the family institute review · this essay explores the theoretical development of therapists‟ use...
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University of Glamorgan
Faculty of Health, Sport and Science
The Family Institute Review
2007 Volume 1
Contributors Jimmy Jones
Adrian Perkins
Mark Hendy
Sian Smith
Lucie Robinson
Damien Black
Anna Jenkins
Cathy Huxley
Editorial team:
Billy Hardy, Kieran Vivian-Byrne, Jeff Faris, Brenda Cox, Mandy Westlake.
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Contents: 3. Editorial ……………………………………………………………………………Kieran Vivian-Byrne
Billy Hardy
4. A discussion and critique of systemic theories of change……………………. Jimmy Jones Abstract
The focus of this essay is to describe and critically evaluate current theories of change within the systemic
literature. The article begins with a discussion of theories of change in terms of the diversity of different
perspectives or models of psychotherapy that are current within the systemic literature. It then moves
onto consider how we might understand the process and outcome of change. Finally, we consider the
wider context in which theories of change operate.
17. The clinical psychologist is not the expert: how “not to know” whether to take a
directive or non-directive position in relation to change in clinical
practice………………………………………………………………………………………….Lucie Robinson Abstract
This essay explores the theoretical development of therapists‟ use of directive and non-directive positions
in relation to change in the field of family therapy. Reflections upon my own experience and knowledge,
provide a first hand account of an emerging therapist‟s understanding of how these ideas can be useful in
clinical practice.
29. An Exploration of Communication Theory and Therapeutic Practice
………….……………………………………………………………………………………………Damien Black Abstract:
This essay explores the application of communication theory in a counselling interview with a client who
has been experiencing mild depression. Based on the first 30 minutes of a one hour audio-taped session
(4) the writer reflects on a number of communication issues and explores the impact of these on the
client, himself and the counselling process.
36. “An inspired journey” .………………………………………………………………..Anna Jenkins Abstract.
When asked to write an essay comparing two counselling approaches, I had an instinctive and irresistible
urge to explore both the Existential and Jungian Approaches, both of which resonated very strongly with
me, despite my knowing very little about either at the time. Writing the essay was an inspired personal
and professional journey of discovery. As I unearthed the vast and intriguing vista of Existential and
Jungian ideas, the experience felt like a very significant part of a much bigger transpersonal journey,
which had begun long before this essay and has continued with greater clarity and impetus since.
46. Theories of change in the field of systemic psychotherapy: A Critique
………………………………………………………………………………………………………..Mark Hendy Abstract
Theories of change provide the foundation for models used in systemic psychotherapy. This essay
considers the way that thinking about change has developed within the field and its relationship to wider
societal developments. It also observes how practitioners use language to create both dialogic and
narrative spaces that are congruent with these theories.
56. Counselling in the context of an ethical dilemma……………………………….Sian Smith Abstract
A man is referred for counselling following a disclosure to his GP that he has been sexually abused as a
child. In the course of my work with him he tells me that this happened when he was 10 years old and
that the perpetrator is his older brother. He tells me that his older brother has remarried a woman who
has a 10 year old son. My client does not want to inform the authorities. (This essay is about a
hypothetical situation allowing me the opportunity to explore ethical perspectives in Counselling).
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65. A Critical evaluation of cognitive behavioural therapy ………………….. Adrian Perkins
Abstract
The author considers the breadth of application of CBT before challenging reliance on the evidence –
based medical model as the sole means of measuring its effectiveness. The central contention is that the
measure of success of CBT should not be limited to symptom change; the author argues that the healthy
development of CBT will depend on a shift from the patient symptom paradigm to an integrated
approach which takes a holistic view of the person as an individual.
73. Following the Threads: Bateson to Ecosystemic Therapy…………………Cathy Huxley Abstract
The concept of Bateson as a father of family therapy is investigated and connections are made between
his ideas and current movements in science and therapy. The future of systemic therapy in the light of
new therapeutic movements and the current ecological crisis is discussed. The essay ponders why
Bateson is not more acclaimed in the UK.
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Dear Reader
Welcome to the first edition of The Family Institute Review. This review is
one small way of gathering and celebrating the work that you the students
of The Family Institute produce in the normal course of studying and
training to become Counsellors, Psychotherapist and systemic
practitioners. During the intensity of training, ideas from across these fields
are described, de-constructed and developed, adding depth and texture to
our understanding of this complex area of study and practice and benefits
us all.
In keeping with essay writing and „small-house‟ publishing as another way
of creating a spirit of inquiry, this review is offered as a „learning tool‟ for
student groups and colleagues associated with The Family Institute.
We are certain that this bundle is packed full of challenging, creative and
often inspiring writing. We are also certain that we could quite easily have
added to this list other essays, which in their way are examples of fine
academic writing, but the limitations of this publication would not allow.
Enjoy.
Kieran Vivian-Byrne
Billy Hardy
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Title: A discussion and critique of systemic theories of change
Jimmy Jones is a Consultant Clinical Psychologist in the Older People‟s Mental Health Service, North
Glamorgan NHS Trust. He is also a second year Clinical Associate on the MSc Systemic Psychotherapy
Course at the Family Institute.
Introduction
Change might be seen as difference between two (or more) points in time. A theory of
change then would specify how we might recognise and/or experience this difference,
the process by which this came about and the relationship between these. In essence,
all models of psychotherapy provide a theory of change (Fosha, 2005). However,
systemic psychotherapies might usefully be defined by an interest in context and
relationship (Flaskas, 2005). Accepting such a definition entails a particular dialogue
about change. Namely, that systemic theories of change focus at the level of system
organisation and/or the relationships between the constitute parts. These working
ideas regarding systemic theories of change will guide the following discussion.
However, we will examine the usefulness of these ideas throughout the article. We
shall begin with a brief description of current theories of change.
Models and theories of change
Common ideas The idea that reality is negotiated through language and that there are many equally
valid ways of describing experience seems to be a key principle within systemic theories
of change (Gehart-Brooks and Lyle, 1999). This idea is based on a social
constructionist stance, which suggest that experience and knowledge is the product of
social interaction. Language not only reflects our experience but actively shapes it. The
essence of therapeutic conversations (in regard to change) is that multiple descriptions
of experience are „co-created‟ and considered. Perhaps it is important to highlight an
important qualification at this point. For many, the idea that psychotherapists change
people is seen as an epistemological error (Bateson, 1979). Anderson and Goolishian
(1988) suggest that a social constructionist perspective would describe the dialogue
between clients and therapists as a process of making new meanings. These
conversations do not act to „remove‟ the problem but change the language that is used
and thereby evolve new meanings for all those involved (Seikkula, 2003). In a sense, the
therapist co-creates the conditions which promote change but this process is driven by
the recursive links between people rather than the unilateral decisions or actions of one
member (Bateson, 1979).
