can be tough but that must be endured. In other cases, however, when the process seems to be stuck and the system generates various symptoms on either physical or psychosocial level, we try to set the process again in motion by carefully supporting the appropriate oscilations in the basic triangle mother- adolescent-father. In all cases we must be well oriented in both the complex relationships of broader family and the transgenerational narratives.
With families, whose problems seem to be complicated and long-term, we usually work as two co-therapists, male and female. This setting allows us to take advantage of both our biologicaly and gender based differences in how we cognitively and affectively experience various family issues including parenthood and partnership. For some families, we might as well function a “transferential couple” that mirrors the male and female experiences and that serve a “binocular lens” regarding various dilemmas in the family. This way of working could be likened to “stereo receiver and output” providing richer perspective on families experiences and narratives. In our experience, this way of work often helped to improve both the therapy process but also the collaboration, mutual engagement and attunement in the families.
Although we integrate psychodynamic, structural and transgenerational ideas in our systemic framework, in conversations with families we often, if not always, apply narrative approach. In general, it means careful listening to diverse and sometimes contradicting family stories and bringing forth those narratives that have the potential for hope and change (Skorunka, 2010). Specifically, we learned to apply both externalisation and letter writing through collaboration with Torben Marner (2000) according to narrative therapy developed by White, Epston (1990). Particularly the externalisation combined with the concept of social uterus enabled us to sensitively intervene with respect to complexities of development of the family system. If the therapy went well, then relationships in families improved and symptoms seemed less troubling and sometimes even disappeared, no matter whether they were considered medically unexplained or not. It goes without saying that it is not only our way of work that was accountable for this process. The outcome of the therapy depends on resilience, readiness and potential to change in the particular family. Some family lines seem to be so emotionally exhausted because of traumatic events and emotional deficits in the previous generations so that progeny is hindered and even appear unlikely in the current or subsequent generation. We see our role in either helping the families to find the capacity for recovery and restoration of health or in accompanying them with respect to unchangeable reality.
The concept of social uterus helps us with orientation in bio-psycho-social structure and dynamics in complex family systems. Unlike descriptive nosological categories that may be insufficient for understanding of the living systems´ dynamics, the concept enables us to capture the seemingly incomprehensible but mutually related psychosomatic and psychosocial processes. In this respect we found Maturana´s (1987) notion of autopoietic processes well fitting with what we regularly see in our practice, the complex family system resembling in some aspects dynamic living organism. From a perspective of chaos theory, ordered movements can be discerned in the otherwise unpredictable, non-linear evolvement of dynamic systems including family (Prigogine, Stengers, 1984). The concept of social uterus helped us considerably to “feel” such movements in family therapy sessions so that we could use them as orientation marks in the therapy process with the families.
Clinical validity of the concept and supporting research
When formulating our concept for publication purposes in the past and presenting it to various audiences, we realised that it shares similar aspects with other influential concepts in family therapy. For instance, our observation of both “hunger” for affection and need for structure in the development of interaction in triangle of woman-child-man overlaps with Bowen´s (Bowen, Kerr, 1996) notion of family as emotional system and his transgenerational perspective on the process of self differentiation and separation. In contextual therapy developed by Boszormenyi-Nagy (1973) with its emphasis on fairness, caring and accountability in family relationships we found another concept partly corresponding with our clinical experience. It fits well with our observation that patterns of relating laden with imbalance between affection/caring and obligations/responsibility are passed on from generation to generation often with detriment to family fucntioning and family members´ health. In adopting the transgenerational viewpoint we do not suggest that earlier generations should be blamed for causing current family problems. Rather we see historical patterns of family emotional functioning and particularly patterns of separation difficulties as important context for our understanding of both individual and family functioning, including their health conditions. The available research that provides some evidence of such interrelation is encouraging and at least partly alleviate our concern about being inappropriately biased (Grames et al.; 2008; Klever, 2003; Harvey et al. 1991).
Another supporting arguments come from Minuchin´s et al. (1975)research on so called psychosomatic families and his seminal concept of structural therapy. The notion of child´s triangulation in parental conflict that often lead to behavioral or health problems is in accord with our experience. Although it may be an adult family member who signals developmental difficulties in the family systems, we mainly observed that it was a child and/or adolescent who was brought to therapy for various mental or physical problems and whose emotional tension was manifested in physical symptoms including syndromes that could be classified in the ICD-10 or DSM-IV like, for instance, eating disorders or somatoform disorders. Not only representatives of structural family therapy but also therapists who integrate current attachment theory with systemic thinking describe triangulation as frequent phenomena in family therapy practice (Dallos, 2004; Dallos, Crittenden, 2009). Research on attachment also provides sound knowledge about important subtleties in family relationships, albeit they are described in terminology that differs from ours. For instance, some studies on attachment informs us about fathers´important contribution to child development in terms of their secure attachment, their ability to both connect to and explore the outside world, and to develop peer relationships (Suess et al., 1992; Verschueren, Marcoen, 1999). It provides so called scientific evidence on what we see lacking and what we try to encourage in collaboration with some families – the fathers´ vital influence and his appropriate engagement in relationship with both partner/wife and with their children according to developmental needs.
