Therapeutic Letters: Pacing With the System

THERAPEUTIC LETTERS: PACING WITH THE SYSTEM by Lee G. Shilts, PhD· and Wendel A Ray. Ph.D··. ABSTRACT experiences into stories, and that these stories shape The use of letters with individuals and families as part of the overall therapeutic process is discussed, and case examples are provided. These letters utilize the classification system as advocated by deShazer, et.al. to provide a useful map to follow while working with clients/families. Since letters may have a profound impact, it is imperative that they are designed carefully and with regard for all that they their lives and relationships. According to White & Epslon (1990), the narrative mode redefines the relationship between the observer and subject. Both the observer and subject are placed in the story being performed, in which the observer has been accorded address. the role of the privileged author in its construction. This paper is intended as a contribution to the value Cecchin (1987), in referring to systemic therapy, of writing letters to clients to accomplish specific purposes a "polyphonic orientation. n He encourages goals in therapy. We have used letters with a variety the use of ordinary, poetic, and picturesque language of clients in therapy to accomplish a plethora of in the description of experience and in the endeavor to tasks. We began writing letters to our clients to construct new stories. expand the nature of our relationship with them. We typically use letters during the rust session. The letter is constructed by the therapist during a break midway through the initial session. It is then read by the therapist back to the clients toward the end of Elkaim (1985), in his reference to systemic therapy, uses letters in therapy to modify the rules of the system by reframing the symptom as being preferable to the therapeutic result the rust session. The letter attempts to address the Wilcoxon & Fenell (1983) report using letters to client system at a point which the therapist feels engage non-attending spouses in marital therapy. would be beneficial. whether or not the point had The authors state the goal of such a letter is to been made earlier. We. therefore. write letters to strategically engage the non-attending member. engage clients at their particular level of involvement Letters may also be the vehicle to offer in the therapeutic process. HISTORY BEHIND THE IDEA OF USING the WRITTEN WORD interpretation, hypotheses, messages about self-. esteem, or to strategize (Wojcik & Iverson, 1989). In practice, letters may be designed to manage a Jerome Bruner (1986) believes that people generally variety of concerns. The letters we have written are ascribe meaning to their lives by plotting their designed to reinforce clients and to engage them into • the therapeutic process. The understanding of when Lee O. Shilts, Ph.D., is an Assistant Professor. Institute for Systemic Therapy, School of Social Sciences. Nova University, 3301 College Avenue. Fort Lauderdale. Fl. 33314. •• Wendel A. Ray, Ph.D., is an Assistant Professor and Clinical Director, Marriage and Family Therapy Program, Northeast Louisiana University, Monroe, LA. 71209. Journal of Strategic and Systemic Therapies - 92- to use therapeutic letters, method of use. and bow the client may understand it can only come from evaluating the therapy relationship. For this reason, it is important to consider the cautions of Weeks & L'Abate (1982), to think through any letter, Vol 10 #3 &: 4, Fall &: Winter, 1991 especially a strategic one, before delivering it to clients. We only deliver letters after we have does not see the "problem" as directly pertaining to them. obtained permission from our clients during the initial session. Finally, we use therapeutic letters as one of several intervention techniques throughout the The type of letter employed with these clients are designed only to compliment the individual for attending therapy. In most instances no direct nor overall therapeutic framework. indirect interventions are given to the visitor. The Letter Design: Three Client/Therapist Relationships Matching The Client. Rather, the letter is designed to meet these clients at their current level in the therapeutic process. The rationale for our letter writing is found in the Therefore, we have found it useful to give visitors a clinical writings by Berg (1989) and deS hazer (1985, series of compliments, but no task at the end of the 1988). These will be useful for clinicians when initial session. attempting to develop therapeutic letters with clients. The group at the Brief Family Therapy Center Complainants are those clients who can readily (BFTC) in Milwaukee have developed a map to identify the problem, but cannot see themselves distinguish between three different types of empowered with the resources to arrive at a solution. client/therapist