Medical Psychology & Rehabilitation Neuropsychology Service

NETWORK THERAPY:

A Potent Therapeutic Tool

Mike Martelli, Ph.D.

An individual's social network, as aptly defined by Garrison (1975) is the sum of those human relationships that have a significant effect on his or her life. Members of an individual's network may represent both affective (i.e. psychosocial support and supplies, such as personal interest and emotional support) and instrumental (i.e. money, housing, etc.) resources, and include relatives, friends, neighbors, associates, employers and so on.

Social Network Therapy is further defined by Garrison as the clinical technique of involving a person's social network with the goals of modifying the network of emotional influence or affective resources in order to facilitate active reality based coping and problem-solving and articulation of the instrumental resources available. His underlying assumption is that the solution to a variety of "human dilemmas" lies within the expectations and collective resources of an individuals social network.

Rueveni (1979) describes the process as " a time limited, goal oriented approach that will help family members in a crisis to assemble and mobilize their own social network of relatives, friends and neighbors; this network will become collectively involved in developing new options and solutions for dealing with a difficult crisis". This is, in Speck's (1973) words, the setting in motion "the forces of healing within the living social fabric of people", and the revamping of the social network by increasing "bonds" and decreasing "binds" between people. Reuveni's underlying assumption is similar to Speck's in that it extends deeper than Garrison's, positing that our lives, well-being and even ability to function on a daily basis "depend on the quality of our social support systems and our ability to mobilize these systems, particularly during crises" (1979).

Some related approaches, all hall marked by their mobilization or resources in an individual's relational field, have been variously referred to as social system psychotherapy, ecological therapy and kinship therapy. These approaches share similar goals, designate the social network as the therapeutic unit of intervention, and employ similar techniques for achieving their goals and can therefore be considered synonymous with social network therapy or "networking". Given the systems oriented nature of networking, as a reference point, a brief sketch of the historical development is in order. The antecedents or historical roots of the networking approach generally includes general systems theory, group and family sociology/ anthropology, group psychotherapy, family therapy, multiple family therapy, field theory, and the community mental health movement.

Tracing the clinical development, Pattison (1975) notes six distinct steps:

• 1. The proliferation of the child guidance movement in the 1920's which included the parents in the treatment of "disturbed" children.
• 2. The development of group psychotherapy, partially dictated by of the traditional one-to-one psycho- dynamic model & economy.
• 3. The development of family therapy in the 1950's, where interpersonal and systems conceptualizations began to eschew treatment of individuals "in vacuo" and instead on pathological interpersonal interactions.
• 4. The organization of multiple family therapy groups in which several families were treated simultaneously as one group. Again, economy and expedience, as well as theoretical influences from general systems & field theory, prompted inception of this approach.
• 5. The development of home visit treatment programs. Most noted, is Minuchin's work with slum families, where he found that the typical middle- class nuclear family was fragmented, and their functions met by extended family members, friends and other significant others (1). Other clinicians also reported that when home visits were conducted, significant others who were not part of the nuclear family, or even extended family were present and played essential roles in family functioning and were hence allowed or invited to participate.
• 6. The formalized "network therapy" approach, first elaborated on by Ross Speck (12) which included nuclear and extended family members and those related by friendship, community residence or employment (typically around 40 people).

A significant influence on the development of the network approach was exerted by the theoretical formulations of Kurt Lewin and von Bertalanffy. Lewin's Field Theory maintains that human behavior can only be adequately conceptualized in relation to ongoing human relationships. That is, the social field in which a person operates will significantly influence that person's behavior, and it follows that a person's social field, especially in the case of an emotionally disturbed or crisis stricken person, can be especially therapeutic or detrimental.

General Systems Theory of Physical Energy, as noted by Marmor (1975), was originally expounded on by von Bertalanffy, and defines a system as a complex of components in mutual interaction, or as a set of units containing common properties that are conditioned by or dependent on the state of other units; that system may itself be a subsystem of a larger system and may have subsystems within it. A system has permeable boundaries, allowing information and energy to pass from inside to out and the converse. Assimilated into the system theory when applied to active organismic systems such as man is the idea that the total system is greater and different than the sum of it's parts. Thus, an individual is an integral, inseparable part of a highly complex system, the family, which is itself a subsystem of it's functional social network of extended kin, friends and significant others (itself a subsystem).

