The Family Therapy Collections. Individual and Family Therapy: An Overview of the Interface.

"The editor of this volume, Stuart Sugarman, is Associate Professor of Psychiatry in the School of Medicine of the University of Connecticut. He is also the Director of the Partial Hospital Program at the University of Connecticut Health Center. Trained in both individual and family therapy, Dr. Sugarman continues to work as a practicing therapist. He also has a major interest in training, serving as the head of the Training Directors Organization of the American Association of Marital and Family Therapy. Dr.

Sugarman has presented workshops on six continents, many of them focusing on the critical issues at the interface of individual and family therapy. The articles that Dr. Sugarman has selected for this volume will stimulate thought and enhance practice."

-James C. Hansen

---

Stuart Sugarman, MD

Director, Family Therapy Program and

Associate Professor of Psychiatry

School of Medicine

University of Connecticut Farmington, Connecticut It is difficult to know where to start a discussion of large areas of psychotherapy. Arbitrary distinctions must be made, even in an examination of an "interface" between two areas. For example, the individual and family perspectives are arbitrary areas of the bio-psychosocial continuum of a general systems model.

The interface between these levels and the biological, group, and the macro-systemic therapeutic levels is equally critical. Unless specified, the terms individual therapy and family therapy will be used in their broadest connotations. I am not defining them by who is present in the therapy room at the moment. By individual, I am referring to any process of assessment, diagnosis, intervention, and outcome measurement in which the unit of analysis is one person. Family therapy indicates any process of assessment, diagnosis, intervention, and outcome measurement in which the unit under consideration is more than one related person. Individual includes the psycho-analytical, behavioral, and humanistic therapeutic orientations. More emphasis will be on the psychoanalytic orientation, than other individual orientations.

However, I consider that primarily a function of the experience of the writer rather than a statement of any unique stance of the psychoanalytic relative to other individual orientations. Family includes dyadic/marital work and the structural/strategic/systemic, intergenerational and communication/experiential therapeutic orientations.

When viewing any clinical phenomena, the clinician can focus in depth on one level or in greater breadth (but less depth) on more than one level. The physician who treats a psychosomatic ill-ness, for example, focuses simultaneously on the levels of person, nervous system, and organ system (in the Engel hierarchy), believing that a psychosocial stressor is eliciting a response that could be at any of the three system levels. The anthropologist may focus simultaneously, or shift back and forth rapidly, between various system levels (i.e., society, culture, community, fam-ily), the physiologist may move back and forth on various levels (i.e., organs, tissues, cells, organelles, molecules).

Lastly, Engel made the point that a "good" physician often focuses simultaneously on several of the intermediate levels of his hierarchy. Traditionally, psychotherapists have focused on a single, specific level. For instance, the family therapist has focused on the family, the marital therapist has focused on the two-person group, and the psychoanalytical and behavioral therapist has focused on the individual, the person. Clearly, good practice, even on one level, necessitates some focus on the other levels. In psychoanalytical models, however, the individual is the primary unit of assessment and treatment; outcomes are judged by changes in the one person. In a similar manner, intervention and outcome measurement in the structural/strategic family therapies are judged primarily by family relational change. Recently, psychotherapeutic models that simultaneously focus on more than one level or a rapid oscillating movement between two levels have been developed. In these models, there is equal representation or balancing of the individual and family levels.