relationships. Since these clients feel "stuck" with their particular These include the visitors, complainants, and customers. The group at Brief Family Therapy Center (BFTC) define visitors problem, they need to be complimented on their insights into their particular situation. These as those persons who are often involved in therapy particular clients may be receptive to thinking about because they are so ordered or perhaps are attending their current situation or to observe those particular sessions due to some other family member's events that may lead to solution-patterned behaviors. Further, these particular clients may benefit from problem. deShazer (1988) states: therapeutic letters that address prediction tasks. Sometimes people seem to have no complaints and their reason for being in the therapist's office is simply that someone told them to come or someone brought them. Since there is no complaint to work on. therapy cannot begin; and therefore, it is a mistake for the therapist to try to intervene no matter how obvious the problem may be to an observer. With "visitors" like this, any intervention is likely to be rejected and, thus, the therapist's error is not recognizing these people as visitors sets up a classic resistant relationship between the therapist and the other people in the office. (p. 87). deShazer and Berg (1988) have had remarkable success in using tasks in which people are asked to predict when exceptions to the presenting problem will occur in their own behavior or the behavior of other family members. We have used this approach through the use of therapeutic letters with similar positive results. Examples of prediction tasks we bave used in letters include predicting times when clients feel they will not binge food or times when Examples may include the court-ordered individual or they will not feel depressed. the peripheral father. In most instances, this client Customers are those clients who indicate a good perception of their problem as well as the desire to do Vol 10 #3 & 4, Fall & Winter, 1991 - 93- Journal of Strategic and Systemic Therapies something about it. These clients are well motivated the system and interrupt the repetitive cycles that in therapy and the use of direct tasks and keeps the client from changing. interventions are well warranted. In general, letters for customers are often straightforward and employ tasks that can be used between sessions to aid these clients in addressing their problem. Customers typically respond well to letters asking for certain behavioral tasks. Examples may include such tasks as counting the number of times clients choose not to smoke a cigarette, abuse their spouse, or binge on food. Our first case is a middle-income family with two children. The parents are divorced, but both willingly attended therapy for their oldest son. The family's presenting problem was the oldest son who was described as being out of control and difficult to diSCipline. The son was in the mother's custody and bad routinely scheduled visits with the father. Therapeutic letters may prove beneficial with two therapeutic maneuvers that are part of the work of Milton H. Erickson. CASE ONE First, letters may prove beneficial in demonstrating the "join the patient" principle (Rosen, 1982). This appears particularly plausible with the "visitor" client. Second, letters may be seen as promoting one of Erickson's basic approaches to therapy - to initiate a small change During the initial session, all participants willingly agreed that there was a problem.. However, each participant was assessed at different levels in their perspective attitudelinvolvement in therapy. The son (complainant) admitted to his unruly behavior, but offered little insight and motivation toward change. This could be expected due party to the age (7) of the client The father (visitor) although willing to attend therapy, saw little difficulty in the son's behavior and (Haley, 1973). stated that he had no difficulties with his son during In summary, the therapeutic letter is designed to their visitation. The mother (customer) not only saw match with the client's current level of involvement the problem, but voiced the motivation and desire to in the therapeutic process. That is to say that we try anything to make the situation better. attempt to develop our letters at the level congruent with client's motivation an willingness to seek solutions to their problems. This could range from the individual seeking therapy for some other family member to the individual who readily identifies his or her problem and is ready to find alternatives to the We sent them a letter at the end of the initial session which i~ excerpted here: (son), We want to compliment you for coming to therapy this evening and for being able to accept some responsibility for your behavior. We are intrigued by those days