Another area that has greatly contributed to the development of the network approach is the area of group and family sociology/ anthropology. The kinship system that has predominated human societies is the extended kinship system, in which an individual's social network is comprised of members of the extended family, who provide affective (i.e. psychosocial supplies like emotional support and involvement) and instrumental (i.e. food, shelter, money, etc.) resources (Garrison & Howe, 1978). In recent times the extended family has often been replaced by a complex of friends, neighbors, clergy, social agencies, associates, employers and so on, but this social network remains an important source of affective and instrumental resources, or in Caplan's (1976) terminology, basic supplies. In comparing traditional to modern societies, Parttison analyses the response of each to disruptions in psychological well-being. In the traditional society, which employed an"open" model of psychotherapy, the whole kinship network is mobilized and it's functioning is dependent upon returning the member to his previous level of functioning. In the modern "closed" one-to-one system of psychotherapy, the individual, who is much more expendable, is often isolated and the process is a private one, in which the social network is mostly excluded. Interestingly, many of the network oriented therapists explicitly compare their' treatments to tribal healing ceremonies.

Further, as reviewed by Pattison (1975), much data has accumulated evidencing the disruption of the social network in families with "disturbed" members. Studies comparing groups of normal families with those of a members applying for treatment at family service agencies have found that the client families had fewer memberships in voluntary associations, fewer friendships with relatives and fewer relations living in the same community (and, fewer pets). Similar results have been found for families applying to group services agencies. On the basis of these findings, Pattison (1975) developed a psychosocial kinship inventory and found that the normal, healthy (urban) person has an intimate psychosocial network of 20 to 30 mernbers, whereas mildly and severely mentally ill individuals have less intimate social networks of 10 to 12 and 4. to 5, respectively. In addition, the social connectedness/ unconnectedness ratio (i.e. members in one's social network who have relationships with each other divided by those who don't) was much lower for the neurotic and psychotic populations. In general, the compiled data shows that impoverished social networks where the resources of a social network are not available are highly correlated with maladjustment. Tying right into this research is the development of the community mental health movement. Caplan and Killilen (1976) in an effort to conceptualize the preventive and public health side of "community psychiatry", have proposed that professionals must learn to appreciate the "fortifying potential of the natural person-to-person supports in the population", and discover ways to use it in developing helpful community action. They notice the value of support systems" in providing protection against the vulnerability of persons in crisis and high risk (for decompensation) situations, and emphasizes the families role as a natural support system. Additionally, mutual help organizations and other artificially built social support networks such as widow, rape and ex-mental patient groups, have emerged and prospered.

In summary, various trends and approaches to dealing with emotional difficulty have converged and culminated in a network therapy approach, and erected an observation and tenet as to the importance of the social network in maintaining stable adjustment and functioning of it's members.

The first author credited with coining the term "network" therapy was Ross V. Speck (1973), who initially experimented with involving the social network in families with schizophrenic patients. Later, in conjunction with Carolyn Attneave and eventually Uri Rueveni, this approach was refined and applied to numerous other disorders. Speck and Rueveni are currently at the Eastern Pennsylvania Psychiatric Institute and have developed similar formulations of the network intervention process. They have developed a training course program of seminars/workshops for teaching the network intervention process. (In fact, they often utilize members of the training group to fortify networks of individuals with few or unavailable members). It includes the theoretical and experiential-didacti c component s and the introductory program involves meeting 10 consecutive Friday afternoons. In addition, videotapes of actual network sessions are available from the E.P.P.I. in Philadelphia, although they usually require the hire of a lecturer.

Rueveni, in Networking Families in Crisis (1979) outlines the network process. It begins with a home visit of the nuclear family, which allows assessment of the feasibility a of mobilizing the network support system (i.e. availability, willingness, etc.), familiarizing the nuclear family members with the process and establishing the concerns of the "ailing" family and their degree of desperation or motivation. The most appropriate families for the network process are believed to be those who are both desperate and willing and for whom other treatment modalities have failed. It is during the home visit, subsequent to a decision to employ the networking approach that the logistics in terms of space, invitations, etc., for the first network session are discussed.

Six distinct phases of the network process are delineated, including: Retribalization, Polarization, Mobilization, Depression, Breakthrough & Exhaustion - Elation. Notably, these phases happen in a recurring cycle and are present regardless of the frequency or duration of the network intervention process and even tend to repeat themselves within the course of single sessions.