Some essential ideas at the level of technique appear to be the importance of feedback,
offering and noticing different interpretations or meanings, an approach that is
respectful and avoids ascription of blame. Systemic approaches also tend to embed the
suggestion of change; inviting consideration of different possibilities rather than
imposing a particular direction.
We move on to consider the notion that it is possible or even desirable to make a
distinction between current theories of change within systemic psychotherapy. As Jones
(1993) suggests, the distinctions between „schools‟ of systemic psychotherapy have
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largely dissipated and it is perhaps more useful to view distinctions in terms of relative
emphasis.
Solution-focused Therapy
The term solution-focused therapy encompasses several models (de Shazer, 1985;
O‟Hanlon and Weiner-Davis, 1989). However, there are some similarities between
different models in terms of a theory of change. The process of change within solution-
focused models is suggested to be associated with the therapist acting to notice
exceptions to the defined problem and seeking to emphasise positive interpretations
and solution-orientated action (de Shazer, 1985). Conversations within solution-focused
therapy tend to be mindful of time-orientation; focusing on discussion of the here-and-
now understanding of future possibilities, rather than reviewing understanding of past
events.
Milan Systemic Psychotherapy
The Milan group initially translated and applied the theoretical model of Gregory
Bateson to work with family‟s (Bateson, 1972; Selvini-Palazzoli et al, 1978). Change was
suggested to be associated with feedback, particularly in terms of difference to the
family‟s existing explanatory model of relationships. This feedback was provided by the
therapist through the use of hypothesising and circular questioning (Cecchin, 1987).
Revisions to the model placed an emphasis on how the interview format contributed to
participants adopting a more relational view of their experience and how questions
regarding the future invited a particular type of change (Campbell, 2003). In addition,
the Milan model considers how context (i.e., culture, community, family) is the
resource by which individuals create meaning. Discussion of context and changes within
these descriptions are viewed as a central process of change.
Karl Tomm
Tomm‟s model of change highlights the role of interactional patterns in describing
individual experience (e.g., Tomm, 1991). Patterns of interaction are suggested to
influence and in turn be influenced by individuals. Once established, patterns (both
„pathological‟ and „healthy‟) tend to repeat. The process of change described by this
model is to encourage the establishment of alternative patterns of interaction that act as
an antidote to „pathological‟ patterns. At a methodological level this involves inviting
participants to become aware of interactional patterns (particularly those deemed as
„pathological‟), encouraging constructive feedback and highlighting areas of
competence. A further significant factor in this model is the process of externalising the
problem away from the individual, whilst also promoting a sense of personal agency
(Tomm, 1989). In a sense, this model seems to suggest that change is a process of
amplifying some interactional patterns at the expense of others.
Narrative and dialogical models
Within the narrative model the idea of story is used as a metaphor to describe how
individuals integrate their social experience and make sense of this (White 1995;
Epstein, 1998). The process of change is under-pinned by the modification of such
stories (e.g., expanding certain aspects or voices within the story or becoming aware of
what is not said) (Pocock, 2006).
Dialogical models share the idea that linguistic (or symbolic) change is of importance
within psychotherapy. However, these models focus on how psychotherapy participants
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jointly construct stories (Rober et al, 2006). Change involves the co-creation of a shared
language (enriched by inclusion of all participants). Seikkula and Trimble (2005)
describe the influence of dialogical therapy in slightly expended terms. They recognise
the importance of shared dialogue but also highlight the emotional impact of co-
constructing narratives for both family members and therapists. Conversation and
dialogue allows participants to name and reflect on feelings. In a sense, language is a
vehicle to the achievement of greater emotional resonance between family members.
A reflection on these descriptions It is perhaps worthwhile to reflect on how these delineations of models were made by
the writer. Influenced by the imperative of identifying current systemic theories of
change, the literature review was targeted at the mainstream English language journals
over the last decade. Such an approach undoubtedly reflects a particular culture and
context and should be seen as a potential shortcoming. For example, it might be
suggested that journals which reflect a predominately American perspective of systemic
psychotherapy tend to publish articles that focus on the technical aspects of therapy,
deconstruction and the economic context of change; whereas European journals reflect
an interest in theory, the history of therapy and liberal philosophy; conversely,
Asian/Pacific journals discuss holistic approaches, narrative and cultural sensitivity. This
might be seen as a gross simplification (as the hypothesis has yet to be subjected to
empirical review) but it would not seem too far fetched to suggest that models of change
are embedded and understood within their culture of origin. We shall discuss this
further in a later section.
Evaluating different theories of change
Let us return to our endeavour and ask how are we to make sense of theories of change
using the „lens‟ of model? Models of systemic change do not represent reality, rather an
approximation or ideal view of this process. However, it is important to consider
whether all models hold the same relative equivalence. In other words, are all ideas
about change equally relevant?
Value based comparison One way in which we might consider the distinctions between the various models is in
terms of their specification or explicit guidance in regard to key value issues. For
example, in what ways do theories of change create a framework for meaning that
respects diversity, minimises abuse of power and encourages responsibility and
collaboration on the part of the therapist? Using this particular stance, many of the
systemic theories of change have been subjected to criticism. For instance, Dermer et al
(1998) suggest that the idea of circularity within systemic psychotherapy can act to
obscure individual responsibility and inequity of power within relationships. These
authors express specific concern regarding the theoretical application of solution-
focused models; suggesting that an emphasis on accepting definitions of solutions that
can reinforce the subordinate position of certain family members is unacceptable
(Dermer et al, 1998). They ask whether psychotherapeutic change retains an ethical
basis when a therapist seeks to conspire to maintain relationships in which there are
gross inequalities. In contrast, narrative therapists maintain a strong position of ethical
responsibility in regard to change by directly asking if change is worthwhile (Rober et al,
2006).
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The profession of systemic psychotherapy has responded to this in the form of revising
codes of practice, issuing specific guidance and modifying training requirements (e.g.,
AFT, 2000). Similarly, many systemic practitioners are aware of the lack of explicit
guidance in regard to this and actively seek to redress the balance in therapeutic
conversations (Bertrando, 2000). However, this remains a valid distinction and we do
need to be mindful of how ideas regarding power and gender are represented within
theories of change.
How do theories of change impact on therapeutic conversations? An alternative way in which we might consider systemic theories of change is to ask
about their impact on therapeutic conversations. It is tempting to think that there is a
recursive and hierarchical relationship between approach, method and technique
(Burnham, 1992). It is therefore useful to question whether theories about change
actually reflect what happens in therapy.