in The three Client/therapist which you behave well at home and in school. We relationships as advocated by the people at the Brief would like you to focus more on those days and be Family Therapy Center (BFTC) provide a useful map prepared to tell us at our next meeting how you go when designing the therapeutic letter. The letter about having good days. provides the therapist the opportunity to punctuate (Dad) The team would like to take the opportunity to identified problem. thank you you for coming to therapy this evening Journal of Strategic and Systemic Therapies -94- Vol 10 #3 &: 4, Fall &: Winter, 1991 and being a part of the session. We are extremely solutions to the problem. The letter was designed impressed by bow you are able almost consistently and developed to meet eacb individual in the system to bave good days witb your son. You may bold the at his or her level and to ask the clients(s) to do no key to all of the answers. We hope that we will more than they were perceived capable and willing to continue to see you come to· the sessions. do. In subsequent meetings, the therapeutic letters We appreciate the support you are giving all of us. changed to accommodate the shifting of members within the system. While their struggles continued, (Mom) We are extremely impressed by your courage and motivation to help your son. We are further impressed that you are ready to work to find solutions to this problem. We have an assignment we would like you to do from now until our next meeting. Please be prepared to discuss this assignment in full detail at our next scheduled meeting. the roles of members changed and became more flexible with each other. For example, father began to take an active role in helping mother discipline the son. In this case, the letter seemed to compliment the therapy by meeting the clients at their level of involvement. The letter helped to engage the family in therapy. It should be nol~d that other therapeutic interventions beyond the letter were needed in this case throughout the entire process. For example, in DISCUSSION one session the therapist asked the father to take a This particular case illustrates the use of the more active role in disciplining his son. Therefore, it therapeutic letter with a family in which the should be noted that the therapeutic letter alone often participants were seen entering· therapy at different does not make an entire therapy. levels of commitment. The therapist, using deShazer, et al. classification system, saw each family member at varying levels of motivation to seek solutions to their presenting problem. The son (complainant) Jacking the insight and motivation to solve the problem fully on his own, was only asked initially to look for exceptions to his negative behaviors and be prepared to report on them. The father (visitor) seen as somewhat peripheral to the problem and stating tbat be bad no difficulties witb his son, was only acknowledged for his support and seen through the team's eyes as a potential resource toward solving tbe problem. The mother (customer) was willing and able to actively do sometbing to resolve the situation. Therefore, the team prescribed CASE TWO The following case illustrates the use of the tberapeutic letter witb an individual, but further illustrates how the letter can be developed to have the individual use other systems (family, community, etc.) to help seek solutions to problems. The client was referred due to depressed feelings over her recent retirement. Sbe· was having extreme difficulty adjusting to ber new lifestyle and sought help to fmd ways to make a transition to her retired lifestyle. Compounding her situation, the client saw no hope in solving her dilemma and was beginning to see berself as abnormaVcrazy for feeling the way she did. As she stated to the therapist, these were her golden a direct intervention to her in hopes of ber seeking Vol 10 #3 & 4, Fall & Winter, 1991 ·95· Journal of Strategic and Systemic Therapies years of retirement, and she should be enjoying them with her husband. DISCUSSION The following letter was developed and presented to the client at the end of the This particular case illustrates the use of a therapeutic letter with an individual who was adjusting to a new second session. phase in her lifecycle. The individual, during the Dear B first session, appeared to fit at least two of the classifications as identified by deShazer, et. at at FIrSt, we want to thank you for coming here today and allowing us tbe opportunity to belp you witb your situation. These are tbe main points we see in your situation: to how to classify a client, it is always best to err on the side of caution. Therefore, if a client is seen as both a visitor and a complainant, it is often best to 1. It is not abnormal/crazy the way you are tbinking/feeling BFTC. Berg (1989) suggests that when in doubt