A link between father´s involvement and child´s ability not only to “survive” but also “flourish” in the outside world seem to by supported by research in developmental psychology and linguistics. For instance, Glaeson´s (1975) theory of bridge emphasises that linguistic interaction with the father is more challenging for a child than with the mother. Šulová (2005) givesin her review of research on early child development detailed account of knowledge from psycho-linguistics. Some of the research have been carried out in the 1970´ but we found it supporting our clinical observations twenty years later. According to those linguistic analysis´ father is said to be a more difficult conversation partner: he uses less usual words and expressions more difficult to understand, he has more complex requests, he uses indirect hints more often as if to offer logical challenges to child, he seems to care less about continuity of conversation with a child when compared to mother. Overall, father tends to be more cognitively challenging, directive and even somewhat authoritative in both conversation and play. Those linguistic variables seem to support the idea of father being a bridge between accepting environment inside the family and more demanding enviroment outside of it. Thus it is easy to understand father´s role as an important initiator of process of separation. Nutno poznamenat, že máme na mysli kvalitu mateřství a otcovství, nikoli konkrétní postavy matky a otce. Jsme si vědomi toho, že oba rodiče disponují takmé opačnými genderovými kvalitami v komunikaci s dítětem. Z hlediska dítěte je však výhodnější, když biologická žena/matka je především mateřská a biologický muž/otec je především otcovský.
Reflections on concept´s limitations and controversies
No matter how consistent a theory appears and how it looks useful in clinical work, in the current context of evidence based practice we must acknowledge our concept´s limitations. The lacking evidence coming from both process and outcome research is undoubtedly one them. Although the statistics (Trapková, Chvála, 2000) have shown impressive results of family therapy based on the concept of social uterus with some families, we cannot hold it as satisfactory evidence about the conceptual clinical validity. On the other hand, we like the idea of practise based evidence, which we understand as validating the stories and experiences we co-construct with families in the consulting room that should inform family therapy research. In advocating for sharing our experience and its evident value for building our collective understanding we give clear message about our stance with respect to Jerome Bruner´s notion of balance between paradigmatic and narrative knowing.
Nevertheless, in sharing our experiences we frequently trigger off interesting discussions with both curious questions and critical comments. One of the common argument comes from colleagues informed by femminist critique. They argue that our notion of male and female language/principle in the family legitimise gender differences that are primarily culturally based and which result from traditional patriarchal structures and practices persisting in our society. We certainly do not advocate for rigid roles in the family, unequality of power and stereotyped, culturally sanctioned view of men and women. Nor do we deny the influence of culturally shared discourses on our understanding of various aspects of family life. We do, however, assume that things may have gone too far in denying important differences between men and women. In our view, ignoring both fathers´and mothers´ unique contribution to child´s development, particularly to development of interpersonal skills and identity formation including its psychosexual aspects, contribute to various problems families present to us. These subtle family dynamics reflect general decline in what Schultz-Hall (2001) and others consider to be valued differences in both men´s and women´s experiences and ways of “relating to” and understanding of the world.
Other arguments emphasise that our concept neglects the cultural differences in family. We agree that generalising our experience with Czech populations to other cultures with diverse expectations and customs regarding family functioning would be inappropriate. On the other hand, we tend to assume that universal processes related to development could be observed and described. The knowledge of such universal procesess could inform our psychotherapy and family therapy practice and, hopefully, improve the outcome. The vast body of research on attachment is similar in this respect as it describes necessary prerequisites for maturation and healthy development (Cassidy, Shaver, 2008). Other scholars in the same field have made considerable effort to develop assessments that could make psychotherapy approach sensitive to those universal procesess and to both individual´s and family´s developmental situation (Crittenden, 2008). The argument about cultural differences is sometiomes mentioned with a critical remark that our concept is too normative. Although we are careful not to make any prescriptions of what should or should not be done in the family, we do not think of being normative as something essentially flawed. When we speak about prerequisites for healthy development we understand the notion of “normative” as Rivet and Street (2009, p. 31) who speak about normative circumstances as “frequently occuring events in any given culture that many, if not most, families will encounter throughout their life, despite the variety and diversity of families in today´s world”.