Both Flaskas (2005) and Hoffman (1998) reach the conclusion that the model of
systemic theory appears to be only moderately related to what the therapist actually
does in therapy. For instance, the efforts which researchers go to so as to maintain
integrity of approach when evaluating therapy suggests that deviation from the theory of
change is common place. Flaskas (2005) suggests that clinical practice is more
characterised by an integrative approach to change rather than an adherence to one
particular model. Similarly, Hawley and Geske (2000) conducted a content analysis of
the systemic literature, and came to the conclusion that there seemed to be very little
connection between theory and research. Theory provided the conceptual framework
for many articles but very few research reports actually set out to test theoretical
assumptions.
It seems that clinicians develop their own theories of change guided by a process of
enactment and direct feedback. Najavits (1997) suggests that therapist‟s personal
theories of change are distinct but co-exist with formal theories of change. Curiously,
therapists following the same theoretical model can differ widely whereas those
following very different orientations can share many similarities (Najavits, 1997). The
therapist might therefore be seen as a participant influenced by theoretical, professional
and personal internal dialogues regarding change (Rober, 2005). The idea of personal
or multiple theories of change is by no means limited to therapists. Clients presumably
come to therapy with their own theory of change (Singer, 2005). Perhaps, we need to
question whether it is meaningful to ask whether one theory of change is more useful
than another. Further, maybe we should consider theories of change as professional
dialogues, as this allows us to recognise that they are just one of many voices involved in
therapeutic conversations.
Theories of change and the research literature Clinical research is a further way in which we might attempt to make meaningful
comparisons between the different theories of change. Research has tended to
conceptualise change in terms of an outcome (noticing difference over time) or in terms
of process (making sense of how and why difference occurred). However, the two are in
a dynamic relationship whereby understanding the process impacts on the outcome and
vice versa (e.g., the process of asking the question of whether there has been change
and how this came about can become part of the process of consolidating the change.
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In other words, the research becomes recursively linked to the therapeutic intervention;
Christensen, Russell, Miller and Peterson, 1998).
The idea of research within systemic psychotherapy is a contentious issue for both
philosophical and pragmatic reasons. For instance, the field of psychotherapy has been
suggested to lack the external validation, respect and even privilege that are afforded to
the „hard‟ sciences. For some, this is a barrier to be overcome through the adoption of
the epistemological frameworks and research methodologies of empirical science. For
others, this is an endorsement of a position that suggests that psychotherapy has more
in common with the arts and cannot be practiced (or judged) by such reductionist
standards. Even if we are to accept an empirical stance, the issue of describing and
explaining change remains a significant challenge (Bavelas, 1992). For example, what is
change, who should judge this, how much change is significant? Let us approach this
from an initial stance of curiosity and adopt a more critical approach in the proceeding
section.
Outcome and process research and what they tell us about theories of change The development of explicit theories of change would seem to outpace the empirical
demonstration of their value. For instance, Flaskas (2005) suggests that the dominant
ideas regarding change within systemic psychotherapy remain largely un-tested or
challenged. For instance, the use of reflecting teams and more importantly their value in
the change process, is not particularly well understood (Campbell, 2003). Do we even
have an implicit idea as to how reflecting team conversations contribute to the process
or outcome of therapy?
With a broader perspective in mind, Stratton (2005) provides a comprehensive review
of the clinical literature in regard to systemic psychotherapy. His report includes
discussion of several meta-analyses (a statistical method of summating data from
different studies) as well as numerous individual research reports. His interpretation of
the literature is that there appears to be little evidence of difference in terms of outcome
between the various models of systemic psychotherapy. Such a finding would seem very
curious, given that one of the ideas underpinning the notion of different models is that
they represent a meaningful distinction in bringing about change. Perhaps Stratton
(2005) is mistaken in this interpretation? Sprenkle and Blow (2004) would argue that he
is not. In a comparable review, they reached a similar conclusion.
Sprenkle and Blow (2004) suggest that there are three different ways in which we might
understand the similarity of outcome of various models of psychotherapy. Firstly,
perhaps the outcome is similar but the process of change differs between models.
Second, perhaps there are meaningful differences between both process and outcome
but these are obscured by the focus of the initial research question and/or insufficient
sophistication of research methodology. Thirdly, there is the suggestion that change
results from factors which are common to all models. Let us explore this particular
possibility in more depth.
Theories of change and common factors Blow and Sprenkle (2001) suggest that common factors in the process of change are
defined as dimensions that are not specific to any particular approach, method or
technique. Examples of these include elements of the client(s) experience not discussed
in therapy, relationship factors (e.g., the therapeutic alliance) and expectancy. This is
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not to say that one model or approach is as good as another but to highlight that models
are the vehicles through which common factors are activated. The models are by no
means dispensable as they provide a coherent structure for both clients and therapists.
The modest differences between models are explained by specific factors (in that the
method or technique is unique to that particular orientation) although the main
contribution to effectiveness results from shared common factors. Blow and Sprenkle
(2001) do provide a caveat by suggesting that the idea of common factors should be
seen as a general theory of change. They recognise that meaningful differences in
change might occur in specific instances. For instance, certain approaches might be
more useful for certain people, problems and circumstances. The differences between
systemic psychotherapies might therefore represent their relative acceptability to users,
purchasers or providers (Najavits, 1997).
If common factors are important in understanding the process of change then this
would have large implications in terms of training. Particularly as most systemic training
is organised around the idea of specific models/orientation.
Common factors re-considered Perhaps we should not be so quick to accept the notion of common factors without first
considering the way in which this idea was formulated. For instance, Sexton et al (2004)
criticise the common factors approach for de-contextualising the elements of therapy.
Some of the clinically useful concepts within therapy would seem very difficult to
quantify in research and thereby might be „missing‟ from research descriptions of
change. For example, the idea of „opening space‟ has an intuitive place in the practice of
systemic psychotherapy yet evades meaningful measurement.
There is also the suggestion that the common factors hypothesis might be an artefact of
the linear research paradigm. For example, traditional science is founded on the ideas
of determinism and prediction; and that extraneous variables might be controlled or
held equal (Auerswald, 1988). This assumption is problematic in the real world
application of physical sciences; and even more so in regards to descriptions of change
within systemic psychotherapy (Bavelas, 1992). If the whole is more than the sum of its
constitute parts, then a reductionist methodology would obscure this providing nothing
more than a list of potential influences with little specification as to how these might
actually operate in clinical situations. What this questions is the very notion that linear
models might offer any useful description of systemic processes.
Future research and theories of change If the field of systemic psychotherapy is to be considered a radical departure to notions
of change within other areas of the social sciences then perhaps it will need a revolution
in research methodology to explore this. What are the alternatives? One approach
might be to reject quantitative approaches to research and adapt qualitative
methodologies. Such approaches are no doubt valuable and have advanced theory
refinement (Stratton, 2005). However, qualitative processes are by no means a
protection against modelling change within a linear framework. For instance, qualitative
research can often describe therapy as an additive process whereby there is a
relationship between therapeutic input and beneficial output. Similarly, qualitative
descriptions of change can suggest the sequence of change reflects distinct stages and
sequences (although there could be variability in the exact order). Could there be yet
another alternative?
