Barbara Fraser, Linda MacKay and Lu Pease
Private practice.

The following article was written by Dr Michael Kerr in response to questions put to him by Barbara Fraser, Linda Mackay and Lu Pease when he visited Australia two years ago. These three family therapists took it upon themselves to prepare this interview in recognition of Dr Kerr’s unique vantage point on Bowen Theory and family therapy. Michael Kerr was trained by Murray Bowen in the 1970s and subsequently went on to work as faculty at the Georgetown Family centre. He succeeded Bowen as director of the centre where he has devoted his professional life to the understanding, application and extension of theory. He is the co-author with Dr Bowen of Family Evaluation: An Approach Based on Bowen Theory (Kerr & Bowen, 1988), which remains the most esteemed text on this theory. He is also the editor of Family Systems: A Journal of Natural Systems Thinking in Psychiatry and The Sciences. Bowen’s Family Systems Theory grew out of years of research from the 1950s-1970s, which included observations of inpatient families with a schizophrenic member and using data from Bowen’s own interactions with his family of origin (Bowen, 1978). The theory continues to be influential in family therapy, with its most well-known contributions being the process of triangling, the intergenerational transmission of family patterns and the concept of differentiation of self. (Brown, 1999). The following discussion from Dr Kerr brings a fresh perspective on the current applications and developments of this systems theory.

Has Bowen family systems theory and therapy evolved and how?

The same eight concepts comprise Bowen theory today that comprised it at the time of Bowen’s death in 1990. However, I am in the process of proposing a new concept: the unidisease concept. It is an extension of an idea already in the theory, namely, that psychiatric, medical, and behavioural symptoms all reflect the same underlying family emotional processes. My family research along with the work of others convinces me that not only is this idea in the theory accurate, but medical research is also showing that many of the same physiological processes underlie all clinical problems; for example, chronic inflammation plays a key role in most diseases. This existence of common family relationship as well as common physiological processes makes it important to elevate the idea into a distinct concept. Most importantly, the intensity of the emotional process appears to better predict clinical outcome than the particular diagnosis itself.

Another major area of progress on theory has emerged from ‘viable contact with the accepted sciences’. I put this phrase in quotes because it was Bowen’s charge to all of us as a way to keep family theory from becoming a closed system. In other words, by people interested in the theory being constantly exposed to new facts from other relevant academic disciplines, it challenges us to see if the facts support or contradict the theory as it is currently formulated. ‘Theory can be changed by facts alone, not personal opinion’ is another Bowen quote. The nature–nurture debate is resolving in favour of nature and nurture being an interactive system. This is consistent with Bowen theory. If it were not consistent, the theory would have to be changed.

The principal progress with the therapy has developed from more clinical experience with the process of differentiation, both in the nuclear and extended families. In the early days, despite Bowen’s vigorous statements to the contrary, most of his students yearned for techniques on how to differentiate more of a self. ‘Dr. Bowen, I am going home to see my parents, can you tell me how to differentiate from them this weekend?’ It sounds simplistic, but Bowen fielded many such questions. Hard-earned personal and clinical experience on the part of many of us over the 30 years since the idea of differentiation of self in one’s own family was introduced has confirmed that differentiation is a way of being that grows out of a way of thinking. No shortcuts exist. People must think more objectively about their families and then act consistent with that new view. It takes time, but theory provides the lens that makes it possible for people to get beyond blaming their families or blaming themselves.

What would Dr Bowen say about family therapy today?

Bowen believed that the most important contribution of the family movement would be the new theory of human behaviour, not the new method of therapy. The application of natural systems thinking to human emotional functioning is an original idea in mankind’s intellectual history. Bowen’s view does not discount the theory’s relevance to people’s everyday lives, but the implications of the theory extend far beyond the personal. It can potentially alter how human beings perceive themselves and their relationship to planet Earth.