Critical comments sometimes come from colleagues who found inspiration in postmodern philosophy and social constructionism including one of the authors (DS). An idea of male and female language/principle residing in male and female respectively seem rather old fashioned at times when dramatic social changes resulted in blending of qualities that were attributed to either men or women in the past. The impact of discourses disseminated through media on our understanding of various aspects of human life, including fatherhood, motherhood and health is also without question. What´s more, if we move from a social level to a consulting room with the same social constructionist lens, than we just cannot be so sure whether in applying the concept we just observe or interpret our understanding of both difficulties and interpersonal dynamics in the given family. Even if we see the theory of social construction as useful metaposition, it seems insufficient when we make distinction between reality and realness like Flaskas (2002) and between reality that can or cannot be negotiated. For instance, almost any meaning can be ascribed to events, behaviors or symptoms in the family. Yet having a biological father and mother is a fact, even though one was being brought up by foster parents. The contribution of biological parents is unique to one´s life story even though they may, for various reasons, stay disconnect from one´s life. If one loses loved ones because of absurd display of violence, the extreme experience and the tragic consequences goes beyond any construction. In the similar vein, the idea of developing new, alternative story by thorough revision of constraining social discourses seems rather naïve regarding various bodily experiences, which we see difficult to alleviate by mere co-construction of meanings in language. Needless to say, theory of social construction and narrative informed approach enriched our work with families. For all that, we should not forget about biological aspects of our existence.
Last but not least, we are aware that efforts to link patterns of family dynamics with health problems were in the past frequently criticised as being overly simplistic and potentially family blaming. We agree with Dallos and Crittenden (2009) that as family therapists, we are in a difficult position here because, as they say: “we wish to work alongside families in nonblaming manners but at the same time we may need to acknowledge that family members sometimes also act with each other in ways that result in unintended distress and trauma” (Dallos, Crittenden, 2009, p. 400). What we also consider important is the ability to accept not only all family members but also their contradictory and even competing narratives. Just knowing is not enough here as it may keep us distant from the family. We also see the pitfall that we, as family therapists, may end up being paralysed by fear we may hurt and thus not being able to carefully observe, sensibly hypothesise, and sensitively intervene. It is, after all, our responsibility for how we communicate with families about both our process related experiences and ideas and whether our intention is to be helpful in collaborative way or to present ourselves as the overconfident experts who know the “truth”.
In spite of the abovementioned limitations and controversies, we are repeatedly surprised how many of our colleagues acquire our concept in their clinical practice. In the feedback during their supervision they tell us how the concept proved its usefulness for both organisation of information given by families and impressions/observations from family sessions. For some it also provides solid framework for understanding of various procesess in the family system including the biological aspects. To keep a balanced view, however, we must admit that what makes sense to us may be confusing or even implausible for others. When we conceptualise family metaphorically as social uterus and draw relations between language variables, affective proceses and health in the family, we merely speak about correlations. Only strong belief in systemic procesess and circular causality and a community of supporters are hardly sufficient these days. It is also ethically questionable. Thus further research would be needed to give sound evidence on what we experience in our work with families and what we tried to describe in our concept.
Conclusion:
In the concept of social uterus we integrate both biological and psychosocial perspectives on family development and health. On the basis of our clinical experience we see mutual connection between emotional processes, developmental issues and family distress leading to generations of symptoms in the family. Drawing on the bio-psycho-social model, we use the term psychosomatic disorders to emphasise the interconnectednes between psychosocial and bodily processes. The metaphor of social uterus has been particularly helpful for our family therapy practice with families with so called psychosomatic disorders, including both conditions classified in the ICD-10 and/or conceptualised as so called medically unexplained symptoms. In combination with narrative means such as externalising conversations and letter writing, we use the concept of social uterus as a framework for collaboration with families struggling with both health relational issues during the development.
In the light of our experience with families, we cannot be blind to drawbacks of current, fragmentarised, health care system in which the biological perspective on health, illness and the treatment is emphasised. In such system, important psychosocial factors tend to be neglected with the detriment to the designated patient as well as the family. The biotechnological advancement in medicine resulted to improved treatment for many patients. At the same time, however, the enthusiasm about biotechnological progress reinforces the idea of mind-body dichotomy and the notion of body as machine that could be fixed when broken down. Listening to stories and sharing emotionally charged experience does to seem to fit to biotechnological world. However, it is often sharing experiences, listening and narrating, what patients lack in health care institutions. In our vision of collaborative health care we coexistence of both biological and psychosocial perspectives necessary. Treatment based on interdisciplinary team approach is the option for some patients whose problems must be perceived from multiple perspectives. The capability to see patient´s health problems in context and engaging family as a partner for collaboration could be seen as prerequisites for complex treatment many patients would benefit from.
Acknowledgment:
Although the article is a joint project and the pronoun we is mainly used in the text, a clarification regarding the authorship should be made. The original concept of Social Uterus described in the article has been developed by Vladislav Chvála and Ludmila Trapková. Once a trainee in the family therapy training run by a team of supervisors with those two senior colleagues taking the lead, David Skorunka applied the concept in his psychiatry and family therapy clinical practice. He has also been including the concept in his teaching about family therapy, narrative approach and psychosomatic medicine and thus received fruitful feedback from both Czech and international students in the undergraduate programs in medicine and psychology.
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