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Bloom (2000) considers the application of non-linear (or chaos) models within
psychotherapy. Of particular interest is the idea that the process of change within
therapy might be modelled in non-linear terms. Put a different way, change within
therapy might be described by sudden unpredictable re-organisation within the system.
It is important to point out that the use of the term chaos does not imply random as
systems have a range of constraints that limit the potential for re-organisation (Bloom,
2000). These ideas regarding the nature of change would seem to resonate with the use
of therapeutic paradox in the work of many early systemic therapists (Papp, 1983).
However, there seems to have been a gradual shift away from such approaches
(Hoffman, 1995). Sexton et al (2004) suggest that meaningful theories of change, which
explain multiple levels, and the components and process of change can result from
sophisticated empirical procedures. Perhaps a re-discovery of earlier ideas, coupled
with advances in research methodology (video analysis and statistical procedures) could
benefit systemic theories of change?
Summary
Perhaps this is a useful point to take a breath and ask where we are. The discussion so
far has pursued the idea of looking at systemic theories of change through the lens of
model. Several different models of systemic psychotherapy were outlined and
comparisons drawn on the basis of values, impact on therapeutic conversations and
research evidence. A striking feature of this discussion was the recurring proposition
that the difference between models of change is more noticeable at the
theoretical/conceptual level of description than at the level of therapeutic conversations.
However, there is yet another frame to examine systemic theories of change with; that
of context. The cultural context in which change is negotiated (and theories about this)
is an important lens with which to view systemic psychotherapy. The next section will
move onto consider this issue.
The contextual influence of profession
One of the key contexts that provide systemic theories of change with meaning is that of
profession. By this, we mean the body of knowledge, practice and shared identity that
constitute what we call systemic psychotherapy. In relation to theories of change, it is
useful to question how psychotherapy might organise conversations about theories of
change; particularly in terms of those, which are dominant, and those, which are
relatively marginalized (Pearce, 2004).
Theories of change and the position of the therapist Theories of change invariably suggest a level of skill and expertise which justifies
training, professional status and the need to regulate. Theories of change implicitly refer
to what is unique to systemic psychotherapy (often in comparison to other ideas about
psychotherapy) and suggest it is a difference, which makes a difference. Hence, theories
of change implicitly speak about and reinforce the professional position of the therapist.
The business of therapy includes many financial aspects and this impacts on how
theories of change are enacted by therapists. For example, the demise of psychoanalytic
theories of change has been attributed more to conceptions of duration (and hence
cost) than usefulness (Pocock, 2006).
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Professional dialogues and the position of the family/client in therapy Auerswald (1988) suggests that the definitions that bring people to therapy and the
change anticipated often differ dramatically from the therapists and professional
literature that they encounter. Taking this one step further, theories of change have
been suggested to reflect a bias towards the idea that the therapist is more important in
the process of change than the client. Similarly, participants in therapy are rarely
consulted on how research into change might be defined or measured.
Perhaps we have an exaggerated sense of the importance of our explanatory
frameworks and seek out confirming evidence? What the client/family brings to therapy
(in terms of personal resources, support, motivation and agency, and participation) may
actually be more decisive than what the therapist does or thinks they do. The systemic
literature is by no means ignorant of such ideas (i.e., Hoffman, 1981; Anderson and
Goolishian, 1988) but the point remains that theories of change legitimate the position
of the therapist as expert (Vetere, 2006).
Theories of change and their transmission within the profession Framo (1996) highlights the link between theories of change and there transmission (via
training) to others. Change is described at the level of language but there is also a sense
of embodied change. For instance, Fosha (2005) and Brubacher (2006) both discuss the
resurgence in ideas regarding the importance of emotion in understanding therapeutic
change. They suggest that many aspects of the lived experience both within and
between people cannot be easily put into language. Furthermore, experience has a
sensory, intuitive dimension that does not necessarily need language to have meaning or
to make a difference. Systemic theories of change struggle to incorporate such ideas.
Perhaps this is not helped by the way in which theories of change are transmitted (i.e.,
in the form of books, journals and dyadic teaching) which also tend to privilege
language based descriptions. Systemic psychotherapy might then represent just one
aspect in which expression and emotional connection might be found. Art, music,
movement and poetry might provide equally useful theories of change.
Systemic theories of change and the wider cultural context
There is a wider debate on how systemic theories of change represent the culture in
which they are enacted and how culture impacts on the conceptualisation of theory. For
instance, Western society embraces the disposability of ideas, commercialism, the next
new thing and hype; all of which could play a part in privileging some ideas of change at
the expense of others (Framo, 1996).
Foucault (1987) expands on this by pointing out that change is an omnipresent
phenomenon in regard to patterns of relating. However, the aim of psychotherapy
seeks to bring into being a particular type of change. The focus of this change is often
the resumption of culturally indexed normative standards. By the action of the therapist
signalling interest in a particularly thematic area, the therapist is thereby punctuating
what needs to change. Foucault (1987) suggests that the process and outcome of change
within psychotherapy has a political dimension. Theories of change define power
relationships and amplify difference in terms of identifying deviance.
Theories of change and representations of cultural diversity Culture has a contextual influence on ideas of gender, ethnicity, age and ability that
impact on how change is described and defined within psychotherapy. What impact
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might this have on our discussion of systemic theories of change? Feminist models
suggest that action and doing are descriptions of experience that are more familiar to
men whereas thinking and feeling are more salient in the experience of women.
Theories about change should recognise and validate both experiences (Knudson-
Martin, 1997). However, theories of change systematically privilege the experience of
men, reflecting the dominant culturally position. For instance, Vatcher and Bogo (2001)
suggest that women carry more cultural responsibility for change within therapy (i.e.,
initiating and maintaining contacting, and participation within the therapeutic process).
This places considerable expectations on women as being both responsible and
accountable for change within the family. The contextual and implicative force of
gender (or any other label for identifying diversity) might therefore be under-estimated
by theories of change. Similarly, Gehart-Brooks and Lyle (1999) suggest that clients
identify gender as an important influence in therapy whereas therapists do not.
There is also the suggestion that theories of change tend to be described in terms that
refer to adult members. Children, and to some degree older adults, are marginalized
theoretical in that any change is not conceptualised in how their narratives shift (Lund,
Schindler-Zimmerman and Haddock, 2002). In this way, theories of change not only
represent culturally hierarchy but also serve to maintain the position of marginalized
groups. Asking „what works, why and for whom?‟ avoids the broader question as to how
inequality arises and what might be done about this.