These psychotherapy models can be viewed along a continuum. At one end are the models that cover a given level in the most depth; at the other end are the models that cover the most breadth at the individual/family interface. There is considerable overlap of models along this continuum. At the risk of some distortion due to simplification, however, one end can be called purist psychotherapy approaches; the center, eclectic psychotherapy approaches; and the other end of the continuum, integrated psychotherapy approaches. Purist models include traditional psychoanalytical, individual therapies, as well as traditional structural and strategic family therapies. The more traditional models focus primarily at only one level, the individual or family level. The eclectic approach is more complicated and is not easily represented by a widely disseminated model. The integrated approaches include aspects of traditional individual and family work (e.g., the object relations school, Bowen therapy, the Palo Alto MRI (Mental Research Institute) models, integrative problem-centered therapy [Pinsof, 1983], integrative multi-level therapy [Feldman, 1985], and the

psycho-educational family models (Anderson, 1983; Falloon, Boyd, McGill, Strong, & Moss, 1981). In these models, the oscillation" between levels is so rapid that, at times, the levels can be considered "merged." For simplicity, I will use this term "merged" in the remainder of the paper although, at times, a more accurate reflection might be "rapid oscillation between levels."

No value judgment is implied that either end of the continuum is better. As I will discuss below, studies of psychotherapy outcome research comparing the integrative, eclectic, and purist treatments are only in their infancy and are inconclusive. Furthermore, there are experienced, purist individual and family therapists who do not consider other orientations to any extent, but do excellent work. Harold Searles and Roy Schaefer give minimal consideration to the system; vintage Sal Minuchin and Jay Haley do not consider the individual in much detail. Sigmund Freud made an arbitrary decision to focus on the internal world while he could have focused on the family and other dimensions.

Until recently, much of the literature has been filled with the conflict between the two purist camps. Two of the more common arguments that purists evoke for their stance include not having enough time to cover such broad areas during therapy (i.e., individual and family areas or that more leverage can be applied from their particular point of view. In a more disparaging vein, Framo wrote that, in the early 1970s after a lecture, an analyst said to him, "Doctor, you are doing a very dangerous thing, treating parents and children together" (Framo, 1980, p. vii). During that time, many analysts felt that the issues of transference and countertransference, the core of the analytical experience, would be hopelessly contaminated by family treatment. As Anthony (1978) put it, "The individual psychotherapist, in his constant search for primitive etiological factors, regards here and now etiology not based on transference as proverbial red herrings having much to do with reaction and interaction but little to do with causality and change', on the other hand, described the psychopathology of individual family members as "irrelevant, a bore to the patient, and a waste of time" Other analysts began to criticize their own stance in this regard. For instance, Erikson (1968) complained that analysts still continued to regard outer reality as a conspiracy against the instinctual wishes rather than an entity of importance in itself." Family therapists also became critical of the parochial fight (Malone, 1979; Pearce, 1980).

Much of the literature in the last decade seems to imply a peace treaty between these two perspectives. Debate has usually focused on ferreting out legitimate differences and synthesizing issues (Stierlin, 1977; Sander, 1979). For example, Anthony (1978) pointed out the difference between the two approaches: The family psychopathologist shifts the emphasis from past to present, from psychodynamics to communications, and from pathology to a peculiar sort of adaption overlying power struggles. The individual psychopathologist remains content oriented while the family psycho-pathologist has become context oriented and is prone to think not etiologically but ... in terms of pattern and relationships rather than in terms of cause and effect, individual vs. environment, past vs. present, or inside vs. outside. More recently, Friedman (1980) said, I believe that psychoanalysis and family systems theory are ultimately complementary, similar to the relationship of wave and particle theories of light. Psychoanalysis leads to a detailed understanding of meanings, provides personal psychohistorical depth while slighting the effects of ongoing relational processes and problem maintenance. Only that which can be verbalized is accessible. Pure family systems work clarifies interpersonal transactions rapidly, gaining breadth while losing depth.

Integrating these two powerful approaches uses the strength of both to facilitate problem resolution. (p. 63). Several books (Slipp, 1984; Wachtel & Wachtel, 1985) and an increasing number of articles have come out in the interface territory in the last few years.

CLINICAL ISSUES: THEORY AND PRACTICE

In order to construct a framework for considering psychotherapy models in relation to the individual/family inter-face, it is necessary to distinguish between the therapeutic and meta-therapeutic levels. The meta-therapeutic level includes all issues contextual to actual therapeutic techniques and procedures, such as the goals and objectives of the specific therapeutic procedure, selection criteria for patients), and specific value assumptions. With this in mind, it is possible to divide all psychotherapy models into integrative, eclectic, or purist approaches (Table 1). In reality, however, these are overlapping continuums.

