_____________________________________________________________________________________________________________

Fam Proc 33:341-355, 1994

Sculpting Present and Future: A Systemic Intervention Model Applied

to Psychosomatic Families
LUIGI ONNIS, M.D.a
ANGELO DI GENNARO, Ph.D.b
GIULIA CESPA, Ph.D.b
BARBARA AGOSTINI, Ph.D.b
ANA CHOUHY, M.D.b
ROSA CELESTE DENTALE, Ph.D.b
PAOLO QUINZI, M.D.b
aProfessor, Department of Psychiatry, "La Sapienza" University of Rome; Training Director, "Istituto Europeo di Formazione e
Consulenza Sistemica (IEFCOS), Piazza Buenos Aires 5, 00161 Rome, Italy. Send reprint requests to Dr. Onnis at Viale Ionio 389,
00141 Rome, Italy.
bThe co-authors are psychologists or medical doctors working in the Family Therapy Service of the Department of Psychiatry, "La
Sapienza" University of Rome.
We present a therapeutic intervention model for use with psychosomatic families. This method, the result of our
extensive research on various psychosomatic disorders, uses family sculptures of the "present" and "future": each family
member is requested to represent the family as it now "is," and how it "will be" in the future. We discuss the theoretical
reasons for our choice of this method: (a) the opportunity to use a therapeutic language that is similar to the nonverbal
language of the psychosomatic symptom, and (b) the usefulness of reinserting temporal dimensions into family systems
that seem to have lost their evolutionary potential and to be in a sort of "time lock." Two clinical cases are discussed (a
child with chronic asthma and an anorexic adolescent); the use of sculptures in both cases revealed the underlying
problems and made positive therapeutic interventions possible. Finally, we point out how the use of sculpture as a
therapeutic technique enables therapists to deal with multiple systemic levels.
Research work on therapeutic intervention in families with psychosomatic disorders is the natural evolution of our
previous research (Onnis, Tortolani, & Cancrini, 1986). In that first study, we evaluated interactive models and patterns of
communication in psychosomatic families, identifying the correlation between these and the persistence of the
psychosomatic symptom. We also demonstrated how medical therapy, which ignores the correlation between the patient's
symptom and the family context, contributes to the perpetuation of the chronic nature of the illness. For these reasons, our
present study is focused on the elaboration of a therapeutic strategy that attempts to prevent chronicity by combining family
therapy with medical-pharmacological therapy (Onnis, 1993a).
Parallel to this, during our therapeutic work with psychosomatic families, we experimented with a specific model of
intervention, which we will present later in this article. It is a method that employs nonverbal techniques to explore the
family's time dimension and, thus, its evolutionary capacity, with the objective of stimulating therapeutic evolution. The
method involves the use of family sculptures of present and future. Although this technique has been used in family therapy
in the past, in this case the innovation is the association of the spatial metaphor, which is always present in sculptures, with
the diachronic dimension of time. As often occurs in therapy, this model of intervention was arrived at empirically, but it
was gradually refined in the course of various experiments. Even though it has not yet been evaluated by a rigorous
scientific study with control groups, today it is a frequent if not constant choice in the therapy of psychosomatic families.
We believe that two major reasons led to this choice:
1. The first reason relates to the profound conceptual innovations that have taken place in the systemic field in recent
years, and which have had inevitable repercussions on therapeutic practice. Particularly, therapeutic models centered
on a concept of the therapist's "neutrality" are being replaced by therapeutic interventions that leave greater room for
free, creative interaction between the family system and the therapist (for an epistemological point of view, see
Bateson & Reusch, 1968; von Foerster, 1981; Maturana & Varela, 1980; for theoretical developments and clinical
applications, see Andersen, 1987; Cancrini, 1987; Cecchin, 1987; Griffith, Griffith, & Slovik, 1990; Hoffman, 1985;
Onnis, 1987, 1989a,b, 1990; Penn, 1985; Tomm, 1987; White & Epston, 1990). The frequent choice of analogical
language in therapy is a result of such orientations (see Andrey, 1987; Caillé, 1985; Caillé & Rey, 1988; Chasin,
Roth, & Bograd, 1989). Analogical language, which is less well-defined but richer in possible meanings than digital

1
_____________________________________________________________________________________________________________

language, better stimulates the mutual creativity of the family system and the therapist and also permits the
exploration of more profound, less manifested emotional levels.
2. In addition to these general epistemological considerations, which we reconsider in the conclusion of this article,
there are motives of another nature that led us to use the model of sculptures of the present and future. These motives
are relative to the specific nature of the situations in which we began to experiment with this method. In families with
psychosomatic disorders, the origin of the problem appears to be a blockage of the evolutionary process. This "time
lock" can be explored and eventually removed with therapeutic interventions that reintegrate the dimension and
perception of time in the system. Furthermore, in psychosomatic situations, the disorder, which is physically
manifested, expresses itself in an analogical manner in the form of nonverbal communication. Our study began here:
we asked ourselves if in these situations a therapeutic language more similar to the language of the symptom would
be more useful and effective.