Theories of change and the culture of Western healthcare Diagnosis and physical treatment remains the dominant model within Western
healthcare (Framo, 1996). It permeates the thinking of what to do and how in terms of
developing and refining theories of change. For instance, the suggestion that some
systemic theories of change might be more (or less) applicable to some people, in
certain contexts or in certain relationships could be said to reflect the idea that a theory
of change can be separated from the problem it is suggested to address. Foucault (1987)
suggests a dynamic relationship between the notion of therapeutic change and an
identified problem, whereby psychotherapeutic change is a culturally defined entity that
has no meaning distinct from the problems it seeks to alter. Foucault (1987) would
therefore suggest that theories of change have little value in themselves to explain the
existence of problems.
Systemic models of change are a representation of change but at a particular level (i.e.,
the family). Can we use these models to understand change at different levels (i.e., how
change happens in communities) or to embrace a much wider perspective (e.g.,
understanding peace in a country whose divisions are magnified by a „liberating‟
coalition army)? Indeed, might our theories of change be very different if we viewed
them through the lens of community rather than model of psychotherapy? For
instance, the reality for many clients of psychotherapy services is that they are
connected (temporarily or semi-permanently) with several agents of change (e.g., GP,
social services, education). Each of these has a theory of change to implement, acting
on different and similar levels to psychotherapy. Auerswald (1988) describes a model,
which he terms „eco-systemic‟. The defining feature of this model is the way in which
mental health is conceptualised in terms of the local community. The formulation and
approach to intervention represents the locally based knowledge accumulated by the
therapy service. There is no place for general models of classification as each
community represents its own unique combination of social, economic and
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ethnological influences. Such a stance would help us consider the socio-economic
context of therapy.
Conclusion
This essay has examined systemic theories of change from many different positions.
Firstly, we considered whether it was possible to make meaningful distinctions between
particular models of change and examined how useful this was. The second section
focused on the context in which systemic theories of change are enacted, and asked
whether it is possible to see past culture.
Our current conceptualisation whereby the approach creates a context for the
therapeutic method, which in turn, provides a framework for the selection and
application of specific techniques (Burnham, 1992) perhaps presents an illusion of
purpose (e.g., all change is in the intended direction or it would not be deemed change
but a further symptom of the identified problem). Cecchin et al (1992) raise the
suggestion that we should view theories of change with a certain degree of irreverence.
For instance, a theory driven approach to change would tend to suggest that the
approach creates a context for the therapeutic method, which in turn, provides a
framework for the selection and application of specific techniques (Burnham, 1992).
Theories of change can therefore present an illusion of purpose (e.g., all change is in
the intended direction or it would not be deemed change but a further symptom of the
identified problem). However, clinical practice suggests a different picture; change is a
complex endeavour and failure is relatively common (Flaskas, 2005). Theory might
therefore be considered as part of a multi-dimensional and recursively interconnected
web in which psychotherapy conversations take place.
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18
The clinical psychologist is not the expert: how “not to know” whether to
take a directive or non-directive position in relation to change in clinical
practice
Dr Lucie Robinson currently works as a Clinical Psychologist for Bro Morgannwg NHS Trust with
children who have learning disabilities and their families.
Introduction One universal goal which is arguably shared by all family therapists
1
is to alleviate family
distress and create change for families in relation to the problems they bring to therapy.
Broadly speaking during family therapy, insight or concentrating on the past is de-
emphasized and action in the present promoted (Partridge, 2000). In particular change
is effected by working with families to disrupt and examine patterns of communication,
interactions between family members and/or rules, beliefs, or stories held by the family.
Within this broad definition of family therapy, the therapist‟s position is (again
arguably) one of a collaborative change agent and thus is generally viewed as active and
directive (Hayes, 1991).
During my training as a clinical psychologist 2000 - 2003, I had the privilege of working
alongside several professionals who located their practice within the theoretical
approach, method, and techniques which broadly speaking have evolved from later
Milan and Narrative family therapy and systemic approaches (see part two below). At
that time, I first read a paper published by Harlene Anderson and Harold Goolishian
(1992), which had a particular influence on my developing concepts about the
therapist‟s position in relation to creating change with families. The approach to
therapeutic work with families presented in this paper has also continued to influence
my thinking about my position within therapy as a qualified clinical psychologist, and as
a student gaining further knowledge of family therapy and systemic practice3
.
In particular, I have drawn upon the concepts outlined in this paper in my struggles to
make sense of and reflect upon questions such as: “What is family therapy?”, “What is
change?”, “What is the role of the therapist in family therapy?”, “How does the
position taken by therapist influence opportunities for change?”, and “How can a
therapist make useful decisions about whether to take a directive or non-directive
position in relation to change in clinical practice?”
In response to the invitation to write an essay about the development of a theoretical
concept in the field of systemic therapy relevant to my clinical practice, I decided to
revisit and explore possible answers to some of these questions about change. In this
essay I have not aimed or hoped to formulate a comprehensive answer. However, I
hoped that the process of completing this piece of work would allow me an opportunity
1 Family therapist is a term used throughout this essay to refer to a therapist who uses family
therapy systemic concepts (with or without the support of a family therapy team) to inform their
practice in work with families or other systems² of people, e.g. individuals, organisations or staff
teams. “A system is defined as a set of units or elements standing in some consistent relationship or
interactional stance with each other.” (Steinglass, 1978, p. 305; cited in Hayes, 1991). 3 The term family therapy will be used throughout this essay to refer to family therapy and systemic
approaches to working with families and other systems of people.
19
to rethink and reflect upon my personal and professional beliefs about the process of
change in therapy. In particular by reflecting upon my increased knowledge and
understanding of family therapy approaches and practice, as taught on the course, and
from my further experiences over the past three years of working as a qualified Clinical
Psychologist with children, adolescents, and families. I also hoped to explore within a
historical and theoretical context, the development of concepts about the therapist‟s use
of directive and non-directive positions in relation to change in family therapy.
Therefore in this essay I begin with a brief overview of my professional and personal
development as a therapist working with families, and of the concepts presented by
Anderson and Goolishian (1992). I also present some of my reflections upon what
connected with me initially about the “not knowing” approach described in relation to
the direction of change in therapy. In the second part of this essay, I have attempted to
locate the theoretical development of Anderson and Goolishian‟s concepts within a
historical context of wider family therapy approaches. I have focused upon differing
concepts within each approach about the therapist‟s active use of directive and non-
directive positions within therapy, in attempts to create change for families. In
particular, I will highlight the development of concepts about the process of change that
occurs in family therapy. First I present early notions located within Structural,
Strategic and Milan approaches. Second, I discuss later concepts located within Post
Milan, Social Constructionist and Narrative approaches to family therapy.