Integrated Approaches Karasu (1979) has suggested that at least parts of the psychotherapies "may be combined to produce the most important therapeutic regimes". Lebow (1984) has eloquently described the advantages of integrated approaches, noting that they draw from a broad theoretical base and can explain human behavior in a more sophisticated manner than the simple theories can. Further-more, they allow greater flexibility for the treatment of any given individual or family, thus offering the opportunity for increased efficacy. He cited several other advantages, including the fact that the therapist can combine the best parts of specific approaches. Pinsof (1983) coined the term patient system. He stated: The patient system consists of all the human systems (biological, individual-psychological, familial-interpersonal, social-occupational

etc.) that are, or may be, involved in the maintenance or resolution of the presenting problem. The patient system encompasses different, hierarchically integrated levels of systemic organization, without locking the therapist in one level exclusively. The new task that confronts the therapist treating a patient system is not to choose between the biological, the psychological/individual and the social/familial but rather to determine and address the relative contribution of each to the presenting problem's maintenance and resolution.

The same concept has been implicit (and to some extent explicit) in certain aspects of the psychotherapy field for some time. The Palo Alto MRI approach has always focused on solving problems, whether individual or family problems, in the patient system. The critical issue is the "event shape"-the point of maximum therapeutic leverage. In their classic book on the MRI approach, Watzlawick, Weakland, and Fisch (1974) mentioned the words individual and family equally, but not at all in the titles or the preface.

As an example of focusing on the family level, they presented the following fragment of a case: A somewhat similar form of reframing can be used with the frequent conflict generated by the nagging wife and the passive-aggressively withdrawing husband. Her behavior can be relabeled as one which, on the one hand, is fully understandable in view of his punitive silence, but which, on the other hand, has the disadvantage of making him look very good to any outsider.

In a similar way, they presented a case in which they focused primarily on an individual and her problems of depression and low self-esteem: Another young lady, also unmarried, was leading a promiscuous life that made her feel very cheap but at the same time was her alternative to the depressing idea that otherwise no man would care for her company. To make things worse, after every sexual encounter she felt totally dissatisfied and therefore also worthless as a "lay." She would then typically be too ashamed to see that man again and would start going out with another one. What she was unable to see was that under these circumstances her attempts at solving her problem (i.e., to start all over again with somebody else who again was interested in her sexually) actually were her problem. To get her out of this vicious cycle, and in keeping with our rule that the therapeutic intervention must be applied to the "solution." We instructed her to tell her next boyfriend that for reasons which she could not possibly reveal, but which were of highly symbolic nature, she could make love only if he first gave her twenty-five cents but that it had to be an old silver quarter and not a new alloy coin. Here, too, we offered no explanation for this prescription. She was shocked at this implication but on the other hand sufficiently interested in continuing therapy, and this left her with no alternative than to stop sleeping around, thereby discovering to her surprise that men would not simply ditch her because she refused to go to bed with them. In this way, a change was achieved even though she never did carry out the instruction. Thus, an individual or a family focus becomes secondary to the mission of problem resolution in a patient system.

Other traditional family therapy approaches, such as Bowen's (1978), also appear to be integrated. Differentiation of the self is an individual concept, but is intimately connected with the multigenerational projection process and de-triangulation family approaches.

Furthermore, although usually classified under the purist family rubric, Whitaker

(1982) appears to move quickly between the individual and the family level within his work. The title of the book compiling his work, From Psyche to System, is more than just a historical metaphor. My experience, having worked with him for a decade first as a student and, more recently as a colleague, is that he is equally concerned with individual growth as well as family change.