Revising the Concept of "Alexithymia"

A fundamental problem when dealing with psychosomatic disorders is the language of the symptom. For many years,
from Freud (1894, 1901) onwards, there has been discussion in the various schools of psychoanalytical psychosomatics on
the reasons why the disorder is manifested somatically and why the symptom chooses "body language." In particular, the
question has been whether the totally nonverbal and analogical form through which suffering is expressed is related to an
impossibility or difficulty in verbalizing certain emotional experiences.
This hypothesis is traditional in those writers with an individual, psychodynamic orientation, and has been used to
explain certain psychosomatic manifestations with the name, proposed by Sifneos (1975), "alexithymia," which means
"lack of words to express emotions," or "difficulty in recognizing and describing one's emotions, defining them in terms of
somatic sensations or behavioral reactions" (Stedman's Medical Dictionary, 1990, p. 43). Also related to this concept is
the earlier phrase "pensée operatoire," an expression used by the authors from the French school, Marty, De M'Uzan, and
David (1966). All these authors with an individual orientation believed that this difficulty was due to an alteration of the
structure of the patient's personality, an intrinsic "constriction of emotional functionality" (to use Sifneos' expression).
Therefore, the difficulty in verbalizing emotions rapidly became synonymous with the "absence of emotions." These studies,
typically limited solely to the observation of the patient, perceived the pathology as residing in the individual.
Our studies, however, suggest a possible revision of this concept in systemic terms (see Onnis & Di Gennaro, 1987). If
the patient is observed in the broader context of the family system, and if there is an effort to find a correlation, which
Bateson (1979) called the "pattern which connects" (p. 11), then this phenomenon can be observed from a different point of
view: the constriction of emotional functioning attributed to the patient appears to be an "attribute" of the system rather than
a characteristic of the patient's personality. It appears to be a phenomenological expression of interactive models and shared
myths, which are more evident in the symptomatic family member. These models and myths rigidly control the systemic
communication and the patient is "forced" to conform to them.
The well-known pioneering work of Minuchin and his colleagues (1978), and our studies on the structure and dynamics
of families with psychosomatic patients (Onnis, 1985; Onnis, Tortolani, & Cancrini, 1986; Onnis, Tortolani, Di Gennaro,
et al., 1985), have clearly demonstrated that one of the most typical disfunctional characteristics in these families is the
tendency to avoid any manifestation of conflict and emotional tension. Thus, it can be understood and verified how the
difficulties in "verbalizing emotional experiences" are not the consequence of an "absence" of imagination or emotion but
rather the consequence of the fact that emotions are accurately filtered out to avoid tensions or conflict, and to maintain the
"pseudo-harmony" of the family system. It can also be observed that not only the patient but all the members of the family
cooperate to maintain this situation. It is perhaps thus possible to affirm that the language of the symptom, even though
somatically manifested by the patient, is the body language not only of the patient but of the entire "family body." On the
basis of these considerations, we began to elaborate a model of therapeutic intervention that we will now describe.

The Model
This model is based on the hypothesis that, in therapeutic work for families with psychosomatic disorders, the
intervention and gathering of information should not use verbal communication but, rather, analogical levels of
communication. The attempt was made to adopt a therapeutic language analogous to the language of the symptom,
modulated by implicit and metaphorical significance of body language (which is, as we have seen, the "official" language of
these families), that is, by using physical and spatial metaphors. One of the objectives was to explore, through this
similarity of languages and through the "unspoken" and analogical, the aspects the family usually does not reveal: the
mythical image, shared by its members, that the family has of itself (refer also to Caillé, 1985). For this reason, we began to
experiment with the use of family sculptures.
This technique is still experimental and the subject of a current study (see Onnis, Di Gennaro, & Cancrini, 1988). But
there is no doubt that the information obtained to date is extremely encouraging and confirms the validity of the method

2
_____________________________________________________________________________________________________________

both for the quantity and quality of information obtained, and for the areas of therapeutic intervention it opens up.
As is known, "sculptures" were introduced into family therapy by Satir (1972), Duhl, Kantor, and Duhl (1973), and by
Papp (1976). They consist in requesting that the family make a visual and spatial representation of their self-image through
the position of their bodies in space, their expression and posture, through their use of closeness or distance, and through
the direction of their glances. It is thus a totally analogical and nonverbal representation that, when completed, can be
followed by individual members' comments on their personal feelings.
Our model has been modified with respect to Papp's original method. Each member of the family is asked to make two
sculptures: the first is a sculpture of the present, representing the family as the "sculptor" sees it, in the phenomenology of
current interactions. The second is a sculpture of the future, representing the family as the "sculptor" believes it will be in
the future, for example, in 10 years from the present.
This is an important modification in our model with respect to Papp's method, which, instead, proposed a second
sculpture representing the desired "change": how each member "wished" the family were. We chose to introduce this
modification because of specific characteristics of families with psychosomatic disorders. What we have often observed is
that the second sculpture we propose, despite the fact that it is projected into the future, is not a representation of change
or, in any case, that it reveals a resistance and a fear of (rather than a desire for) change.
In some cases of the most classic psychosomatic situations, the interactions, roles, ties, and reciprocal relationships
remain unchanged: it is as though the evolutionary capability of these families or, more precisely, their ability to "see
themselves" in evolution were blocked. (For this kind of family's development as "frozen in time," see also Steinglass,
Temple, Lismand & Reiss, 1982.) In other cases, the attempt to represent a more dynamic situation of development is
accompanied by strong fears of change, as if the potential evolution of the family were perceived more as a "threat" than as
an experience of mutual growth. It is, therefore, through metaphorical representations that emotions are implicitly and
analogically expressed. They are emotions of fear of any change that might modify the painful but reassuring stability of the
status quo. They are fears that the individualization of the members could disrupt family unity; they are the phantoms of
threatening and unresolvable conflicts if the growth and "break-away" of the children forces the parents to remain
"face-to-face" without mediation.
Through the sculptures, the myths and phantoms found in these families emerge: myths of "family unity" as a supreme
value to be defended at all costs, accompanied by "phantoms of break-up" because any evidence of autonomy generates fear
of disintegration and ending. Sculptures therefore open up a rich source of information for the therapist, offering elements
for a new interpretation of the situation (redefining the symptom is often difficult when dealing with somatic symptoms),
and useful in elaborating strategies of intervention.