In the final part of this essay, I present some further reflections about my current
clinical practice, and my ongoing dilemmas about how best to position myself in work
with clients in relation to the use of directive and non-directive family therapy
approaches. I have also considered how my clinical experience has widened my
understanding and ability to remain curious about how to usefully make decisions with
clients about whether to position myself to be actively and intentionally directive or non-
directive in my attempts to produce change in therapeutic work with children and
families.
Part one: A not knowing approach to change in therapy?
As a beginning therapist my early theoretical influences were located within person
centred approaches to counselling, in particular the work of Carl Rogers and Gerald
Egan (e.g. Rogers, 1951; Egan, 1998). I took from these experiences increased
knowledge of many concepts, which included: the importance of building a therapeutic
relationship with clients, and techniques that could be used to directively structure
therapy sessions around problem solving models. Further, these approaches informed
my early emerging notions about the therapist‟s position in creating change with clients,
in particular, that the therapist‟s use of a non-directive position of empathic listening
enabled change to occur. However later, as I became immersed in clinical psychology
training, for example, the directive, structured and evidence based approaches of
cognitive behavioural therapy, I was faced with the dilemma of creating a new
understanding about therapy. Further, these experiences challenged my understanding
about the therapist‟s position in creating change with (or was it now „for‟?) clients during
therapy.
During the first six months, I felt pressure to adapt my therapeutic style, and fully
embrace the science-practitioner model I was being taught about. As a therapist this
20
implied that from my position of trainee clinical psychologist, I would assess, formulate,
and treat clients under the supervision of a qualified clinical psychologist (see Carr
(1999) for further elaboration on theory driven directive clinical psychology approaches
to therapy with children, adolescents, and their families). Initially, and perhaps
intentionally by the course providers and my supervisors so as not to overwhelm, there
were fewer opportunities to question or reflect upon the therapist‟s position within
therapy or to look at the process of how change occurred during therapy. However, my
later experiences of family therapy during training, and with supervisors who located
their practice within family therapy approaches, enabled me to begin to reflect more
widely upon these issues.
In particular, I was struck by many of the family therapy concepts I first found within
the pages of Anderson and Goolishian‟s (1992) paper, “The client is the expert: A not
knowing approach to therapy”. Anderson and Goolishian (1992) locate their
descriptions of the therapist‟s “not knowing position”, within the influences of
hermeneutic and interpretive theories, and the related concepts of social
constructionism, language and narrative (e.g. Gergen, 1982; Shapiro and Sica, 1984;
Shotter and Gergen, 1989, Wachterhauser, 1986; cited in Anderson & Goolishian,
1992). For example, they emphasize the view of Wachterhauser (1986) that there is no
privileged standpoint for understanding distress. Rather, through the use of curiosity
and by taking each client‟s story seriously, the therapist joins a client(s) in a mutual
exploration of their understanding and experience, and thus maintains a collaborative
position towards the process of change in therapy (Anderson & Goolishian, 1992).
From a “not knowing position”, new concepts and meaning are not offered by the
therapist, rather they emerge from the dialogue with the client and thus are co-created
(Anderson & Goolishian, 1992).
Anderson and Goolishian also describe the “not knowing position” as the therapist
using their ability to seek and be curious about novelty and newness, in order to stay
with a client‟s reality, rather than challenging it and therefore being closed to the full
meaning of their client‟s descriptions of their experiences. The therapist communicates
an attitude of genuine curiosity and a need to know more about what is being said by
positioning him or her self to “be informed” by the client(s) and to interpret and analyse
experience as it occurs in context (Anderson & Goolishian, 1992). That is not to say
that the therapist does not have unfounded concepts or inexperienced judgement but
instead requires that a therapist‟s understandings, explanations, and interpretations are
also questioned and reflected upon.
Further, Anderson and Goolishian (1992) write that: “change in therapy is the dialogical
creation of new narrative, and therefore the opening of opportunity for new agency.”(p.
28). This narrative approach to therapy emphasizes the expertise of therapist as not in
producing change during therapy, but rather in their skill in asking questions that open
spaces for „new conversation‟ and „not-yet-said‟ stories, with change in story and self-
narrative being an „inherent consequence‟ of the dialogue held between the therapist
and his or her clients. Within this approach to therapy, the therapist‟s position is not
viewed as that of an “expert” about change for clients. Nor does the approach suggest
that the therapist has pre-held theoretically based concepts about the direction of
change that needs to occur. Instead although the therapist brings pre-held theoretical
narratives to understand a family and knowledge of how a family could change, he or
21
she is not limited by his or her prior experiences, knowledge or theoretically formed
“truths” or assumptions about change.
Thinking back I wonder if part of the appeal of the “not knowing position” for me as an
emerging therapist was that I did not have the confidence to challenge clients‟ beliefs or
take an authoritative directive position in therapy. Instead this approach allowed me to
widen my understanding of the use of what I had defined earlier as client centred non-
directive therapeutic position to creating change with clients. In the next section of this
essay, I present a overview of the historical development of family therapy and highlight
many of the authors and therapists who influenced and continue to influence, theories
about change in family therapy. In order to create enough space in part three of this
essay to discuss my further reflections upon the “not knowing position”, this overview is
not intended to be a complete descriptive list of all family therapy approaches (see Carr,
2000; or Dallos & Draper, 2005 for a comprehensive overview). Instead I will highlight
the historical and theoretical development of concepts related to process of change in
therapy, and related the therapist‟s use of directive and non-directive positions within
therapy. In doing so, I hope to locate Anderson and Goolishian‟s “not knowing”
position, within the wider historical and theoretical context of the development of
family therapy approaches.
Part two: One overview of the historical development of family therapy and concepts
related to the therapist‟s use of directive and non-directive positions in relation to
change
First order cybernetics (1950s – mid 1970s)
The theoretical perspectives first written about by family therapists in the 1950s
represented an important shift away from earlier psychodynamic theories about
working therapeutically with families. One premise about change within
psychodynamic theories at that time was that psychological relief and change during
therapy was achieved through a prolonged process of becoming aware of repressed
feelings associated with historical traumatic events in early childhood (Anderson &
Goolishian, 1988). In contrast family therapists begun to develop approaches to
therapy which emphasised thinking about the interconnectedness of behaviour,
relationships and events within families.
As the field of family therapy emerged, early thinking was influenced by many social
scientists and therapists from a variety of backgrounds. Key figures included Gregory
Bateson, an anthropologist, who used general systems theory (Ludwig von Bertalanffy;
cited in Anderson & Goolishian, 1988) and cybernetic principles (Norbert Weiner,
cited in Dallos & Draper, 2005), to describe how a small change in the desired
direction during therapy could assist a family to move from strength to strength (Hayes,
1991). These early family therapy perspectives removed blame from families for the
development of “symptoms” within one individual, as a causal link between the
problems of an individual and his or her family was not assumed (Hayes, 1991). This
shift had profound implications for thinking about the process of change in therapy,
and about the position taken by the therapist in creating change with and for families.