as give~ your recent act as if you bave a visitor. Our letter was purposely designed to address botb classifications (visitor/complainant) and proceed in an orderly retirement. fashion when addressing both. Therefore, the first 2. You have solutions to your situation. We part of the letter was designed to compliment the beard many of them, and we know there are client for attending therapy and to assure her that her more. We just need to find them. abnormal feelings were alright given her current situation. However, since the client was able to give 3. You are very aware when you need to apply these solutions, thus you have an abundance of motivation and fighting spirit. us some situations when the problem did not exist, we added to our letter an assignment to watch for times when she was able to stop her depression, belplessness, etc. A follow-up session saw the client For our next appointment able to identify exceptions to the problem and build 1. Give us an account of all the times, places, upon these exceptions. She bad secured a volunteer and events when you noticed you were job at a local school and was attending a nigbt class. beginning to experience negative feelings It should be mentioned tbat many of our solution- and what solutions you found to stop them. focused approaches in tbis letter draws upon tbe WotX Give us a complete list of these times. of other cited authors in the field (deShazer, 1985, 1989; O'Hanlon & Weiner-Davis, 1989). In this 2. Work at ways to make a commitment to a project, be it school volunteer, attending a night class, etc. particular case, the therapeutic letter appeared to aid the client/tberapist in finding otber resources in tbe community to belp tbe client adjust to ber new retirement lifestyle. Thus, the letter was only one See you in one week! part of the entire therapeutic process. It should be Journal of Strategic and Systemic Therapies -96 - Vol 10 #3 &: 4, Fall &: Winter, 1991 noted that other resources and interventions were and school needs more of you. I'm wondering if it needed for this client to find solutions to her would be possible for you to "just think" if you presenting problems. could and would be willing to get more involved with your family. For this week, develop a list of CASE THREE things you would be able to do to help your family, This case involved a mother and son who referred themselves to our offices due to the son's apparent lack of interest and motivation in school. Further, the son was a highly gifted student with an interest in computers. The problem rested in the fact that the son had gotten so involved with his computer that he had no time for his family. He only wished to retire to his room and spend time with his computer, often until in the late evening/early morning hours. This e.g., go grocery shopping with Mom, cut the lawn, etc. Also, see if you can find things to do with your family that you may enjoy. Keep a log on your computer of these activities. We can use Mom as a consultant !n this assignment, and she may even be able to help find activities that the whole family can enjoy. Be prepared to share your assignments next week. DISCUSSION routine made it difficult to get him to school the next day. The family (mother and son) was seen for two In this case, the therapist saw the son as a willing sessions. As could be predicted, the son (visitor), participant in the therapeutic process, but not as a entered therapy in a receptive style, but perceived his participant who recognized the problem. However, situation as not really a problem. He stated that due to his motivation and willingness to try some school was boring and that his computer was the things, the therapist asked via the letter to "just source of entertainment and challenge he required. think" about ways to get more involved with the Mother (complainant), easily identified her family. Also, drawing upon his rich interest and dissatisfaction with the current situation, and readily motivation with computers, the therapist asked him expressed her frustrations. However, she had no to record on computer his results. Thus, no direct clues as to what to do to remedy the current tasks were given. The son was given the option of situation. After some initial discussion, the therapist either doing or not doing the tasks. The mother, took a break and returned to address the family with seen as a complainant, was asked to monitor the the following letter: Dear Mom & K., son's progress. Therefore, she was asked only to observe what results occurred during the week. It I'm obviously impressed at how articulately and thoroughly you people understand your current situation. Having this knowledge should be extremely helpful. K., you have a wonderful mother who loves you and is concerned for your future. I'm sure your mother's love for you is equally could be argued that the