CHARACTERISTICS OF THE STUDY

We would first of all like to point out that the method of intervention described is still currently the result of extensive
clinical work being conducted in various therapeutic settings, and that it has not yet been validated by rigorous scientific
study with control groups. Nevertheless, the data obtained to date are encouraging with respect to the efficacy and
usefulness of the method.
This method of intervention, based on sculptures of the present and future, was used in public health facilities (such as
the Family Therapy Service of the Department of Psychiatry of the University of Rome) and in private facilities (such as our
Institute of Systemic Therapy, IEFCOS). These facilities are equipped with one-way mirrors and video tape recorders,
though this equipment is dispensable with the use of sculptures.

Subjects
We have used this method in the treatment of 41 families with psychosomatic problems (15 cases of bronchial asthma, 5
of enuresis or encopresis, 6 of obesity, 7 of anorexia, 4 of ulcerative colitis, 1 of diabetes, 1 of alopecia, 1 of psoriasis, 1 of
gastritis and psychogenic vomit).

Results
With the exception of 3 cases (1 of encopresis and 2 of obesity) in which therapy was interrupted, all the other cases
showed either improvement or disappearance of the symptom, and, simultaneously, the family evolutionary process
resumed. Of course, many of these situations still require followup and, thus, results are still incomplete. We can, however,
affirm that in all cases the sessions dedicated to family sculptures represented a therapeutic turning-point. It is probable that
the sculptures, in addition to providing a means of collecting information, also have a therapeutic effect in that they give the
family an opportunity to "see itself" in an intense sequence of imagery. The similarities to psychodrama are very strong
because it is in the psychodramatic game, in the role of organizer or participant, that patients can recover or discover
something about themselves.

3
_____________________________________________________________________________________________________________

We now discuss two clinical cases that will better clarify these concepts. They will also help illustrate two scenarios that,
though peculiar to individual family situations, are the most frequently represented in sculptures:
• the evolutionary immobility of the family such that it is difficult to foresee a potential future
• a more dynamic scene that is, however, accompanied by feelings of fear and dread of what might happen in the future

The Case of Gianni: When the Future Seems Impossible

Gianni is the first-born of a family of four: the father, age 45, a blue-collar worker; the mother, age 40, a housewife who
occasionally does dressmaking and alterations at home; Gianni, age 10, who is in 5th grade; and Sabrina, age 7, who is in
2nd grade.
The referral of the patient came from a pediatric ward, which presented Gianni to us as one of the most serious cases of
asthmatic children currently under its treatment. He has had asthmatic crises since the age of 4 and, despite
pharmacological treatment and vaccination for an allergy to pollen, he has shown only temporary improvement. He has had
repeated crises, almost daily at the beginning of the therapy, to the extent that his asthma was judged "untreatable."
In addition to the problem of asthma, Gianni is a particularly restless child: his parents cannot make him respect any rule,
and at school he is a poor student and highly undisciplined. There are obvious analogies between the "untreatable asthma"
and the "uncontrollable behavior" of Gianni. And, in fact, during the initial therapeutic sessions we worked primarily on
these analogies in an attempt to introduce an emotional and not exclusively biological factor that could justify the asthmatic
symptom: "All Gianni's restlessness cannot fail to manifest itself in emotional tension, which inevitably effects the
oncoming of the crises."
The parents are thus motivated to unite their strengths in order "to build a wall" to control Gianni, and thus to have a
beneficial effect on the crises as well. "If there are cracks or holes in this wall, Gianni will be tempted to blow into them to
see if he can make the wall collapse." The metaphor serves two purposes: to give a relational, not just a biological
explanation of the asthmatic crises, and to allude to the potential weaknesses of the mother who presents herself as the
conciliatory and permissive parent, while the father makes resolutions of authority and firmness that are regularly not
respected because of his "peripheral" involvement. The existence of a privileged relationship between Gianni and his
mother as a mediator of the latent conflict between parents was thus hypothesized. This conflict had been briefly manifested
and immediately suppressed during the pre-therapy interview (during the interviewer's absence), and no further mention
was made of it. On the contrary, the family always gave the impression of closeness and harmony.
Despite the fact that, by following the prescription, the parents managed to control Gianni better due to a more active
role of the father, and despite the fact that there was also some improvement in the asthmatic crises (less frequent at night),
it appeared necessary to open up new areas of information in order to continue therapy effectively. It was therefore decided
to have the family make "sculptures."
For the sake of brevity, we will describe only the two sculptures made by Gianni, the patient, which are particularly
significant because they provided the "key" to how the therapy should continue.

Sculpture of the Present

Asked to represent his family "as it was presently," Gianni, after some uncertainty, leaves an empty chair between his
parents. He places his sister Sabrina in front of and facing his mother, asking them to look at each other. He places himself
in front of the other members of the family, opposite the empty chair and farther back than Sabrina. It's as if he is in a
position of control; but, in particular, he faces his father and says, "He must look at me." After completing the sculpture he
quickly runs to sit down in the empty chair between his parents.
It is as though this sculpture reveals a secret: there is a void between the mother and father. It is significant and also very
touching that Gianni, immediately after completing the sculpture, tries to hide this secret by occupying (thus covering up)
this "void." Through this analogical metaphor represented by the family sculpture, Gianni sent a very clear, implicit
message to the therapist: "There is a distance between Mom and Dad. I have to capture Dad's attention and check that he
stays here, but I'm more certain that neither of the two will leave if I am between them."