In the Retribalization phase, the family calls together the network members, providing the setting while the intervention team is responsible for explaining the rationale and significance of the network meeting. A problem-solving explanation in which the difficulty or "problem" is redefined in terms of the functioning of the social network is utilized, and a blueprint for the, different phases to occur is given to the entire network. In addition, the intervention team must reduce tension and. promote a "we" feeling through encounter type experiences aimed at making the network visible and rebuilding ties or bonds between members.

Some of the specific retribalization techniques which are employed to rapidly increase the participation and energy level of network members have been borrowed from experientially oriented practitioners in Gestalt, Psychodrama, Group and Family Therapy. Network Milling involves the instruction for members to make contact with as many people as possible in a 3 minute period. They greet each other, exchange bits of information and move on, and variations include shaking hands or touching. "Network Screaming" occurs when members are first instructed to scream simultaneously, followed by pairing up, exchanging and screaming each others first names. Variations include jumping up and down in place and joining in small groups of name screaming partners. "Circle Movements" involves holding hands in a circle and moving toward and away form each other as one body; with variations :including pattern and direction changes and sound making. The "Family Song" occurs when nuclear family members choose a song which the whole network joins in to sing, with such variations as clapping hands and swaying. The "Network Speech" is given by the network intervention team leader who: 1) introduces him/her self; 2) outlines the need to work toward solving the family's problems; 3) indicates that the family needs all the help it can get from the network in helping the family to solve the crisis; 4) emphasizes involvement, sharing openness and the development of support. The "Network New Times" consists of a recap of events over the past week. The team leader shares what he has heard through the network "grapevine" and encourages others to do likewise.

The Polarization phase involves the family presenting to the network problems and issues relating to the crisis, and the network members offering different reactions to these issues The intervention team functions to find and activate the conflicting positions and points of view and sharing of concerns and discourage dependency on themselves and to encourage greater participation and involvement, especially of "activists" to initiate problem solving efforts. The goal of this phase is to draw out different attitudes and feelings of members and promote confrontations that shake up old stereotypes and lead to new interpersonal perceptions.

Polarization techniques allow for rapid involvement by network members. In the "Inner -Outer Network Circle", nuclear family members form an inner circle and are prompted to report how they perceive family conflicts. When finished, they switch places with network members in the outer circle who now comment on what they heard (in terms of thoughts and feelings). In the "Empty Chair", an empty chair is placed in the inner circle and taken by network members wishing to comment, who vacate it when finished (a modified version is "sit next to the one you feel closest to"). "Whose Side Do You Take?" is simply that provocative interrogative, and other variations include intervention team members asking "Who is having a problem in the family?" or "Are there any secrets in the family?" "Removing Family Member" is employed when, in order to interrupt an intense and escalating scapegoating of a single family member, it is suggested that that individual temporarily leave the room accompanied by a team member (variants include changing topic of discussion, stating the observation or placing the individual at the periphery of the room). "Communication With an Absent Member" is utilized when an important family member is unavailable (due to sickness. death or unwillingness). Communication with the absent member can be encouraged through, for example, the use of the empty chair, role playing or the telephone.

The Mobilization phase entails the effort and work of the entire network, including the small groups having formed within it, to generate possible solutions to specific problems. The intervention team, meanwhile, presents specific problems to the network and facilitates productive group interactions, aimed at focusing the energy and resources of the network on creating, new solutions. Mobilization techniques aimed at mobilizing network member resources usually promote confrontations and often result in strong cathartic expressions of emotion.

In "Promoting Direct. Confrontations", a family member is asked to setup up onto a chair and talk to the family member he wishes to confront. Some variants are having the confronted person kneel down and look upward, having the confronting member shout, and having either the network members stand on both sides of the confronting member and add encouragement, or the team leader touch and encourage confrontation. Further, a switching of places in the confrontation, as well as the nonverbal expression of feelings between the two members may be encouraged. "Stimulating Disengagement from Home" helps family members experience and acknowledge the desirability and feasibility of such a move. One variation is to have the family member physically try to break in or out of a circle of hands-joined network members (symbolic disengagement). Another is to tie a rope around two symbiotically attached family members and sparking discussion. "The Death Ceremony" is a powerful technique for dealing with issues of disengagement, as well as loss of a family member. A family member is selected and asked to lie on the floor and imagine they are dead, while covered with a sheet. Each network member is then encouraged to kneel down beside and eulogize the "dead" family member, expressing his or her feelings. "Sculpting the Family Network" generally requires some variation of having family members arrange themselves spatially to depict a particular feeling they have toward one another. In addition, "Role Playing" and "Role Reversal", followed by discussion are also employed.

