40 Journal of the Royal Society of Medicine Supplement No. 8 Volume 78 1985 Family circles

Thomas Boyd MA MRCGP General Practitioner, Bushey, Hertfordshire

The consultation in general practice has been threatening for the novice; it is probably best portrayed as a dialogue between an analytical, undertaken with supervision. perspicacious individual with a thorough know- ledge of the latest scientific developments-the Method patient - and a confused, harassed person The family circle method was devised by Susan struggling to come to grips with a multitude of Thrower, a family therapist in North Carolina diverse innovative therapies - the doctor. I offer to (Thrower et al. 1982). It allows one to introduce the latter an introduction to a technique which will concepts from family systems theory within the permit him to utilize concepts from family therapy constraints of general practice (though not perhaps in his work with his patients. the six-minute consultation) and in consultations with individuals. The patient is given a large piece Introduction of paper, a flip chart is ideal, with a circle drawn Doctors are often uneasily aware that the symptom on it and instructed: to a some presented them is manifestation of 'I think I will be better able to help you with your distress in the family. This awareness may stem problem(s) if I know more about your family. This circle from a pattern recognized in encounters with other represents your family. I would like you to draw other individuals from that family or from direct circles representing yourself and individuals within or observation of some aspect of family functioning, outside your family who are important. The circles may sometimes on a home visit. The general practitioner vary in size and you may place them inside or outside your is in an ideal position to formulate hypotheses family circle as you wish. Circles may touch or overlap. about families under his care in this way but may Please label each circle with the initials of the person it find it difficult to exploit their therapeutic potential represents.' in his work with the individual patient. Carefully These instructions may be expanded to allow phrased open-ended questions may not elicit the inclusion of circles representing important activities desired confirmation of the difficulties within the (work or recreation), events or inanimate objects. family or, if they do, may not open up any avenues Most people can complete their family circle in leading to a solution. five or ten minutes. They are then invited to explain Recognition that 'when one person in a family their drawing to the doctor or therapist. It is has pain all family members are feeling this pain important to allow the patient to take the lead in in some way' (Satir 1978) has led some general this process of self disclosure and not to seize some practitioners to adopt the methods of family feature of the circle which appears important to the therapy and introduce them into their work by therapist. Many patients will include features of seeing whole families at home or in their surgeries. their families which they would previously have This has led to impressive results in some hands found difficult to verbalize or, indeed, of which (Neighbour 1982), but it is time-consuming and they might not have been consciously aware.

Figure 1. (Reproduced by kind permission of Michael Heath and The Guardian) Journal of the Royal Society of Medicine Supplement No. 8 Volume 78 1984 41

Once the patient has explained his circle, the changes you would like to see?', 'What effect doctor may make comments or attempt to elicit would such a change have on others?' and so on. further information. Some of the central ideas of It may help to monitor changes by asking the family systems theory may be applied to the patient to redraw his circle at a later date. analysis of the patient's family in this way. These include the concepts of alliances, boundaries and Example change. Susan, a 36-year-old housewife, presented to her general practitioner with depression related to her Alliances recent separation from her husband Paul. Paul was In assessing a family prior to or in the throes of wound up in his work, firfancially irresponsible and therapy, a family therapist notes the presence, spent little time with his wife or their three composition of and role of alliances. These may children - Amy, Barbara and Chris, aged 13, 9 and be central to the way in which the family deals with one year respectively. Amy presented at the same stresses or defuses conflict. time with recurrent abdominal pain. Examination of the circle may reveal 'family triangles' of which the archetype is the father, mother and child relationship. Such a triangle may face problems from an early stage (Figure 1). Study of the circle may similarly permit the exploration of intimacy and distance. Who is close to whom? Who interposes himself between conflicting individuals? Who sides with whom? Boundaries Boundaries define the sub-systems in the family. According to the structuralist school of family therapy (Minuchin 1974) the healthy family needs to maintain boundaries and rules to define the participation of each member within a particular sub-system. An 'enmeshed' family is one in which boundaries are blurred, family members are over- involved with one another and stresses on one individual reverberate inappropriately through the whole family. Such families are thought to be particularly predisposed to psychosomatic illness affecting one or more members. They may reveal Figure 2. Susan's family circle themselves in a circle which is drawn containing many very close or overlapping or even super- Susan was treated with antidepressants which imposed circles. had little effect. She was invited to draw her family A family in which boundaries are excessively circle (Figure 2). Susan explained, 'I am the circle.' rigid is termed 'disengaged'. These families are It transpired that she felt responsible for all the characterized by emotional distance between their members of her family including her chronically members who respond little or not at all to each depressed housebound mother, her stepfather and other's distress. Members of such families are prone her husband. Paul was also coping badly with the to anxiety or depression. Circles drawn by members separation and was blaming Susan. Amy was the of disengaged families may reveal the isolation felt same age that Susan had been when her own by those within them. mother had first become depressed as a result of marital difficulties. Amy was increasingly Change shouldering the burden of caring for one-year-old Those of us seeking to help our patients in distress Chris. have a vested interest in achieving change in them. Therapy focused on helping Susan adopt a more Such change inevitably causes changes within other realistic and less overwhelming view of her members of the family and may be resisted by the responsibilities - seeing herself within the family family's 'homeostatic' mechanisms. The way in circle rather than forming it. This led to exploration which a family reacts to stress or change is one of the role played by guilt in the functioning of the measure of its health. Such issues may be addressed family. Susan became less depressed and was able by asking questions like 'How would you like your to release Amy from her inappropriate parental family circle to be different?', 'To whom would role. Amy no longer complained of abdominal you like to be closer?' 'How could you achieve the pain. 42 Journal of the Royal Society of Medicine Supplement No. 8 Volume 78 1985

Applications I have found the method useful in introducing I have described the use of the family circle in the family therapy to trainee general practitioners. context of the one-to-one interaction between a Drawing circles of their own families in pairs or doctor and a patient, as this is the situation with small groups gives them confidence in the which most of us are most familiar. I have technique, facilitates the introduction of some of suggested that it is a useful tool for exploring family the useful but repellent jargon of family therapy dynamics with a symptomatic individual. It is easily and begins the process of understanding themselves learned and allows limited disclosure or quite and their families. intense examination of sensitive interpersonal Finally, I would like to suggest that the method issues. In contrast to the genogram, it is more is an ideal one for you to examine your own family, concerned with the 'here and now' aspects of family prior to exploring those of some of your patients. interaction, as is most family therapy, than with Why not draw your own family circle and discuss the historical and structural features of the family. it with another member? The family circle may also be used with the whole family. Each member of the family may be invited References to draw a circle and compare his view of the family Minuchin S with that of other members. Alternatively the (1974) Families and Family Therapy. Tavistock, London Neighbour R H family may be asked to cooperate in drawing a (1982) Journal ofthe Royal College ofGeneral Practitioners 32, circle together. This exercise itself gives valuable 737-742 information about how a family operates and may Satir V (1978) Conjoint Family Therapy. Souvenir Press, London permit the therapist to focus on issues of leadership, Thrower S M, Bruce W E & Walton R F hierarchy, cooperation and conflict. (1982) Journal of Family Practice 3, 451-7