The family movement surfaced in 1957. The most important discovery was that the family must be considered as an entity in its own right. This means that individual theory is inadequate for explaining family processes. Within a short time, pioneering therapists began treating families. Unfortunately, while many of the pioneers developed some family concepts, the potential of the new discoveries being the basis for a new theory of human behaviour was largely lost. Bowen and Don Jackson were unusual in maintaining a focus on theory as well as therapy. An explosion of approaches to family therapy has characterised the decades since the 1960s, with groups splitting into schools of therapy on that basis.

Societal forces have also had a significant impact on the family movement. I refer to the family movement as suffering from a ‘failure of nerve’. It has wilted in the face of the biological paradigm that has come to dominate psychiatry and allied mental health disciplines since the 1970s. Those claiming biological causes for mental illness assume that the family research that implicated the critical role of family relationships in the development of schizophrenia is now invalid. Psychiatry pretends to be more ‘scientific’ than it really is, but its emphasis on biological causes has put family therapists on the defensive. Other societal forces, such as health care’s growing focus on quick fixes and symptom relief, have also undermined interest in a more complex systems understanding of human problems.

I believe that family research, based on its larger systems perspective, can lead rather than follow. It requires conviction about the value and accuracy of applying natural systems thinking to human behaviour to stand up to people who cling to cause-and-effect explanation. The science is there to merit viewing mind, body, and relationships as an integrated whole.

There is a view that Dr Bowen died before his theory was fully appreciated and that he was so passionate about his approach that he believed it would become the next ‘theory of humanity.’ What is your view?

My response to the last question addresses my view. Dr Bowen often commented, ‘I know within me that the theory is accurate’. Bowen could be emotional — passionate if you will — but his primary effort was to develop a theory of human emotional functioning that could eventually become a science. It required an effort to construct a theory based on facts alone, not personal opinion. He used systems thinking to combine knowledge of Homo sapiens as an evolutionary being, with facts about human behaviour drawn from many disciplines. No one has ever done that before. Individual theory still dominates the culture, and many serious students of Bowen theory mix ideas from individual theory with Bowen theory. The accumulation of factual knowledge will eventually determine the accuracy and thus influence of Bowen theory. For now, each of us must do enough serious observing and considering of our own emotional functioning and that of others to be sufficiently convinced to let go of individual thinking and move all the way to the systems paradigm.

As a ‘protégé’ of Dr Bowen, have you forged your own views of family systems theory and therapy? What are your conceptual departures?

When I returned from two years in the Navy in July 1973, Dr Bowen told people that I knew the theory as well as he did and I probably did the therapy better than he did it. He was wrong on both counts, but that was 35 years ago. I do not believe that I had the capacity to originate a new theory, but Bowen developed a theory that could be successfully transmitted to the next generation. Some others and I have now learned the theory and therapy well and may match Bowen in those regards. Four primary elements have contributed to my progress: (1) the long-term association with Murray Bowen, (2) clinical practice, (3) writing Family Evaluation, other book chapters and journal articles, and various research projects, and (4) using theory to tackle emotionally difficult issues in my nuclear and extended families. These have all been exercises in being more of a ‘self ’, personally and professionally.

As I said in response to the first question, I am attempting to extend Bowen theory with the unidisease concept. I am also trying to extend another idea in the theory, emotional regression, to the level of cellular relationships. Aggressive cancers and other clinical conditions may be propelled by regressions in cellular system functioning that parallel regressions in family system functioning. I am attempting to extend the theory in these ways, but have no differences with the basic ideas Bowen developed. Always there is the risk of learning to see things in a particular way and thus being oblivious to other ways of looking at things. I try to deal with that risk by being on the lookout for facts that may not fit with the theory. I also try to listen carefully to people with the expectation that they may see something that I do not see.

How is Bowen family systems theory misunderstood approaches?

