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Bigger picture, lighter touch
I have just hosted the first European conference on systemic family medicine. This happened more or less accidentally. I have a good friend in Finland, Pekka Larivaara, who is the only professor of systemic family medicine in Europe. Pekka asked me a few months ago if he could bring over some GPs to meet like-minded colleagues in Britain. I sent round a few emails to people who might be interested, and then decided it might be fun to invite some contacts in other countries too. They passed on the message, and the event started to gather momentum. When it finally arrived we had 70 people from seven countries, and enough offers to put on four symposia, eight workshops and three plenary talks. It certainly didn't seem too grandiose at that point to call it the first European conference on systemic family medicine, so we did.Systemic family medicine, in case you are wondering, isn't a way of delivering primary care intravenously. It draws on skills and ideas from family therapy, and applies them to primary care. Systemic practitioners pay attention to the family, the team, the organization, and a range of other networks including social and cultural ones. They examine how these influence human problems and, more importantly, how they can be resources for resolving them. Systemic practitioners prefer to focus on three-dimensional processes rather than linear ones, so they are interested in patterns rather than facts, stories rather than diagnoses, and the creation of understanding rather than mere ‘solutions’. Sometimes, this means working with a couple, family or group rather than just with one individual, or with more than one practitioner in the room at the same time.
Clinically, systemic approaches are helpful with many kinds of mental health problems, with ‘grey area’ conditions like chronic fatigue and fibromyalgia, with unexplained symptoms, and with frequent consulters. (There is good evidence, for example, that systemic consultations with married couples are more effective in depression than other forms of therapy or than drugs.) Some systemic GPs, like Pekka and myself, have dual training in family therapy and general practice. Others learn the approach mainly through experience. Not surprisingly, some of us are also involved in team development, supervision, interprofessional education and organizational consultancy.
In many ways it was fitting that the conference should have occurred in such an improvisatory way. After all, systemic practice is itself about letting things happen rather than making them happen: in other words, about ‘trusting the system’. All systemic approaches depend on the notion that complex adaptive systems, including human ones, contain an inherent capacity to change, if encouraged and allowed to do so. Although there is a tremendous amount of theory to explain how this works (ranging from cybernetics and general system theory to linguistic philosophy and social constructionism) it is easier to convey this through metaphor. It helps, for example, if you can imagine that you are taking a small part in a vast collaborative dance ... or offering people a few sentences in a vast and as yet unwritten play with millions of other cast members who are offstage and invisible.
Some people, particularly those with an artistic or religious bent, seem to grasp such ideas instantly. Others struggle with them, because they seems so much at odds with all that medicine has taught them previously about single causes and predictable effects, and the importance of reaching ‘the right answer’. Even sceptics become convinced, however, when they have learned some of the core techniques of systemic work: neutrality, curiosity, interactive questioning, how to develop hypotheses in the round, and how to tolerate multiple views of reality at the same time.
There is, of course, a question as to whether systemic family medicine can really ‘exist’ as a distinct approach. How can an approach that depends on exploring different ways of constructing the world be pinned down with a single description? How can something so elusive, provisional and evolutionary be captured by a single, unchanging term? There is also a big overlap between systemic practice and many other contemporary ways of thinking: these include patient-centred medicine, shared decision-making, narrative-based medicine and complexity. Some of the people who practise systemic family medicine don't actually want to identify it as such, for fear of seeming too exclusive. Yet there does appear to be something—a stance, perhaps, or a turn of mind—that distinguishes the systemic approach from most other ways of looking at medicine.
Will there ever be a second European conference on the subject? Pekka is more strategic than I am, and he wants us to start planning now. He tells me that we would have attracted more Nordic participants if we had been able to send out a programme 6 months in advance, rather than putting together the final version at four in the afternoon on the previous day. I am sure he is right. But if we are to be truly systemic, we will probably need to watch out for early signs of institutionalization, or a hardening of the philosophical arteries. And if we ever turn into another boring orthodoxy, and lose our capacity to improvise, we will need to reinvent ourselves as something else.
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