Sculpture of the Future

Gianni was asked to represent the family as he imagined it would be in 10 years. He places his sister at a distance from
the family, but much farther to the right of both parents. She is facing away from them, "towards a friend," he says. Then he
places himself in front of his parents so that all three of them form a triangle, with himself as the apex. Although he is a
teenager or young adult, he has thus placed himself so that he is at the center of their attention, saying "They are looking at
me!" When the therapist asks, "And where are you looking?" Gianni first replies "I'm looking in the mirror," indicating the
one-way mirror on the wall in the room. But when his father and mother object: "We don't have a mirror like that at home!",
Gianni corrects himself and, turning toward his parents, says, "I'm looking at them. They are looking at me, and I'm looking

4
_____________________________________________________________________________________________________________

at them, like three pillars!" During the silence that accompanies the execution of the sculptures, Gianni begins to cough as
if he were about to have an asthma attack.
With this sculpture, this new metaphorical representation of the imagined future family situation, Gianni sends us an
implicit message of extreme importance: "I can't leave my parents alone. Sabrina can perhaps look outside, have her own
life, but I must stay here. I would like to see myself, reflect on myself [the desire to look into the mirror], but I cannot. If we
are no longer three pillars, everything can collapse." Gianni has represented a sort of eternal triangle where everything is
completely immobile, and where the dimension of time appears to have been lost. The family's evolutionary block is, in this
case, so rigid that it seems impossible to predict the future. The representation of the family provided by the sculptures has
torn the veil: the myth of family unity must be maintained at all costs, and the phantom of break-up and disintegration, if the
conflicting tensions become explicit, has materialized before our eyes. Gianni cannot find words to express either the myth
or the phantom, but he can represent them metaphorically. His loyalty to the family myth, those "invisible loyalties"
(Boszormenyi-Nagy & Spark, 1973; Stierlin, 1978), prevent him from thinking he can break away from the family because,
if a pillar is missing, everything would collapse. But the weight of the burden he is bearing is excessive for a child, and it
can suffocate him"take his breath away."
Based on the implicit messages sent by Gianni through his sculptures, in the following session we constructed a new
reframing that opened new therapeutic avenues:

The sculptures you made have proven very useful to us to better understand what is happening in your family. We
were particularly impressed by how Gianni sees himself in the future. Sabrina can have a friend and begin to go her
own way, even outside the family. But Gianni cannot! Gianni must stay near his parents to sustain the family. "We
are three pillars," he said.
We now understand how great an effort Gianni is making, how heavy the burden he is bearing is, an excessive
burden for a child, a burden which can suffocate him, cut off his air, take his breath away. But there is one thing
which remains obscure to us: why does Gianni think that his parents, alone, cannot carry this burden or organize
themselves to sustain it. We believe that there is another possibility: that his parents succeed in reassuring Gianni,
proving to him that they are capable of this. Perhaps then Gianni will find it easier to breathe, to begin to look at
himself and find his own way.

This redefinition has a paradoxical aspect because it is a positive connotation of the symptomsomething that Gianni is
generously offering in order to help the family. But, contrary to a classical paradoxical intervention, it ends not with a
prescription of the symptom but rather with the presentation of an alternative. Following Cancrini (1987), we have defined
this form of intervention, which is particularly useful in situations of psychosomatic or psychotic crisis, as the strategy of the
"double alternative" or of the "two roads" (see also Onnis 1987, 1989b). The family is faced with two possibilities: to
continue along the road followed in the past, the one leading to the positively defined symptom, or to turn down the road
toward change. And it is left up to the family to make this choice.
In Gianni's case, the family implicitly responded by choosing the second alternative. Affected by the emotional mood that
dominated the family (the sentiment of family unity), in the subsequent session the parents manifested a new and particular
solidarity with respect to the necessity of "reassuring" Gianni. The improvement in the parents' relationship also had a
positive effect on their relationship as a couple. This relationship was initially dealt with implicitly, but it later, almost
spontaneously, opened itself up to manifest problems and tensions that were dealt with in private sessions with the couple
in the final phase of therapy.
This final phase will not be discussed in detail. We can, however, affirm that as the emotional atmosphere between the
parents gradually improved and the manifestation and resolution of their tensions became possible, Gianni's symptom also
began to improve, with a surprising coincidence in timing: the asthmatic crises began to diminish in frequency from almost
daily to only one during the last 2 months of therapy; the spirometric data returned to normal levels; Gianni's restlessness
diminished and his scholastic performance become more satisfactory. A year after the conclusion of therapy, a subsequent
followup revealed that this improvement had continued.

The Case of Tiziana: Fear of the Future

Tiziana is a 15-year-old adolescent who, during the last 5 months, has undergone dramatic weight loss, rapidly dropping
from her normal weight of 100-102 pounds to 81 pounds. During the last 2 months she had also begun to suffer from
amenorrhea induced by her refusal to eat. This is the problem for which her mother requested family therapy, which was
recommended both by Tiziana's teacher, who is very close to her, and by the pediatrician who found no physical
justification for Tiziana's refusal to eat and therefore diagnosed mental anorexia.
The family is composed of four members: father, mother (both approximately age 45, lower middle-class), Tiziana, and

5
_____________________________________________________________________________________________________________

her 12-year-old brother, Massimo, who had suffered from allergic asthma for years. It is interesting to note that Tiziana's
anorexia became severe when Massimo's asthma began to improve.
The typical family structure, with poorly defined generational and individual boundaries and avoidance of conflict, was
apparent from the very first sessions. Every tension was deviated and polarized on Tiziana's eating problem. There was a
strong conflict with a tendency toward escalation between Tiziana and her mother who attempted to force a substantial diet
on her daughter. Tiziana's father appeared to be more tolerant and permissive. The occasional disagreements between the
parents are always relative to Tiziana's eating problem. Thus a typically rigid, triangular structure emerged. In this triangle,
Tiziana's eating problem and her privileged relationship with her father appeared to mediate a latent conflict between the
parents, covering it up and leaving it unresolved. This conflict did reveal itself, however, despite the apparently harmonious
family atmosphere, through the almost total absence of direct interaction, both verbal and nonverbal, between the two
parents.
Through a number of structural interventions aimed at creating a greater collaboration between the parents in dealing
with Tiziana, by directing attention away from the "eating problem" and by redirecting the adolescent rebellion toward
areas more useful for Tiziana's growth, a number of positive results are obtained and Tiziana begins to gain weight. As her
eating problem gradually ceased to dominate attention, however, other problems began to emerge: her poor socialization
and lack of relationships with classmatesdespite excellent scholastic performanceto the extent that she manifests an
actual "fear" of going out of the house.
It was immediately clear to us how difficult it would be to obtain meaningful information about these areas that were
more directly related to adolescent development and implicitly involved the problems in the parents' relationship. We
therefore decided to use family sculptures. We will briefly summarize the wealth of information the sculptures immediately
provided, which led to a therapeutic turning-point, and limit our discussion to two of the "sculptures of the future": the
father's and Tiziana's.