Object relations theory, although developed by Fairburn, Dicks, and Winnicott as an individual theory and practice, has many integrated applications that have bridged individual and family therapy. For example, the concepts of projective identification, split-ting, and collusions are very powerful in this regard. Stewart, Peters, Marsh, and Peters (1975) described crucial applications of this approach to work in the family area. Slipp (1984) stated that "object relations theory is used as a bridging concept between the individual and the family system. It will serve to indicate the fit of the individual into the system and the effect of the individual on the system."

Other recent advances in the integration of various therapeutic approaches include the work of P.F. Friedman (1980), Wallace (1982), Feldman (1982, 1985), and Moultrup (1982). Although their work often focused only on the integration of family therapy schools, their recent efforts appear to combine individual and family therapy in creative ways. The psycho-educational models developed by Falloon (1981) and Anderson (1982) are also among the new integrated approaches. These models, which are specifically applicable to the treatment of schizophrenic patients, have an equal focus on two levels: the individual schizophrenic patient and the family context. The goal of the intervention is to reduce the stress caused by the family and to increase the schizophrenic person's use of the family as a resource. The patient system is both individual and family.

In this volume, three articles focus on integrative therapy. Ivan Nagy presents an article in which he articulates his view that individual/family integration must occur on a certain dimension (ethical), while it cannot occur on other dimensions (psychodynamic and transactional). David Kantor expands his own writing in the integrative area. He reviews the "critical identity image" —a bridging individual/family concept-and gives a detailed clinical case on the genesis of a system. Michael Kahn considers the integration of two specific models of psychotherapy: the Milan model of family therapy and the Kohut model of individual therapy. He suggests that a theoretical framework, based on a synthesis of these two approaches, form a very powerful clinical model for integrative therapy.

Eclectic Approaches: In eclectic psychotherapeutic approaches, the meta-therapeutic level is

merged, while the therapeutic level is discrete. The emphasis is on deciding which modality of treatment is appropriate. This is in contrast to the purist and integrated models which at worst seem to take on everyone or at best have only inclusion or exclusion criteria.

With eclectic approaches, once a decision for a particular therapeutic approach is made, it is usually discrete; i.e. individual or family. Thus, the underlying assumption of eclectic approaches is that the individual and family purist models are therapy techniques or tools in the overall armamentarium of the clinician.

In contrast, the purist approaches are not only techniques, but also ways of think-ing. The eclectic and purist approaches are the same on the level of technique and procedure. In the integrated approaches, however, the individual and family components are no longer separate (discrete), but form a patchwork or mosaic of individual and family components.

Frances, Clarkin, and Perry (1984) noted that, in the eclectic approach, merging occurs on the meta-therapeutic level; among other issues, they considered the pros and cons of individual or family (or combined!) therapy. Most eclectic theorists/clinicians feel that the power of the purist models is diluted if they are merged on the procedure/technique level. For example, the power of psychoanalysis results from the analysis of the transference a procedure that is contaminated if more than one person is in the room. Likewise, if the classic structural family therapist also does "individual" therapy, the family therapy may suffer from the burden of the collusive, therapeutic coalition between the therapist and the given family member.

One format is specific to eclectic approaches combined therapy. Any clinical situation in which at least two therapists are involved simultaneously in different modalities in a given clinical case can be considered combined therapy. For example, a spouse may be in individual therapy with one therapist, and the couple may be in couples therapy with another therapist. Some clinicians consider this a preferred therapeutic method in that it allows for different interventions at different levels of dysfunction. The presence of two therapists can allow for maximization of the traditional power of each modality. For instance, a family therapist can make an alliance with the whole family without being subject to the collusive effects that can result from working with one family member, and the individual therapist can avoid contamination of the transference working with only the one family member. Although it is possible to consider approaches with one therapist under this rubric, the single therapist often combines bits and pieces of various purist modalities; this format seems further along the continuum toward an integrated approach. Steinhauer and Tisdall (1984) examined the conditions necessary for two clinicians to work together, particularly an individual and a family therapist. They noted that, as a minimum, each therapist must respect the other's approach. Their decision about communication between them vis à vis confidentiality issues is also extremely critical; such communication is often quite hap-hazard, which is clinically destructive. Finally, the therapists must work to keep competition between them to a mini-mum. Shapiro, Shapiro, and Zinner (1977, 1978) provide an example in their writings of the application of combined therapy to borderline adolescents.

