Systemic Thinking for “Individual Diagnoses”

Systemic Thinking for “Individual Diagnoses”

In response to several prior blog posts, many have questioned the necessity of systemic family therapy for dysregulation that on the surface appears to be centered in the individual. For example, one commentator asked, “What difference does it make to think systems about an individual diagnosis such as this?” in reference to my thoughts on treating the alcoholic family. Others have questioned the feasibility and logistics of gathering multiple family members as well as the lack of commitment or ability of family members to acknowledge their role in creating and maintaining the individual disability. Thankfully a systems perspective can be utilized regardless of how many people are physically present in the consulting room.

An individual’s behavior takes place in context and emotional connection with others. It is both reciprocal and interactive. While individual traits and temperaments help determine one’s initial self-representation, the response of others modifies, reinforces or diminishes one’s thought, feelings and behaviors. I would maintain in consonance with John Donne,

No man is an island,

Entire of itself.

Each is a piece of the continent,

A part of the main.

The Systemic Family Therapy perspective is holistic and integrative. It is based on an all-encompassing theoretical orientation that views the family as a social system, the whole being much greater than the sum of its parts. Family systems theory addresses both the intrapsychic and the interpersonal realms and connects individual and relationship problems to the multiple triangles that surround and entangle them. While it may be true that each family member has a different point of view, a different agenda and different needs, wants and desires, it is also true that they all ultimately want the same thing – a better, more productive, less antagonistic way to solve problems. The patient/client is the relationship.

Ronald B Cohen of responds to feedback he's received from his previous posts on systemic family therapy.We have all experienced being stuck in repetitive cycles of approach/avoid, criticize/defend or attack/withdrawal. Conflict must disappear for issues to be resolved. This necessitates addressing the saint/sinner or victim/villain dynamic. This necessitates a re-organization of the family in order to establish health relationships, adapt to new roles, address other family issues and help achieve desired level of intimacy. Helping the family learn new behavioral skills for coping with stress and conflict is both healing and protective.

Current evidence supports increased emphasis on family-oriented clinical practice. In one of my own disciplines, the Residency Review Committee for Psychiatry core competencies require psychiatric residents to be specifically taught how to assess the patient within the family and larger social system, how to formulate a treatment plan that includes these psychosocial elements, and how to support the family system. The American Psychiatric Association practice guidelines for schizophrenia, bipolar disorder, major depression, panic disorder, eating disorders, alcohol dependence and substance abuse disorders all include recommendations for early family involvement. Management of biologically based severe mental illnesses occurs within the context of ongoing transactional processes that can influence their future course and outcome.

Systemic family therapy requires an extensive knowledge base and a unique skill set built upon specialized training, experience and expertise. Working with families and thinking systemically is hard work. If it were easy we’d all do it. The pathway is paved with difficulty and challenge but the result of second-order systemic change in both a time and cost effective manner is almost magical.

Please feel free to ask any questions or to comment in the “Leave a Reply” box below. To request more information and/or schedule an initial consultation, click here (
You are encouraged to forward this blog to anyone who would be interested in reading it.


Ronald B Cohen, MD, PC Ronald B. Cohen, MD
Bowen Family Systems Coach
1 Barstow Road, Suite P-10
Great Neck, NY 11021
(516) 466-7530
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  1. Jude Webster on January 12, 2013 at 9:05 am said:

    Ron, as a fellow family therapist, I completely agree with you. Thanks for posting this. Always good to see the family perspective is alive and well! Jude

    • Ronald B Cohen, MD on January 17, 2013 at 8:45 am said:

      Hi Jude,

      Thank you for the supportive comment. I think it behooves all of us in the trenches to continuously highlight the value of family interventions as they are distinctly not normative in most therapeutic circles. Keep up the good work.



  2. Hanna Perlberger on January 12, 2013 at 9:19 pm said:

    This reminds me of the saying – “Some things are true whether you believe them or not.” If there’s more than 1 of you, it’s a system.

    I’m a divorce lawyer – turned marriage coach – started reading up on constellation theory, Bowen, and thinking about getting an MFT.

    I am happy to forward your blog. If you like my blogs, may I ask you to do the same for me?

    • Ronald B Cohen, MD on January 17, 2013 at 10:00 am said:

      Hi Hanna,

      Well said. Life is lived in context and relationship. The negative side of the triangle is merely a symptomatic expression of a total family problem. There is no differentiation without connection, no autonomy without healthy interdependence. If I can help with your career transition and learning please don’t hesitate to ask. Looking forward to continuing the conversation.