Father's Sculpture of the Future

The father represents the family as follows: he places Tiziana and Massimo standing in front of the window, looking
outwards: "They are beginning to go their own way," he says. He then places his wife and himself (at a slight angle to his
wife) seated behind the children, but at a distance from each other: "We are sitting at home." His wife's eyes are downcast;
she is distracted, silent, wrapped up in her thoughts. "She is thinking about the children," says the father. "She is asking
herself what they are doing, if they have eaten!" He observes his wife wrapped up in her thoughts from the opposite corner
of the room and then begins to read a newspaper. On completion of the sculpture, which is in itself full of analogical
meanings, the feelings expressed by the individual family members are particularly interesting:
F: I felt like a stray dogsad and lonely at the sight of what was left of family unity. I felt totally alone, or
rather [glances at his wife] half-alone because she was there. [His tone of voice implies "It was as if she
weren't there at all."]
Mo: [strongly melancholy tone of voice] I felt lonely too: it won't be nice to be without the children.
T: [hesitantly] I felt good. I thought I had more freedom and I had my friends, but I would have preferred
that Mom and Dad weren't at home but out for a walktogether. I was happy for myself but worried
about them, sitting at home alone.
Ma: [who during the sculptures was unable to follow his father's instructions and kept turning around to see
what his parents were doing behind his back] I felt both good and badgood for myself but bad for them
who were alone. I thought [almost whispering] that I would go back to visit them!

Tiziana's Sculpture of the Future

Her sculpture is a reflection of her father's. She places herself near the window, looking out, and creates space all around
her. Massimo is seated on a motorcycle and is together with other friends. The parents walk along the street but at a
distance from each other, and each stops to look at a different shop window (and it is on this aspect that the sculpture is
"fixed"). The metaphorical significances are also very evident in this sculpture, and the feelings expressed by the individual
family members confirm them:
T: [always a bit hesitant] I felt good. I was sorry that they were a bit distant from each other. I would have
preferred them to look at the same shop window.
F: [sounding depressed] I felt old, like those old men you see in the street and I felt her [his wife] old too,
following me.
Mo: Yes, I felt old too, old and tired. And I was worried about them [the children] out of the house.
Ma: It was nice to be on the motorcycle, but I was thinking about them. I was wondering where Mom and Dad
were going and what they were doing.
These two sculptures are sufficient to demonstrate that the "myths of unity" and "phantoms of break-up" are all there,

6
_____________________________________________________________________________________________________________

represented in those scenes, almost materialized before our eyes. The atmosphere of solitude, feelings of conjugal distance,
and of the finality proposed by the father as the necessary consequence of the family's division, is also reflected in the scene
represented by Tiziana and her feelings: a deep preoccupation about her parents' destiny, a feeling that "ties her down" and
contrasts with the expressed need for growth and autonomy.
How, in fact, can Tiziana break away from the family and open herself up to the world; how can Massimo take command
of his life if what remains behind them is the ruin of a myth they cannot renounce? And, although the scene presented
implies a possibility of movement and change, it is accompanied by deep fears and preoccupation with regard to what may
lie in the future. Thus, through the sculptures, this contradictory tumult of contrasting emotions, which cannot be directly
expressed in words, can be represented. It is as though the myths and phantoms take shape, separating themselves at last
from the patient and, at the same time, conferring new meaning and sense to Tiziana's suffering. These can now become the
privileged ground of therapeutic intervention as they are now evident and can no longer be disguised. Referring to the
sculptures, it is possible to explain Tiziana's "fear," and her reluctance to go out of the house can be positively redefined as
the "affectionate preoccupation that children feel for their parents in such a close family if they think that their growth and
detachment could be a source of sadness and loneliness for them." At the same time, the family's dominant feeling, that of
unity and reciprocal care and concern, is utilized by pointing out that "parents who have always been so sensitive and
concerned about their children's well-being must be able to demonstrate that they are capable of reassuring them."
The final phase of therapy was fundamentally focused on the parental subsystem. Although the therapeutic work
explicitly obliged them to find a better cohesion as parents (using the emotional channels easiest to move along), the
relationship between the couple was also implicitly transformed, as evidenced by a new solidarity and more intense
manifestations of affection.
Together with the improvement in the atmosphere between the parents, not only did the anorexic symptom disappear,
but both Tiziana and Massimo showed a remarkable increase in adolescent development. During the last session of therapy,
an acknowledgment of the results obtained was expressed by the father, who was initially the family member most skeptical
about the therapy and least willing to participate. It is the father who greets us, using a metaphor that could not better
synthesize the objective of the therapeutic process. "In a phase of our lives," he says, "we found ourselves facing a wall.
Coming for therapy we found a door. Together with you we have created a key." And replying to the mother who asks, as
she is leaving, if she can see us again should they have any further problems, we expressed our readiness to help. But at the
same time, we also expressed our confidence in their own ability to deal with their problems because "even if the door
should close again, we know that you now have the key."