Broadly speaking, early family therapy models placed the therapist in a position of
being an expert in diagnosis and treatment as a result of his or her knowledge about
social systems and their function. Within these approaches, change in families was
determined by the therapist‟s expertise in promoting change. This view of the
22
therapist‟s directive position was in the context of other concepts which were dominant
in social science at that time, for example, empiricism, the notion of an objective
reality, and the hypothetical-deductive model of explanation. In this context, the
therapist determined the pathology within the system and then fixed the system to
create change towards pre-determined theoretical concepts about how families should
function. Therapists working with individuals and families who had a influence on the
theoretical development of these family therapy concepts about the process of change
and the therapist‟s position in creating change, included: Salvador Minuchin, Jay
Haley, and the Milan associates. Key concepts about change in therapy discussed by
these authors will be briefly outlined below.
First, the work of Salvador Minuchin has been widely defined as the „structural‟
approach to family therapy (e.g. Jones, 1993; Partridge, 2000). Minuchin and others
working within a structural approach, proposed that change occurs during family
therapy through the therapist‟s deliberate attempts to „unblock‟ or „un-stick‟ obstacles
that may have arisen during transition points in „normal‟ developmental processes
within family life (Dallos & Draper, 2005). Therefore the therapist is viewed as having
an active role as an „intruder‟ within his or her „map‟ of the family structure (e.g. of
alliances between family members) and challenges „dysfunctional‟ patterns of interaction
using techniques such as enactments or sculpting, which aim to unbalance the family
structure (Partridge, 2000). Later in therapy, family hierarchies for example, may be
restructured by offering families alternative ways of operating.
Therefore, within the structural approach, the process of change occurs by the therapist
intentionally and directly challenging the family‟s perception of reality, offering
alternative ways of interacting, and bringing these about by providing a new experience
within the family which reinforces new structures and relationships (Partridge, 2000).
The therapist is viewed as an expert who sets clear goals for therapy and takes on an
educative position in bringing about alternative transactional patterns, new relationships
and family structures that are self-reinforcing and lead to continuous step-wise change
outside of therapy (Israelstam, 1988; cited in Hayes, 1991).
Second, the work of Jay Haley has been referenced by many authors as a „strategic‟
approach to family therapy (e.g. Dallos & Draper, 2005; Carr, 2000; Hayes, 1991).
Haley was curious about semantics, how change within the hierarchy of a system
changed communication, and how this perspective could be used strategically by a
therapist to produce change for families (Dallos & Draper, 2005; Anderson &
Goolishian, 1988). Haley‟s strategic approach was influenced by the work of Milton
Erikson, and later influenced theoretical developments, such as brief solution focused
therapy (see Steve DeShazer; cited in Carr, 2000).
Within strategic approaches, the therapist‟s position is viewed as being to actively and
intentionally create change by identifying and disrupting self-reinforcing cycles that are
acting to maintain “symptoms”, as well as to introduce the conditions for more
appropriate transactional patterns to develop (Nichols, 1984; cited in Hayes, 1991). A
prerequisite for using the approach is a therapist‟s accurate knowledge of the systems‟
organisation around the symptom, for example, the families‟ pattern of problem
maintaining behaviours, which have evolved within the family system in their attempts
to solve their problems (Hayes, 1991). In order to create change, directive or specific
paradoxical tasks are used by the therapist to reframe the solution as the problem.
23
Further, the strategic approach is based on cybernetic concepts that the whole system
does not need to be changed as change is discontinuous process that can be started by a
small change in therapy (Partridge, 2000). Also, within the strategic approach, the
therapist does not predict the direction or magnitude of change in therapy, which would
instead by determined by the family (Hoffman, 1971b; cited in Hayes, 1991).
Finally, alongside the developments in family therapy above, therapist‟s working within
what came to be defined by many as the “Milan approach” to family therapy,
incorporated Bateson‟s concepts with the work of Watzlawick and colleagues. For
example, Watzlawick, Beavin, and Jackson (1967) (cited in Cecchin, 1992) wrote about
theories of communication, and introduced a paradigm within psychology and therapy
of looking at how people fit together in a communication system. Therapists working
within the Milan approach, who included Mara Selvini Palazzoli, Luigi Boscolo,
Giuliana Prata, and Gianfranco Cecchin, incorporated these concepts in their work with
families. For example, they began to consider the „games‟ families members played
with each other, whilst attempting to understand the impact of these games within
cybernetic models of how systems functioned (Cecchin, 1992).
Within this approach, the therapist is still considered to an expert who observes
families from an outside position. In particular, the therapist attempts to punctuate
symptoms as between people rather than within one person, and to look for the logic
within a system that will allow change whilst positively connoting the interactions of all
family members (Cecchin, 1992). This approach is based on the Milan team‟s concepts
about change being more likely to occur if families are neither blamed nor judged for
their behaviour (Cecchin, Lane & Ray, 1994). Instead therapists aim initially to
understand why families play certain games or have taken on certain roles in relation to
these games. Within this approach, therapists also use a directive and confrontational
style in their attempts to bring about change in the family‟s games, for example by using
a paradoxical intervention that brings the family‟s games to a stand still and therefore
makes it impossible for the family not to change (Tomm, 1984a).
Second order cybernetics (mid 1970s – mid to late 1980s)
Since the mid 1970s onwards, there has been a continuous development within family
therapy literature from an epistemology based on earlier cybernetic principles to one
based on the premise that human relationships emerge through patterns of
communication and socially produced stories (Cecchin, 1992, see also next section).
This development initially led many family therapists to examine how different levels of
meaning were related to each other within a family, in circular and constantly evolving
patterns, and to reject the usefulness of earlier concepts about hierarchy and stability
(c.f. structural and strategic approaches to family therapy; Partridge, 2000). These
developments in family therapy were influenced by emerging social constructionist
theories that went beyond empirical theories, in attempts to consider how humans
create meaning in order to understand their experiences (Anderson & Goolishian,
1992).
In particular, new theoretical concepts and perspectives about the influence of the
therapist in relation to the process of change began to emerge. The therapist began to
be viewed as part of the family system that evolves over the course of a therapeutic
conversation, defined by many authors as a second order cybernetic paradigm shift (e.g.
Partridge, 2000; Dallos & Draper, 2005). Within this perspective, human interactions
24
provided more opportunities for change than the therapist‟s earlier outside position of a
directive expert about the process of change. Therefore the therapist‟s skill began to be
reframed as his or her ability to understand and reflect upon how his or her position
within the therapeutic system was co-constructed with the family during therapy.