Modality Selection Criteria: Those who adopt the eclectic approach explicitly consider the goals and objectives in therapy (Offer & Vanderstoep, 1974). Eclectic writers/clinicians appear to ask, "For what goals and objectives is one modality better than another?" This is reflected in the research paradigm that has evolved over the last several decades: what therapy, for what purpose, under what conditions, by what therapist, for what problem. Abroms (1981) argued that the goals of the bio-therapies, psycho-therapies, and socio-therapies differ markedly. Even within the therapies there appears to be a vast difference between the goals and objectives of, for example, a behavioral therapy and those of an insight-oriented approach or between the goals and objectives of short-term strategic therapy and those of long-term family-of-origin therapy.

Thus, the criteria for modality selection are largely dependent on the goals and objectives of the particular treatment.

Common Clinical Parameters: Unfortunately, there have been few attempts in the literature to specify criteria for modality selection among the purist models. Clarkin, Frances, and Moodie (1979), three of the few exceptions, presented a "decision tree" for analyzing selection criteria. Choices are generally made on the basis of clinical rules of thumb, however, such as the way in which the problem is initially dis-cussed. For instance, the problem may be presented primarily as a problem within one person (e.g., anxiety or depression) or as a problem between people (e.g., "the problem is my relationship with my husband''). In other cases, the patient may agree to participate only in a particular modality. It is then up to the therapists) to decide if that modality is clinically acceptable.

Another clinical rule of thumb is based on the family life cycle. Similarly, the therapeutic life cycle can be used as a framework. For instance, Whitaker considered individual change impossible without simultaneous change in other family members and in the family relationships. In his view, individual psychotherapy becomes a "Ph.D. course in human relationships' worth engaging in only after graduation from "high school" and "college" (i.e., after an individual has worked out the major interpersonal struggles with his or her family of origin and family of procreation).

The treatment modality can also be selected according to the stage of illness. Wynne (1983) conceptualized a phase-oriented approach to the treatment of schizophrenia, for example. He believed that there are different nodal points within a schizophrenic illness in which family therapy or individual therapy is more appropriate. As he said, "Writing as a family therapist, I believe it is important for me to say explicitly that family therapy as ordinarily understood may be a crucial component of treatment, but that, alone, it is never an adequate or sufficient approach to schizophrenic problems" (p. 252). He felt that the family should be involved in the first crisis contact, but that there are times during the sub-chronic phases of the psychosis during which family involvement can be contraindicated.

There are similar rules of thumb or clinical parameters for making decisions about combined therapy (Sugarman, 1982):

• Does it appear that different modalities would help significantly with different therapeutic goals in different levels (e.g., social versus psychological)?

• Does it appear that a given modality is either not helpful or of limited usefulness without the additional modality?

• Is there significant motivation on the part of the patient system to combine modalities?

• Are the modalities synergistic, enhancing each other?

  Jerry's father had died when Jerry was an infant; he had felt chronic guilt most of his life, related in part to his inability to take better care of his mother, who lived alone in Texas 1,000 miles away. After 4 years of working on Oedipal and self-esteem issues in individual psychodynamic therapy, he was referred for couples therapy by a colleague who felt that

  "too much of Jerry's self is tied up in the marriage...

  and, thus, couples therapy seems like a necessary intervention at this time."