Importance of the Past

The use of sculptures of present and future to explore the evolutionary dynamics of the family, the delays in the "life
cycle," and the difficulties of predicting the future, does not, of course, induce us to ignore the importance and influence of
the past. Here, in fact, implicit questions arise: How are the "myths of unity," which seem to constitute the cement of the
family, organized? From where do the "phantoms of break-up" emerge? What provokes the fear of family disintegration that
appears to dominate each individual's feelings and at the same time constitutes the common emotional bond that unites
them? Certainly, myths and phantoms are created and emerge over a period of time through a series of partly common,
partly individual experiences in a complex, intertwining network. It is a history that often has its roots in the parents' family
of origin and thus involves a trigenerational dimension of investigation.
We have been impressed by the frequency with which we have identified the occurrence of traumatic events such as
premature deaths, premature separations, serious illness, or abandonment in these families. In a word, the theme of "loss"
often appears to dominate these histories, and is accompanied by profound feelings of anguish and separation. (For the
importance of the theme of loss in family histories, see also Bowen, 1976, 1991; Paul, 1967; Paul and Grosser, 1965.)
For example, in Gianni's family, both the father and the mother lost one of their parents at an early age, when they were
still small children. In the second family, before Tiziana's mother married, she had assisted her chronically ill father for
many years and thus would have desired a husband capable of protecting her. But her husband had difficulty in responding
to this need because he had been, and continued to be, his mother's most beloved son, abandoned by the father when he was
still an adolescent. We therefore asked ourselves if the "myth of unity at all costs," which was so frequent in these families,
was born as a common defense to protect against fears of loss and the anguish of separation. For the moment, this is only a
hypothesis that must be more thoroughly examined. It stimulates us, however, to investigate more systematically the
trigenerational history of these families. Perhaps it would be possible to use an analogous tool: a "sculpture of the past"
(similar to experiments conducted by Chasin et al., 1989).

THE THERAPY
When to Use Family Sculptures

7
_____________________________________________________________________________________________________________

Contrary to the experience of other authors (for example, Caillé, 1985; Chasin et al., 1989) who used their model of
family sculptures from the beginning of therapy, often during the first session, our experience convinced us that this is not
possible when dealing with families who present psychosomatic disorders. In fact, these cases are so dominated by the
preoccupation with a physically apparent disorder that there is, consequently, a diffidence in these families toward therapy,
whose rationale is not understood despite years of excellent collaboration with and referrals from pediatricians and doctors.
There is, therefore, an understandably defensive attitude in the family, even if it is masked by apparent cordiality and
interest.
The initial phase of therapy is thus necessarily dedicated to the creation of a therapeutic alliance and a climate of
collaboration and trust in which the family can gradually open up and express itself. Family sculptures are proposed only
during the 4th or 5th session when an atmosphere of mutual collaboration between the family and therapist has usually been
established. These sculptures demand an effort of great emotional intensity, which the family would be unable to sustain in
the early phases of therapy. Usually, and particularly when dealing with large families, we dedicate two sessions to the
execution of sculptures: one to those representing the "present" and the other to those representing the "future."
After each session, the family is dismissed without any particular comment or with only a brief phrase such as: "We think
you have said many things to each other. We also feel we have nothing more to add." Only in the following session, after the
family members have had the opportunity to elaborate and assimilate the numerous messages they have exchanged, does
the therapist pick up on the elements that emerged from the sculptures, "recomposing them" to construct a redefinition of
the problem.

Redefinition of the Symptom As a Specific Family Metaphor

The objective of every systemic redefinition of the symptom is to extend its significance, relating it to a more global
family problem and thus offering the family a different view of reality. But to make this possible in the case of somatic
symptoms, it is necessary to identify the symbolic significance while at the same time amplifying it so that it becomes a
metaphor of the family problem. In this respect, the material that emerges from the sculptures is precious because the
sculptures themselves are metaphors as often as are the relative comments made by the individual "sculptors."
In our experience, redefinition is the more efficacious the better one is able to identify the specific relationship between
the "quality of the symptom" (which always has to be mentioned) and the metaphor of the family problem revealed by the
sculptures. Thus, in the cases previously discussed, Gianni's asthma is re-proposed as "the interrupted breath of a child who
is bearing a heavy burden if he feels he must be the third pillar"; and Tiziana's refusal to eat and fear of going out are
redefined as "the difficulty of detachment for an adolescent who foresees a future in which her parents cannot manage to
look at the same shop window." The information provided by the sculptures is therefore reorganized (like pieces of a
mosaic that have been rearranged) and reconnected to the symptom so that it acquires the significance of a "specific" family
metaphor.

Final Phase of Therapy

As illustrated by the case examples, the final phase of therapy is usually dedicated to working with distinct family
subsystems; when treating a child or adolescent patient, it is dedicated to the parental subsystem. In families in which the
avoidance of tensions is one of the specific characteristics, it is certainly not possible to deal directly with conjugal conflict.
Following the predominant emotional feeling (that of unity and reciprocal well-being), the objective of therapy is to induce
the parents to form a stronger parental cohesion in dealing with their children; at the same time, the relationship between
the couple also transforms itself. We have verified that this can also occur in cases where conjugal problems remain totally
implicit. It is not improbable that the intense emotional atmosphere that the couple experiences during the sculptures has an
influence in this type of situation. In other cases, the couple manages to express their conflict and the family system can then
begin to move toward a more mature evolution.