son, due to his willingness to try to experiment, could be assessed as a complainant. However, due to his lack of recognition of the presenting problem, the therapist felt safer with the visitor assessment. A subsequent follow-up session with the family saw positive results from the reciprocated. It appears to me, K., that your family Vol 10 #3 &: 4, Fall &: Winter, 1991 - 97- Journal of Strategic and Systemic Therapies use of the letter. The son and mother remarked that who indicate a good perception of their problem as the letter provided them with a way to get mutually well as a desire to do something about it. The involved in a project. The son found ways to get authors have not used therapeutic letters with clients more involved with the family and mother was seen who enter therapy extremely angry, depressed. or as a consultant to monitor his progress. Through upset. Examples of such clients are those who are this relationship, the son and mother both stated that considering suicide and/or substance abusing they felt closer to each other and were finding ways individuals who enter therapy unwillingly due to the to do request of their boss, the court system, or their things together that they mutually enjoyed. spouse. Further it should be noted that a letter CONCLUSION written in frustration. anger. or desperation without As can be seen from the three examples, therapeutic letters can take many forms and can be designed to help clients find solutions to their problems. We use letters, usually during the initial session, to engage clients in therapy, promote cooperation, and find solutions to their presenting problems. Several authors (e.g., Bruner, 1986; White and Epston, 1990; careful regard for all its impacts if far worse than no letter at all (Wojcik & Iverson, 1989). The authors recommend that letters should be stored in a safe filing system. This allows for periodic review of letters and may help maintain some consistency throughout the therapeutic process. REFERENCES Elkaim, 1985) believe that the written word in therapy ascribes meaning into a client's life by plotting experiences into stories, and that these stories shape one's life and relationship with other people. The power of letters isn't necessarily known immediately; but, used effectively, they may allow a stronger or longer lasting message (Wojcik & Iverson, 1989). We have found that letters using the classification system as advocated by deShazer. et. al, Berg, I.K. (1989). Of Visitors, complainants. and customers. Is there really such a thing as "resistance?" NetWOfker. IanuarylFebruary. Bruner. I. (1986). Actual minds. possible worlds. Cambridge, MA: Harvard University Press. Cecchin, G. (1987). Hypothesizing, circularity, and neutrality revisited: An invitation to curiosity. Family Process. 26., 4OS-413. deShazer, S. (198S). Keys to solutions jn brief therapy. New York: W.W. Norton. at the Brief Family Therapy Center (BFrC) provide a useful map to follow while working with clients deShazer, S. (1988). Clues: Inyestj~ai solutjons jn brief therapy. New York: W.W. Norton. throughout the therapeutic process. After the initial session, we have often had clients ask if they can deShazer, S. & Berg. I.K. (1988). Constructing solutions. Networker September/October. keep a copy of the letter. They frequently report back to us that they have referred to the letters between sessions. We have used therapeutic letters with a variety of clients referred for numerous reasons. Specifically, our letters appear effective with clients Journal of Strategic and Systemic Therapies -98- . Elkaim, M. (198S). From general laws to singularities. Family Process. 24. ISI-I64. Haley, I. (1973). Uncommon therapy: The psychiatric techniques of Milton H. Erickson. MJ2... New York: W.W. Norton. Vol 10 #3 &: 4, Fall &: Winter, 1991 O'Hanlon, B. & Weiner-Davis, M. (1989). In search of solutions; A new direction in psychotherapy. New York: W.W. Norton. Rosen, S. (1982) My yoice will IN with you. The teachin~ tales of Milton H. Erickson. New York: W.W. Norton. Weeks, G.R. & L'Abate, L. (1982) Paradoxical psychotherapy: Theory and Practice with individuals. couples. and families. New Yorl<:: BrunnerlMazel. White, M. & Epston, D. (1990). Narratiye means to therapeutic ends. New York: W.W Norton. Wilcoxon, A. & FeneIl, D. (1983). Engaging the non-attending spouse in marital therapy through the use of therapist-initiated written communication. Journal of Marita! and Family Therapy. 12.191-193. Wojcik, lV. & Iverson, E.R. (1989). Therapeutic letters: The power of the printed word. 1Qw:na1 of Strae~ic and Systemic Therapies. 8 (2-3), 77-81. Acknowledgement The authors with to thank Dr. Howard O. Protinsky for his helpful editorial comments and suggestions in the preparation of this manuscript. Vol 10 #3 & 4, Fall & Winter, 1991 - 99- Journal of Strategic and Systemic Therapies