  Jerry continued his individual therapy during the first year of work in

The couples couples therapist made no effort to have him stop the individual therapy. His wife did not appear to feel that the individual therapy was a stumbling block in their relationship. Rather, she felt it had been helpful to Jerry in reducing his depression and making him more accessible to work on the marital relationship. Jerry reported that the first year of couples therapy "unlocked additional material that made sense to talk about in the [concurrent] individual therapy." Also, it appeared that the individual work helped the couples therapy by increasing Jerry's energy, interest, and wish to focus on the marriage as the issues with his parents resolved.

After 1 year of treatment with combined modalities, the individual therapy stopped; the couple continued for 1 more year in couples therapy. At termination, both the spouses and therapist felt that the therapeutic work had been successful and that the combined modalities had been helpful. This was also true on 5-year follow-up.

There are also several contraindications to the use of combined modalities:

• The epistemological foundations of the various modalities are often based on contradictory assumptions. The goal of clinical work is to provide a coherent, cognitive ordering of the world; however, combining modalities can at times confuse the patient.

• The additional time and money involved in combined therapy may be unnecessary. A single modality is often powerful enough to accomplish what is therapeutically necessary.

• Different modalities can dilute the potential commitment to each separate therapeutic involvement. To the extent that the concept of psychic energy has meaning, combined therapy could divide this energy so that not enough is available for any one modality to accomplish therapeutic work. This is similar to the concept of "diluting the transference" in psychoanalytic thought. A case example will illustrate some of these problems.

The Smith family had been in treatment for approximately 6 months. The identified patient was the daughter, who was promiscuous and abused drugs. After 3 months, her misbehavior had stopped, and the covert marital conflict emerged. Kevin, the husband, had been active and involved in the family therapy, but became increasingly anxious and stopped working. The therapist felt that Kevin needed more therapeutic intervention than could be provided in weekly family therapy and urged him to start individual therapy. Kevin's anxiety decreased with a few weeks of individual therapy, and he restarted work. In the ongoing family therapy sessions, however, he became angry and silent. The family continued for only another month.

On 1-year follow-up from an independent source, it was found that the couple had divorced, and neither spouse was doing particularly well. Symptoms in the children had increased. According to the individual therapist, Kevin had expressed a great deal of anger toward his wife and the family in general. Soon, his involvement decreased, in spite of focus on this issue by the individual therapist. Two months after starting individual therapy, he dropped out of that therapeutic process also. Later, Kevin returned to the clinic, stating that he had been extremely unhappy and depressed in the intervening 2 years and wanted to restart therapy. In this case, it appeared that perhaps the two clinical modalities sabotaged each other by allowing Kevin to withdraw necessary affect, at first from only one process, but eventually from both.

Ethical Considerations: The decision to take any treatment perspective requires ethical decisions. For instance, the interests of each family member are not always the same. Wallerstein (1985) reported a study in which the spouse who wanted a divorce is doing quite well 10 years later, while the spouse who did not want the divorce is not doing at all well. Sider (1982) said that it is "epistemological nonsense and a clinical impossibility' to claim ethical neutrality when the therapist functions as an agent of change and has no investment in the outcome. Buber (1937) has said "one cannot be in or act in relationships without doing so as one values certain outcomes." Thus, to the extent that there are possibilities of family or individual therapy, ethical choices are involved. Many therapists do not clearly understand their own ethical values or are quite conflicted about them. It is probably difficult for anyone trained in the individual approach even to consider relational therapies. "Ethical issues in psychiatry, as indeed in all medicine, have revolved around a right, good healing action taken in the interest of a particular patient' (Pellegrino, 1979). Few theorists or therapists discuss the inevitability of "choosing sides" that appears to be a reality in clinical work. Nagy is one of the few who has detailed this issue, encompassed by his concept of multi-directed partiality. In essence, this often means the therapist must be the advocate for the weakest person in the system, which is often the child. Some ethical issues have been explicated in legal/ clinical formats. For instance, the Group for the Advancement of Psychiatry committee report on child custody (1980) contains explicit criteria in this narrow area. Within the general clinical domain, however, these issues have often remained implicit. In this volume, Sider expands on his previous work in these areas of ethical considerations.