EPISTEMOLOGICAL SIGNIFICANCE
Before concluding, we would like to go back to the point mentioned at the beginning and briefly discuss the significance
that this therapeutic model based on sculptures of present and future appears to have in the light of current epistemological
thoughts about family therapy. We particularly point out the evaluation of the system as a complex reality according to the
so-called "view of complexity" (Morin, 1977; but also see Prigogine & Stengers, 1979; von Foerster, 1981; and Bateson,
1979). This "view of complexity" proposes the existence of a complex multiplicity of levels in every human reality, which,
while conserving their autonomy, nonetheless have circular inter-influences, and points of intersection.
While reductionistic models have taken into consideration or privileged only one of these levels, ignoring the others, the
perspective of complexity attempts, on the contrary, to re-establish relationships not in antonymic opposition but of
complementarity among these multiple levels (Onnis, 1993b; Cancrini, 1987). It thus attempts to recuperate not the holistic

8
_____________________________________________________________________________________________________________

sense of a "totality," which is unreachable, but rather the sense of the complex articulation of human reality. How does our
work with sculptures insert itself into this orientation, which does not want to be reductionistic but, rather, wants to respect
this human complexity?
It seems to us that sculptures represent an attempt to deal with a certain number of levels:
1. At the level of the body: The psychosomatic symptom is a symptom manifested through the body. The metaphorical
utilization of the body effected through sculptures introduces the message that the symptom can also have a
metaphorical significance that can be comprehended. Thus the symptom and the body acquire a symbolic meaning in
the true etymological sense of the word, which derives from the Greek word sunballein, meaning "to reunite." The
body "reunites in itself" and becomes the ground of multiple intersecting levels that connect the body to a context and
a history.
2. At the psycho-emotional level of the individual: In the totally particular way in which each member represents the
family in his or her own sculptures, each individual member expresses singular specificity and identity. And it is
precisely in the "singularity" of this personal vision of realitythat "singularity" of which Elkaïm (1983) so often
speaks and which Selvini-Palazzoli and colleagues (1988) refer to in their most recent workthat individuals
propose themselves as a "subject" and expresses their own feelings and subjective experiences.
3. At the family level of shared "myths": Especially in the "sculpture of the future," the representation, images, and
fantasies expressed by the various family members, though singularly different and distinct from one another, are all
constructed around a common "myth" and "value" (see the similar concept of "family paradigm" by Reiss, 1981). It is
absolutely typical and surprising to observe how a game of echoes and resonances is put into play among the various
sculptures, as though an intrafamily language, largely unconscious and emotional, pervaded them. It is here, in
reference to the intersection of levels, that the individual "identity" meets, confronts, and measures itself against the
systemic "membership."
4. At the therapeutic level: As previously mentioned, even though maintaining a differentiated position with respect to
the family, the therapist is continuously involved in the therapeutic process. He or she receives and transmits
information as in a game of mirrors in which the family can see itself not only through the image it projects of itself
but also in its image as reflected by the therapist. The family, in turn, transmits an image that can be incredibly
different from both the "old" image as well as the "alternative" image proposed by the therapist. It is in the play of
circularity among reflected images, starting from the sculptures, that the true process of "co-creation" between
therapist and family takes place.

CONCLUSIONS
In the light of results obtained to date, the method of sculptures of present and future seems to us to be a precious tool in
therapeutic work. It is particularly useful in the therapy of psychosomatic families because it uses an analogical language
that is similar to the body language of the symptom, and because it explores the dimension of time in family systems whose
evolutionary cycle seems to have been blocked (or delayed).
But we feel it can also be used in other situations, both to enrich the clinical repertoire of systemic intervention with
nonverbal techniques (see Chasin et al., 1989) and, more generally, for the significance it assumes in a new epistemology
of therapy. We would like to emphasize, however, that this method is still under study and, therefore, as in every
experimental effort, it must be further verified and examined.
We have had the opportunity to present and discuss this model with many groups of Italian and European colleagues
who, after experimenting with it, have given us valuable comments and suggestions. It is also thanks to their collaboration
and feedback that we will continue to work with this model, leaving it open to criticism, advice, and to the "spirit of
research."

REFERENCES
1. Andersen, T., The reflecting team: Dialogue and meta-dialogue in clinical work. Family Process, 26, 415-428,
1987.
2. Andrey, B., Un recadrage metaphorique: Le conte de la famille. Therapie Familiale, 8, 77-97, 1987.
3. Bateson, G., (1979). Mind and nature: A necessary unity. New York: E.P. Dutton.
4. Bateson, G. and Ruesch, F., (1968). The social matrix of psychiatry. New York: W.W. Norton.
5. Boszormenyi-Nagy, L. and Spark, G. M., (1973). Invisible loyalties: Reciprocity in intergenerational family
therapy. Hagerstown MD: Harper & Row.
6. Bowen, M., (1976). Theory in the practice of psychotherapy (pp. 42-90). In P.J. Guerin, Jr. (ed.), Family therapy:
Theory and practice. New York: Gardner Press.

9
_____________________________________________________________________________________________________________