  3. David Brasted on January 13, 2013 at 2:00 pm said:

    Hi Ronald,

    Yes I too have worked in family therapy as a team member and miss it as I found it really interesting and I agree working with a family systemically does help everyone and is inclusive. However I was on training teams and found the dysfucnctionality and “lord of the flies attitude” of many on the team often harder to deal with than the family we were treating. As a sensitive person and a quick thinking but slower processing person I certainly suffered in this regard at the hands of poor supervision and impatient and possibly less creative fellow team members with large egos and problems of megalomania.

    I have recently seen a job out of my state calling on these skills and I noticed I am sorely tempted to apply for it.

    But I guess the point is the systemic knowledge and experience I have still colours and always will my work with individuals and other groups.


    • Ronald B Cohen, MD on January 17, 2013 at 11:00 am said:

      Hi David,

      In 1972 Bowen wrote a paper entitled “Toward the Differentiation of Self in Administrative Systems” and in 1973 paper he wrote “Society, Crisis, and Systems Theory”. Both address some of your experiences. I will be publishing another blog Systemic Thinking for “Societal Diagnoses” at the end of January. Best of luck.



  4. Michael Browning on January 13, 2013 at 8:39 pm said:

    I agree with Dr.Cohen’s approach and have found it useful when the family is willing. I often see this with parents who bring their teenage or adult children to the therapist. Often they are at their wit’s end and wish for the therapist to help the son or daughter. Inviting them all into therapy can often throw them off their plan as the concern is mainly for their loved one. But building on their willingness to help their family member, and acceptance that their approaches to date have yielded little fruit, they become open to joining in the process of therapy. I believe, much like in the psychodynamic approach, that the intra-psychic domain is heavily influenced by the Family of Origin’s (FOO) interpersonal dynamics. Often, helping the family see the patterns of their interpersonal relationships enables them to identify how their intra-psychic dynamic is affected and how it evokes certain responses in others. Sometimes the process is the reverse with more delving into the intra-psychic dynamics which reveal how the interpersonal dynamics come to be. It is a “chicken or egg” issue in the end as both are intrinsically linked. I look forward to more posts like these.

  5. Lou Engelhardt on January 14, 2013 at 8:23 am said:

    Thank you for this article – it is so important! And in the field of divorce and mediation for families with children (and even some without kids), it is the family that must be addressed, even when a couple no longer wishes to be in an intimate marriage or relationship. They are still a family, and they still will need to communicate effectively and respectfully always when there are children involved.

    • Ronald B Cohen, MD on January 17, 2013 at 10:42 pm said:

      Hi Lou,

      I couldn’t have said it better myself though I did try in two recent blog posts, The Emotional Divorce and We’re Still Family. I have been accused of being the eternal optimist but I nonetheless maintain that family relationships are not optional, that a family with children is always a family regardless of the status of the parents ongoing intimate partner relationship and that all nuclear and extended family members potentially benefit from the maintenance of both filial and in-law relationships.



  6. Hazel Zemel on January 15, 2013 at 11:34 am said:

    Really appreciated your article to ‘re-address’ the sceptics and reinforce the importance of connections. Family Therapy has long been in the forefront of creating meaningful change creatively. All the new brain research is stressing the impact of connections and relationships on brain/mind/health and satisfaction.

  7. Herb ,LCAT, EMDRII on January 30, 2013 at 8:11 pm said:

    I have been twice now referred adult children of other therapists ultimately learning they are the cross bearers in the family system but alone in my office I struggle to find any pathology. In contrast when I am working with a client who has an Axis I Disorder, the family dynamic is (mal)adaptive to the dysfunction of a family member. Sometimes this is a guilt reaction and sometimes it is a denial process. To my client-they are family and yearn to be in a less central role.

    • Ronald B Cohen, MD on February 5, 2013 at 11:07 am said:

      Hi Herb,

      You speak to multiple issues in thinking systemically. Michael Kerr in a recent editorial wrote, “If a therapist mixes cause and effect thinking with systems thinking, it is not a Bowen theory based therapy”. Once one starts to look for causality that is linear thinking and consequently no longer systemic. In family relationship difficulties there are no saints, there are no sinners, there are no victims, there are no villains. Everyone is a player and even though symptoms develop in the most vulnerable family member they always develop in an interpersonal context where the whole is greater than the sum of its parts. The goal of staying connected despite differences is the essence of self-differentiation. Cut-offs are almost always not functional or productive.



  8. Herb Cohen,LCAT, EMDRII on January 30, 2013 at 8:11 pm said:

    I have been twice now referred adult children of other therapists ultimately learning they are the cross bearers in the family system but alone in my office I struggle to find any pathology. In contrast when I am working with a client who has an Axis I Disorder, the family dynamic is (mal)adaptive to the dysfunction of a family member. Sometimes this is a guilt reaction and sometimes it is a denial process. To my client-they are family and yearn to be in a less central role.

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