The Depression phase follows when network members get discouraged and frustrated over the difficulty involved in the task. The task of the intervention team is to acknowledge difficulty, provide encouragement and suggest additional efforts to break the impasse using psychodramatic techniques such as those outlined for the mobilization phase. The important goal of this occasionally non-occurring stage is the generation of positive feelings of solidarity and support to offset discouragement, maintain increased problem-solving efforts and provide new solutions.

The ensuing Breakthrough phase occurs when network "activists" generate feasible problem solving solutions while the intervention team mobilizes support structures and small support groups for each family member and promotes effective small group interaction. It is characterized by increased activity and feelings of optimism and encouragement and serves to reinforce the relentless problem solving efforts made by the network members. It is followed by the Elation/Exhaustion phase or period, where, with solutions progressing, most members feel satisfaction and accomplishment combined with a sense of having worked hard, but having been rewarded for it.

A critical factor in the network process is the formation of temporary support groups. The groups form as network activists take clearly defined positions in support of one or more family members. The intervention team then functions to encourage the "activists" to initiate and lead the way in efforts to organize support groups around each member of the nuclear family. Between network meetings, support group members meet with their respective family member to generate an initial course of action and alternative options for crisis resolution. They maintain telephone contact with each other, the family and the team and arrange future meetings and endeavor to develop and mobilize resources, planning current and future strategies for support. Following the completion of the network intervention, the support group members continue to meet and help their respective family member "reconnect" with additional sources of support from each of them and others in the family or community. They pool and mobilize their own resources with regard to available social contacts, jobs, living arrangements and other community contacts while maintaining face-to-face, phone and letter contact.

The network intervention team, as outlined by Ruevini, generally consists of 3 or 4 members, usually professionals, headed up by a team leader, who has considerable experience and knowledge of family dynamics, group process, intervention techniques and teamwork. The team leader helps other team members identify their preferred areas of active involvement and chooses a a co-leader. The team meets following the first network intervention session, evaluates the effectiveness of the techniques used, analyzes the network phases experienced and evaluates their individual and overall team functioning. In addition, they must devise a strategy to delineate each team members role, the techniques to be used and the general direction and goals to be worked toward. Finally, after completion of the network intervention, the team again meets to discuss outcome & follow-up plans.

The number or sessions for the network intervention process is variable, but most authors seem to regard somewhere between 3 and 8 as ideal. The number of sessions required depends, of course, on such factors as difficulty of the problem, resistance by network members, availability of resources within the network and even the community and so forth. In expounding on the appropriateness of the approach, Reuveni emphasizes the presence of desperation an the family's part, especially when other approaches have proven unsuccessful, which implies additional resources are indicated in order to solve the crisis. Just a few examples of what he considers appropriate referrals for networking include: the experiencing of intolerable turmoil, when, following several years of couple therapy, the husband who was suffering from progressive multiple sclerosis and shunned the help of his family and friends, became unmanageable when his private nurse of several years decided to leave: the continual conflict between family members in response to a depressed son, which interfered with managing the other children: the bizarre behavior of a 29 year old daughter who barricaded herself in her parent's house, refusing to leave following a disappointing love affair; a mother's decompensation as she tried to escape a symbiotic bond to her son.

What is shared in common, by Reuveni and others such as Speck, Garrison, Pattison, and so on, is an eschewing of the traditional psychodynamic one to one model of treatment for those in emotional distress. Again, the unit of intervention is not the individual or even the nuclear family, but rather the social network, with emotional distress formulated in terms of a deficiency in the support systems.

Garrison (1978) has evolved a five component network approach which has been implemented in cases of drug abuse, for elderly persons during times of crisis and as an adjunct in psychiatric hospitals and the community mental health system with psychiatric nurses. His approach, although similar to that of Speck and Reuveni, is somewhat more structured and specific, at least in outline. The five essential components he lists are:

• 1. Inventorying the elements of the situation and very specifically defining the problem;
• 2. Listing alternative courses of action:
• 3. Listing liabilities and assets for each alternative;
• 4. Deciding on and testing an alternative and specifying criteria for improvement; and
• 5. Evaluating the outcome and scheduling another session if necessary.