The three most important and common misunderstandings of Bowen theory are: (1) it is primarily a therapeutic approach, particularly to the family of origin; (2) it is a theory anchored in psychological processes; and (3) the concept of differentiation of self. I have adequately addressed the first of these three points in earlier questions. I have touched on the second point, but it needs some elaboration.

Descartes not only reinforced the mind–body split, but also reinforced the idea that mankind is categorically different from other forms of life. The Enlightenment period successfully challenged all of the human species differences with other species except his behaviour. Darwin moved powerfully to include human behaviour as part of mankind’s evolutionary legacy. Freud included mankind’s instinctual nature in his theory, but emphasised human psychological processes and included enough subjectivity that his theory is not easily extended to other species. I set this historical context because it may play a role in how quickly people assume that Bowen theory is yet another psychological theory.

Perhaps the misunderstandings of differentiation relate to it being counterintuitive. The emotional/feeling/subjective side of human nature can be so compelling, especially if anxiety is up, that differentiation can seem almost alien and even destructive. The consternation about differentiation in the family movement was rampant when I came on the scene in the late 1960s and it has remained so. People respected Bowen and claimed to have incorporated many of his ideas, but differentiation was a problem. Many of those who said they incorporated it did so by distorting what it meant. One comment that I heard from a prominent family therapist was, ‘Poor Murray Bowen differentiated from his family, but now he has no family!’ It was a joke, but one often taken seriously.

Another problem with differentiation is that people can learn what it is, but it is never adequately explained. People can get acquainted with the idea from reading and listening to others, but people still have to see the undifferentiation in their own lives in its myriad manifestations to grasp it. We are all a lot more emotionally immature than we would like to think. Emotional immaturity comes in so many deceptive packages, such as ‘helping others’. We often try to ‘help’ others to relieve our own anxiety about their distress. It is hard to appreciate the depth to which anxiety runs our lives and the myriad ways we try to deal with that anxiety that are out of awareness.

What would a clinical session that included children look like?

I occasionally see whole families, parents and their symptomatic child, assorted other combinations of family members, and sometimes a few sessions with an adolescent when I am also seeing his parents. Most of my clinical sessions, however, are with one person or with a husband and wife. This is the case even if the presenting problem is a symptomatic child or adolescent. No matter what assortment of people I am seeing in a session, I call it family therapy because my therapy is guided by family theory, not individual theory.

There are two reasons I do family therapy in this way: (1) the view that families function as emotional units, which means that a change in one family member is followed predictably by changes in all other members, and (2) progress on differentiation of self is most likely to occur if one person or a marital pair is being seen. When parents are seen with one or more children — and I have tried this in the past — it is difficult to keep the focus of a session off the child and it is easy for the parents not to take a serious look at their own functioning, hoping the family therapy will change the child. One person hoping the other will change can also occur when seeing a married couple, but that is easier to manage.

I did not arrive at this approach without some ambivalence. I did two years of a Fellowship in Child Psychiatry. We used the standard child guidance model in which a social worker saw the parents and a child psychiatry fellow saw the youngster. The majority of youngsters manifested improvement in their symptoms. I am glad that I did the fellowship because it gave me a concentrated experience with kid problems. It also convinced me that the people with the motivation for something to change were the parents sitting in the waiting room, not the child in play therapy. A child may be distressed, but that is different than accepting responsibility for doing something about the problem. It is realistic to expect change in a dysfunctional child, but unrealistic to expect him to take the lead on a process that will lead to change. That responsibility lies with the parents.

It is common for people to voice concern about not seeing a child in therapy if the child is having significant symptoms. A common view is that the child needs to talk to an interested and supportive person about his distress. Parents often think that they cannot provide this for their child. I tell the parents that if they can function with more of a ‘self ’ with each other and with the child, they will become an enormous resource to the child, more of a resource than a therapist can be.

Dr Bowen’s view is that only interested members of a family who attend therapy can promote change. Is that still a central assumption?