Another area of ethical consideration within this interface territory is who should make these decisions? For instance, should the decision making process be done only by the therapist or should it be made explicit with the patient system? When should the pro/ cons of different approaches be elucidated explicitly with patients and should they make the choice versus how often should the therapist make the choice? As an example, if both individual and cou-ple(s) therapy are indicated i.e., both could work well in a given situation), should the therapist make that choice or should the couple be given all the information and they make the choice? Lazare & Eisenthal (1979) have argued that a negotiated approach is indicated when dealing with the modality selection process.

Ongoing Eclectic Treatment: After the initial modality decision has been made, treatment often proceeds until resistance develops or an impasse occurs. This is another common clinical work. At this stage in our theory and practice, should students be exposed primarily to the purist traditions and integrate the traditions themselves, or should we help them with the integration of the models? To the extent that we are practicing in an integrated manner, the latter argument states that training should be isomorphic with our own practice: thus we should teach it that way. Most psychotherapy mentors around the United States have been trained in and practice purist models. Most students, while learning from purist teachers, are also interested in integrated approaches. Goldberg, in this volume, makes the point that one could take advantage of this transitional time in the area of teaching/clinical work. He argues that purist teachers of one persuasion encourage students to synthesize the knowledge from both purist approaches that they learn. In this way, each purist approach itself is deepened by additions from other purist models. Goldberg writes an excellent example of this process in which the teaching and practice of psychodynamic individual therapy is enhanced by family considerations. The growth and development of experienced therapists as they move from purist to more integrated models are also critical issues. The therapist changes from an imitator to a clinician who forms a personal, unique mosaic of theory and practice. This transformation seems to be connected to the notion of differentiation as the therapist becomes more experienced. Moultrup (in press) has conceptualized five stages in the progress of the therapist's personal growth.

"Stage five therapists are the most mature," he postulated, "and able to integrate the most

clinical material along with the experience of their own and with their own personality." He noted the "awareness of the expansive possibilities of multiple theoretical models'

as the primary strength of therapists at stage two, which may follow a period of adherence to one specific belief system. Stage three functioning finds the therapist struggling to organize the material brought together in a way that makes sense theoretically and clinically. Stage four is characterized by the implementation of complex, vast amounts of material; "the implementation has taken on flexibility and sensitivity to the individual situations." Moultrup postulated that few therapists reach stage five and that those who do remain there only for a short period of time. At this stage, how-ever, boundaries are expanded: "there is a talent, an uncommon ability to responsibly and creatively expand boundaries not only for themselves, but for others as well."

In this volume, Carl Whitaker's article follows the same format. He feels that the individual/family interface is reflected in the growth of the therapist. He feels that the therapist moves from an "T" to "We" position and back again.

Whitaker feels this is a constant evolutionary dialectic as the therapist progresses to higher levels, oscillating between what I've described as "discrete" and "merged." Thus, Whitaker's article is an attempt to look at therapist issues using the same framework that we have been discussing from a clinical point of view. Many writers and thinkers in the family therapy field, particularly, feel that therapeutic phenomena are reflected in internal therapist phenomena. Whitaker's article is a case in point that the individual/family clinical dialectic is refected by an internal (I/We) dialectic within the therapist.

CONCLUSION

The territory at the interface of individual and family therapy is vast and uncharted in many ways. Hopefully, this article and the book will accomplish at least two goals. The first is to raise theorists/clinicians consciousness about issues and decisions that are usually made implicitly within this area. Although there are no easy answers, an explicit understanding of these issues will undoubtedly lead to better clinical work. My belief is that all clinicians will do better work with some understanding of the entire individual/family interface terrain. Secondly, it is hoped that the organizing typology that has been provided will be useful for further explication of these issues. As our clinical works expands, research and training extensions will hopefully follow.

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