Cohen (1975), in an article dealing with nocturnal neurosis (syndrome characterized by mixed neurotic symptoms with a pronounced nocturnal increase in severity, occurring in the recently isolated elderly) has analyzed the problem in terms of a failure of the social network support system to function during the evening hours (apparently due to fear of evening city hazards). A number of suggestions for reactivating the system during the evening hours tailored to the Manhatten, New York area are proposed. Suggestions include: the scheduling of evening activities at hotels with large numbers of elderly tenants, social service staff members accompanying elderly tenants to inexpensive restaurants, the scheduling of evening activities at senior citizen centers with transportation provided, group outings held out of senior citizen centers in the evenings (e.g. movies, cards, etc.), and establishment of evening telephone liaisons.

The crisis network approach has also been extended into the area of prevention. Implicit in the network approach (with it's assumption of the importance of the social network support system) is the potential utility of fortifying the social network for individuals in high risk categories. In one report of a pre-retirement seminar at a community college (Guerin, 1976), subjects mapped out their social networks and examined retirement plans in relation to their social networks (which resulted in reassessment of plans to move to Florida, for example, for certain couples), as well as the construction of x network in order to help in dealing with the retirement of a school principal after 40 years in the same community. The potential benefits of networking (whether as an intervention response to an actual or anticipated crisis) seem especially promising for the elderly. Finally, some additional areas that are offered by various authors as potential targets for the networking approach include the birth of a handicapped child, death of significant other aside from spouses, crises of old age and life transitions, institutionalization and crises experienced by persons while in institutions (such as death of significant others), discharge from institutions, drug abuse, natural disasters and so on.

REFERENCES

1. Pattison, E.M., et. al.,: A Psychosocial Kinship godel for Family Therapy. American Journal of Psychiatry, 132: 12, Dec. 1975, 1246-1251.
2. Marmor: The Ralationship Between Systems Theory and Community Psychiatry. Hospital & Commnity Psychiatry, 25:12, Dec. 1975, 807-819.
3. Pattison, B.W.: Social System Psychotherapy.
4. Reuvini, U.: Networking Families in Crisis, Human Sciences Press, N.Y., N.Y., 1979.
5. Garrison, J.8. and Here, J.: Community Intervention With the Elderly: A Social Networking Approach. Journal of the American Geriatrics Association, 24:7, 329-333.
6. Beels, G.C.: Social Netrorks, The Family, and The Schizophrenic Patient. Schizophrenia Bulletin, 4:4, 1978, 512-521
7. Cohen. C.I.: Nocturnal Neurosis of the Elderly: Failure of Agencies to Cope With the Problem. Journal of the American Geriatrics Society, 24:2, 86-8
8. Copeland, H.B. and Resnick, E.V.: The Tuesday Evening Club: Using Corunity Resources to Treat Chronically Ill Patients. Hospital & Community Psychiatry, 26:4, April 1975, 227-30
9. Caplan. G. and Killilen, M.: Support Systems and Mutual Help: Interidisciplinary Explorations, Grune and Stratton, 1976
10. Guerin, P.G.: Family Therapy: Theory and Practice, Garden Press, Inc., 1976
11. Rrickson, G. and Hogan: Family Therapy: An Introduction to Theory and Technique, Brooks-Wadsworth, 1972
12. Speck, R.V. and Attneave, C.L.: Family Networks, Pantheon Books, 1973
13. Speck, R.V.: Psychotherapy at the Social Network of a Schizophrenic Family (1967). Family Process, Sept., 208-214.

For more information, contact the Medical Psychology Service at Pinnacle Rehabilitation, 10120 West Broad Street, Suites G & H, Glen Allen, VA 23060, or call: 804-2709-5484.

In the broader context, as considered by Speck, political & social issues and problems may be appropriate for a retribalizing of persons sharing similar concerns. In this sense, the anti-war movement of the late 60's & early 70's, the anti-"nuke" movement of the 80's, and other issues capable of enlisting social concern & activism are serving to fortify supportive bonds between people. Ultimately, one may wish to extend this network conceptualization to it's fullest macrosocial application & envision a retribalization of the whole planet, in which bonds between people abound, while binds are few.