I distinguish between ‘change’ and ‘progress.’ I reserve the term ‘progress’ for a family system becoming more adaptive, meaning that a system has become better able to manage life stresses that could potentially trigger symptoms. Bowen theory holds that an increase in basic level of differentiation is the process that brings this about. However, symptoms, even severe ones, can improve without a system becoming more adaptive. For example, a person may stop drinking after a divorce. This typically reflects an increase in functional level of differentiation rather than in basic level. I am not suggesting that basic level change is ‘better’ than functional level change — drinking more in moderation is usually a good thing — but basic change (progress) is different than functional change.

That said, ‘interested’ family members may the ones motivated for family therapy, but they may be blaming others and more interested in getting others to change rather than taking a serious look at their own immaturity. Trying to get others to change is not being a family leader. Bowen often used the metaphor of a team of horses: ‘Watch a team of horses: one horse steps out first and the others follow’. This is analogous to the process of differentiation of self. The success of family therapy depends on the emergence of a family leader. This is a person who comes to understand better his or her part in the relationship system problem and is willing to do something about it. They give up hoping others will change, not out of anger or guilt, but out of the conviction that they are part of the problem and thus part of the solution. Ideally, different people can use theory to take the lead at different points in the life of the family.

What is the empirical support for Bowen family systems theory’s effectiveness across cultural and class and racial differences?

The issue of empirical support for the effectiveness of family and other types of therapy is always a difficult one. I have already talked about the difference between basic change in a system versus symptom relief. No one has yet figured out a way to ‘measure’ basic change. Cognitive therapy is cited frequently these days as having empirical support, but its effectiveness is gauged largely by assessing symptom relief. The famous Canadian physician, Sir William Osler, is quoted as saying (paraphrased), ‘Once you find a new and effective therapy, use it quickly before it loses its potency!’ Osler was keenly tuned into the impact of mind and relationships on clinical problems. He was talking about placebo effect, which is well established to be strongly influenced by beliefs and relationships that reinforce those beliefs. I mention all of this by way of acknowledging that no empirical support exists for Bowen theory being effective across cultural and racial lines, but measuring the effectiveness of any therapy is complicated by myriad factors that promote symptom relief, such as having a comfortable and open relationship with the therapist.

When people ask the culture question in meetings, frequently a distinction that the questioners fail to make is that between content and process. For example, content is what people fight about, process is the fact that they fight. Darwin’s book, Expression of Emotional in Man and Animals, demonstrated the universality of basic human emotions and how they are expressed. The assumption in Bowen theory is that the basic patterns of emotional functioning, such as emotional distance, emotional conflict, and triangles, are anchored in the emotional system. Since the emotional system is a product of evolution, theory predicts that the basic emotional patterns will be present in all human families. I have not seen an exception to this.

Two examples questioners frequently ask about Bowen theory not applying to a particular culture or group pertain to oriental cultures and lower socioeconomic families. The oriental cultures are described as emphasising ‘togetherness’ over ‘individuality’, the latter being seen as a characteristic of American and some other Western cultures. Bowen theory is claimed to be ‘too intellectual’ for lower socioeconomic, multi-problem families. Both of these views contain important misconceptions about Bowen theory and how it is applied in therapy.

Time does not permit addressing these misconceptions in detail, but, in the case of oriental cultures, people confuse individuality (differentiation) in Bowen theory with ‘rugged individualism’. Individualism, like rebellion, is a coping style that is unrelated to basic level of differentiation. Differentiation is reflected in the variation in levels of emotional functioning (roughly, emotional maturity) that exists in every culture. Every culture has its better functioning and poorer functioning families. Oriental families are not an exception. As for multi-problem families, the confusion here rests in how Bowen theory is applied in therapy. If you ask the members of a multi-problem, poorly educated family a few theory based questions about triangles, they will describe how triangles play out in the families. Once described, the family members then face the same problem all family members face: can someone get beyond blaming the existence of the triangle on the two other people? You can lead a horse to water, but … A formal education is not required for getting beyond blame. Lower socioeconomic families have their more and less thoughtful members, just like upper socioeconomic families have. It is difficult for many therapists (and the institutions in which they work) to get beyond trying to ‘fix’ a family and to keep the responsibility for progress on the family.