7. Bowen, M., (1991). Family reaction to death (pp. 79-92). In F. Walsh & M. McGoldrick (eds.), Living beyond
loss: Death in the family. New York: W.W. Norton.
8. Caillé, P., (1985). Famille et therapeutes. Paris: E.S.F
9. Caillé, P. and Rey, I., (1988). Il etait une fois: Du drame familiale au conte systemique. Paris: E.S.F
10. Cancrini, L., (1987). La psicoterapia: Grammatica e sintasse. Rome: N.I.S
11. Cecchin, G., Hypothesizing, circularity, and neutrality revisited: An invitation to curiosity. Family Process, 26,
405-413, 1987.
12. Chasin, R., Roth, S. and Bograd, M., Action methods in systemic therapy: Dramatizing ideal futures and reformed
pasts with couples. Family Process, 28, 121-136, 1989.
13. Duhl, F. J., Kantor, D. and Duhl, B. S., (1973). Learning space and action in family therapy: A primer of sculpture
(pp. 47-63). In D.A. Bloch (ed.), Techniques of family psychotherapy: A primer. New York: Grune & Stratton.
14. Elkaïm, M., Des lois generales aux singularités. Cahiers Critiques de Therapie Familiale et de Pratiques de
Reseaux, 7, 111-120, 1983.
15. Foerster, H. von, (1981). Observing systems. Seaside CA: Intersystems Publications.
16. Freud, S., (1894). La neuropsicosi da difesa [Italian translation] (pp. 119-136). Opere (Vol. 2). Turin:
Boringhieri, 1968.
17. Freud, S., (1901). Frammenti di una analisi di isteria [Italian translation] (pp. 301-404). Opere (Vol. 4). Turin:
Boringhieri, 1968.
18. Griffith, J. L., Griffith, M. E. and Slovik, L. S., Mind-body problems in family therapy: Conrasting first- and
second-order cybernetic approaches. Family Process, 29, 13-28, 1990.
19. Hoffman, L., Beyond power and control: Toward a "second order" family systems therapy. Family Systems
Medicine, 3, 381-396, 1985.
20. Marty, P., De M'Uzan, M. and David, C., (1966). L 'investigation psychosomatique. Paris: Presse Universitaire
de France.
21. Maturana, H. R. and Varela, F. J., (1980). Autopoiesis and cognition: The realization of living. Boston: Reidel.
22. Minuchin, S., Rosman, B. L. and Baker, L., (1978). Psychosomatic families: Anorexia nervosa in context.
Cambridge: Harvard University Press.
23. Onnis, L., (1985). Corpo e contesto. Rome: N.I.S
24. Onnis, L., Redefinition des problems: Un exemple de la creativité du therapeute systemique. Therapie Familiale,
8, 59-70, 1987.
25. Onnis, L., Incurabilité ou absence de cure?, Therapie Familiale, 9, 199-218, 1988.
26. Onnis, L., Therapie systemique et optique de la complexité. Cahiers Critiques de Therapie Familiale et de
Pratique de Reseaux, 11, 107-110, 1989a.
27. Onnis, L., A systemic approach to the concept of crisis. Journal of Strategic and Systemic Therapies, 9, 43-54,
1989b.
28. Onnis, L., Relazione terapeutica e orientamento sistemico: Un'ipotesi epistemologica. Psicobiettivo, 1, 37-46,
1990.
29. Onnis, L., (1993a, August). An integrative therapeutic model in chronic asthma: Preliminary data of a research
work. Paper presented at the 12th World Congress of Psychosomatic Medicine, Berne, Switzerland.
30. Onnis, L., Psychosomatic medicine: Toward a new epistemology. Family Systems Medicine, 11, 137-148, 1993b.
31. Onnis, L. and Di Gennaro, A., Alexitimia: Una revisione critica. Medicina Psicosomatica, 32, 45-64, 1987.
32. Onnis, L., Di Gennaro, A. and Cancrini, L., (1988). L'asma infantile in una prospettiva sistemica: Da una revisione
del concetto di cronicità a un modello sperimentale di terapia (pp. 179-202). In L. Onnis (ed.), Famiglia e
malattia psicosomatica: L 'orientamento sistemico. Rome: N.I.S
33. Onnis, L., Tortolani, D. and Cancrini, L., Systemic research on chronicity factors in infantile asthma. Family
Process, 25, 107-122, 1986.
34. Onnis, L., Tortolani, D., Di Gennaro, A., Marinozzi, P., Petralito, G. and Roggi, D., (1985). Il bambino con
disturbi psicosomatici: La famiglia, la domanda, il servizio. Rome: Pensiero Scientifico Ed.
35. Papp, P., (1976). Family choreography (pp. 465-479). In P.J. Guerin, Jr. (ed.), Family therapy: Theory and
practice. New York: Gardner Press.
36. Paul, N. L., The use of empathy in the resolution of grief. Perspectives in Biology and Medicine, 11, 153-169,
1967.
37. Paul, N. L. and Grosser, G. H., Operational mourning and its role in conjoint family therapy. Journal of
Community Mental Health, 1, 333-345, 1965.
38. Penn, P., Feed-forward: Future questions, future maps. Family Process, 24, 299-310, 1985.
39. Prigogine, I. and Stengers, I., (1979). La nouvelle alliance. Paris: Gallimard.
40. Reiss, D., (1981). The family's construction of reality. Cambridge: Harvard University Press.

10
_____________________________________________________________________________________________________________

41. Satir, V., (1972). Peoplemaking. Palo Alto CA: Science and Behavior Books.
42. Selvini-Palazzoli, M., Cirillo, S., Selvini, M. and Sorrentino, A. M., (1988). I giochi psicotici nella famiglia.
Milan: Cortina Ed.
43. Sifneos, P. E., The prevalence of "alexithymic" characteristics in psychosomatic patients. Psychotherapies and
Psychosomatics, 22, 255-262, 1975.
44. Stedman's medical dictionary, (1990). Baltimore MD: Williams & Wilkins.
45. Steinglass, P., Temple, S., Lisman, S. A. and Reiss, D., Coping with spinal cord injury: The family perspective.
General Hospital Psychiatry, 4, 259-264, 1983.
46. Stierlin, H., (1978). Delegation und familie. Frankfurt: Suhrkamp Verlag.
47. Tomm, K., Interventive interviewing: Part II. Reflexive questioning as a means to enable self-healing. Family
Process, 26, 167-183, 1987.
48. White, M. and Epston, D., (1990). Narrative means to therapeutic ends. New York: W.W. Norton.
Manuscript received October 9, 1992; Revisions submitted September 25, 1993; Accepted November 29, 1993.

11