Dr Bowen’s ‘Anonymous paper’ still evokes a strong response from students about his own efforts with his family. Did he continue to talk about it and build his theory from this?

Bowen made the presentation that is the basis for the paper about his efforts in his own family in the spring of 1967. He began talking to trainees about it not long after that presentation. This led in the late 1960s and 1970s to meetings being dominated by a focus on differentiation of self in the family of origin. He presented about his family many times through that period and continued to do so until he died. In the 1980s, Bowen and the Georgetown Family Centre shifted to a less overt focus on the family of origin and placed more emphasis on linking theory to the natural sciences. Bowen thought that theory was getting lost in the rush to focus on the family of origin. Many people were ‘coaching’ people to make efforts in their family of origin, but many of the ‘coaches’ did not grasp the importance of theory to the effort. Differentiation of self in the family of origin (and the nuclear family) remains a cornerstone of the Bowen Centre’s training and clinical activities, but it takes its place along side making viable contact with the accepted sciences.

Dr Bowen and I made a videotape in the Bowen-Kerr series in about 1980 in which he asked me what I considered most important in the effort towards differentiation of self and applying systems thinking to human behaviour. I emphasised the effort in my own family as being central. Bowen responded by saying that was less the case for him in recent years. He emphasised the value of projects that demand ‘theoretical thinking’ for progress on differentiation. As I said in response to an earlier question, both areas remain extremely important.

I have not read the ‘anonymous paper’ for quite a few years, but I listened not long ago to an audiotape of the presentation he made in 1967. A tone comes across in the verbal presentation that does not come across as well in the written paper. It is important because I think the tone captures something that is often missed about efforts in the family of origin. The tone is emotional neutrality. Emotional neutrality derives from applying systems thinking to oneself and one’s family and being convinced that it is the most accurate way to understand what is playing out. Absent that view, people easily fall into blaming others or blaming themselves for the difficulties that exist.

How would you distinguish your differentiation journey from that of Dr Bowen?

The simplest answer is that I had a coach and he did not! I sometimes referred to him as the ‘uncoached coach’. He was guided by deep and hard-earned conviction that his new theory offered a more accurate and useful explanation of human behaviour than Freudian theory. Skilfully diagnosing various members of his family had contributed little to him or them. He used a theory he had originated to guide him.

Increasing basic level of differentiation is the same basic process for everyone who undertakes it. Individuals and families differ in myriad ways, but the undifferentiation in families is analogous to the laws of gravity applying throughout the cosmos. Some stars are more intense than others, but all stars are in the business of fusing hydrogen atoms into helium atoms. People have different degrees of fusion in their families and different perceptions of it, but all everyone is fused into his or her family. Everyone’s efforts thus have much in common. Emotional process is emotional process. Appreciating the simplicity and universality of it all is humbling, exciting, and calming.

One point I would like to add here is the value in having a spouse who becomes a serious student of Bowen theory. (I am not talking about the all too common problem of one spouse trying to sell the other spouse on Bowen theory!) I began coaching with Bowen near the end of my second year of psychiatric residency. Progress in my family of origin contributed to progress in my then 4-year-old marriage as well. My wife, Kathy, did some of the predictable, ‘You’re wrong, change back, if you don’t, these are the consequences’, and I thought that this differentiation thing was great stuff. Not long after my early efforts, Kathy developed a coaching relationship with Bowen as well. She made her own efforts in her extended family — and with me. I reacted predictably to her change. It was humbling.

I mention my wife’s effort just to emphasise that differentiation depends on seeing one’s undifferentiation and the undifferentiation in the family system. It is difficult for one person to see it all or even most of it. Her efforts to separate a self from me and in the family triangles with our children have contributed significantly to my understanding of differentiation and other concepts in the theory.

Can you explain in terms of Bowen family systems theory your conceptualisation of your working relationship with Bowen; that is, Bowen is the oldest of five and you are the youngest of four?

This is obviously such a complex question that it is difficult to address it briefly. Recently, Mrs Bowen, now 90 years old, referred to the relationship between Bowen and me as a ‘good working team’. I think that is true. Bowen often referred to me as his ‘right arm’. Our complementary sibling positions were one factor in that. Not to suggest that our relationship was always smooth. I had my immaturities that got into Family Centre relationships and Bowen was not always calm, cool, and collected. In the end, there was significant mutual respect that carried us through. We were both very interested in theory and ideas. I think it worked as well as it did because both of us tried to be a ‘self ’ with the other and with others at the Centre. That was a guiding principle of the organisation.

What are the challenges facing Bowen theory in the context of ever-increasing neo-liberalist political climate, the push for quick fixes, for employees to be less emotional and to comply and produce more and more?

In 1975, Bowen added an eighth concept to the theory, societal emotional process. It is ironic because the concept describes a process that works against acceptance of the very theory that includes it! The concept describes a regression in societal emotional functioning that began shortly after World War II. Regressions have occurred at other times in human history as well. Key elements of the process of regression in families appear to be identical to key elements on a societal level. Among these elements are heightened chronic anxiety as a driving force; increased cause-and-effect thinking; yearning for quick fixes designed to relieve the anxiety of the moment, but which complicate the long-term picture; a feeling orientation to decision-making rather than decisions based on principles; increased permissiveness in society; and a togetherness pressure for sameness and conformity. As the question implies, the trends in this regression are the opposite of differentiation and a systems view of the human condition.

A historian of science has estimated that when Copernicus died, only about 12 people in the world agreed with his model of the solar system. Another historian noted that in Isaac Newton’s later years, few people were attending his lectures. Darwin’s theory was marginalised for decades. I mention these men who had extraordinary original ideas to make the point that acceptance of ideas that challenge conventional thinking has always been slow. The basic challenge is replacing an individual model of human behaviour with a natural systems model. Societal regression probably slows the process of acceptance even further, but does not cause it.

Given current regressive trends in society, more than one colleague has suggested that Bowen theory could get buried for an extended period. Some argue that much more needs to be done to foster a widespread awareness of the ideas. Many people hear about Bowen theory, but only a small percentage of people take it seriously enough to do the hard work required to learn and apply it. I marvel sometimes that there now exists a coherent body of knowledge about families, yet most human beings continue to follow Einstein’s definition of insanity, namely, doing the same thing over and over again, but still getting the same unsatisfactory result! Human beings are incredibly vulnerable to defaulting into feelings and subjectivity when it comes to human relationships.

I have no clue what the future holds, but I am clear that what we can do right now is maintain Bowen theory as an open system. Bowen and I did a spoof interview back in the 1980s. In that discussion he used a metaphor of pouring facts into a pitcher and stirring them to develop a new theory. The problem is that all those facts make the mixture hard to stir and swallow. It is thus tempting to add feelings and subjectivity to smooth out the mixture a bit and make it more palatable. It is difficult not to do that.

References

Bowen, M. (1978). Family therapy in clinical practice, New York, Aronson.

Brown, J. (1999). Bowen Family Systems theory and practice: Illustration and critique. ANZJFT, 20(2), 94–103.

Kerr, M., & Bowen, M., (1988). Family evaluation: An approach based on Bowen Theory. New York: Norton.

Kerr, M. (Ed.). Family systems: The Journal of Natural Systems Thinking in Psychiatry and the Sciences. Georgetown Family Center. Available at the www.thebowencenter.org