Therapists also began to reflect more widely upon concepts related to how the
therapist‟s use of a directive or non-directive positions within the therapeutic system
influenced the process of change (Cecchin, 1992). For example, in later years the
Milan team began to consider whether the methods and techniques they actively used
during clinical interviews to gather information about relationships within the family
(e.g. hypothesizing, circularity and neutrality) could produce change in the absence of a
final intervention, such as a paradoxical task (Selvini, Boscolo, Cecchin, & Prata, 1980).
These concepts marked a shift within the Milan approach away from earlier attempts to
direct people, towards the use of techniques which retained a more curious stance to
looking at patterns of relationships within families. The therapist continued to hold the
expectation of change but did not intentionally argue for change or impose therapeutic
goals on a family (Cecchin, 1987). Instead, therapeutic change occurred when a family
was enabled to find a path with greater freedom to discover alternative solutions, at the
level of meaning or action (Tomm, 1984a), for example by exploring during therapy,
hypothetical change through an examination of a families‟ beliefs, about cultural and
social concepts (Selvini et al., 1980).
Further, the therapist conducted his or her investigation about the families‟ problems
on the basis of feedback from the family in response to the information he or she
solicited about relationships, and therefore about difference and change (Selvini et al.,
1980). The therapist also began to take a position within therapy that the family had
their own resources which they could use to make their own decisions and choose their
own solutions about change from. Therefore any change which occurred was attributed
to the family and not the therapist, who instead took a position of noticing change
occurring in beliefs or actions and amplifying these changes to facilitate a larger effect
(Hayes, 1991).
During the 1980s, the Milan team‟s concepts were expanded upon by authors such as
Karl Tomm (1984a, b). Tomm explored the use of „strategizing‟ as a fourth position
(or technique), which could be used by a therapist to influence the evolving process of
change within the therapeutic system. He also reflected upon whether the whole
interview with a family could be viewed as a series of continuous interventions,
“Interventive interviewing” (Tomm, 1987a, b; 1988). Other authors have provided
alternative descriptions of these concepts defined as „curiosity‟ (Cecchin, 1987) and
„irreverence‟ (Cecchin, Lane & Ray, 1992) (cited in Partridge, 2000). For example,
curiosity as defined by Cecchin (1987) is an active position which questions all views in
order to create a multiplicity of views. These authors also emphasise the importance of
the therapist remaining curious and treating all concepts, however sacred with
irreverence, because in losing curiosity, the therapist‟s opportunities to develop new
perspectives and for change to occur would be lost (see Jones, 1993).
Therefore the therapist‟s position in relation to change began to be viewed as providing
a „trigger‟ for the family to experience more opportunities for spontaneous change,
within the context of continually evolving patterns of behaviours and beliefs (Tomm,
1984a). Yet the effect(s) of the therapist taking this position was viewed as being
25
determined by client and not the therapist (Tomm, 1987b). As although different kinds
and sequences of questions may be expected to have different effects on the evolving
therapeutic conversation, within this approach, there remained a possibility of
discontinuity between therapist‟s intentions and actual effect (Tomm, 1987b; see also
part three).
Further introduction to narrative approaches (mid to late 1980s and beyond) The impact of second order cybernetic thinking led many other family therapists to
continue to develop concepts which provided a more dynamic view of families and
about how a families‟ belief system could be understood as socially constructed through
language. These approaches to family therapy have continued to be widely associated
with social constructionist perspectives, which do not seek to deny the reality of the
physical world but instead view action in the world as an individual‟s attempt to
maintain the coherence of his or her beliefs or “stories” about the world (Partridge,
2000). By embracing social constructionist concepts, many authors have described a
further paradigm shift which occurred in family therapy approaches, from a modernist
to post-modernist perspective (e.g. Dallos & Draper, 2005). Other authors have
described this paradigm shift as a „narrative‟ or „discursive‟ turn (e.g. Partridge, 2000).
From these theoretical perspectives, a co-evolutionary approach to family therapy has
continued to emerge, concerned with opening up possibilities rather than trying to
change the family system structurally or strategically. These perspectives have also led
to a focus within family therapy approaches on the “storying” of experience. For
example, as action and meaning are seen as recursively connected „stories lived‟ inform
„stories told‟ and hence different lived experiences for people who present with
problems (Pearce, 1989; cited in Partridge, 2000). Approaches to family therapy within
this perspective are broadly associated with the work of family therapists such as
Harlene Andersen, Harold Goolishian, Tom Anderson, Michael White and David
Epston. Additional family therapy concepts related to the process of change in therapy,
described by Anderson and Goolishian, will be briefly considered below.
As well as the concepts outlined in the first part of this essay, Anderson and Goolishian
introduced a description of the therapy system as a „problem-organising, problem-dis-
solving system‟. This approach views problems as being in the inter-subjective minds of
all who are in actively engaged in communication about a problem. As such, linguistic
definitions of problems are viewed in context and therefore always changing (Anderson
& Goolishian, 1988). Within this approach, a therapist‟s position is described as
actively influencing the linguistic process of change through attempts to open up new
meanings and understandings or descriptions with the family, that are no longer
labelled as a problem. The change which occurs in therapy is therefore viewed as
change of meaning derived through dialogue and conversation. The therapist actively
takes a role in the system‟s process of creating language and meaning to keep the
dialogue going toward „dis‟-solving the problem and dissolving the system itself rather
than offering directive solutions (Anderson & Goolishian, 1988).
Therefore the therapist takes a position of actively influencing the therapeutic
conversation but not actively seek to direct the conversation or be responsible for
direction of change (Anderson & Goolishian, 1988). Instead, the therapist uses
concepts, methods and techniques as „temporary lenses‟ that evolve over time, and seek
to find a lens with the family that when looked through dissolves the problem, redefines
26
it and reduces the dominant story of the family (Sluzki, 1992). Thus the therapist aims
to co-create a story with a client(s) through a skilful dialogue aimed at protecting the
client from the therapist‟s prejudices and interference, from a position of non-authority
and ultimate respect for the client. (Cecchin, Lane & Ray, 1994).
Summary
Within all of the approaches described, the therapist can be viewed as taking an active
position in relation to the process of change in therapy. In early approaches the
therapist‟s position could also be considered to be directive, in terms of setting explicit
goals for therapy and in determining the direction and nature of change to occur.
Later approaches have focused more explicitly on the therapist‟s use of a non-directive
position in relation to change. Instead authors have explored how the relationship that
evolves between client(s) and therapist, the position taken by the therapist, and the
methods and techniques he or she uses, can enable families to gain new
understandings about their difficulties, and alternative views of problems, which
ultimately open up possibilities for change to occur. In the final part of this essay I
conclude with some further reflections on my wider understanding of the “not
knowing” position. I also attempt to draw some conclusions about how I can continue
to challenge myself to reflect upon how to make use of both directive and non-directive
positions as a therapist.
Part three: Further reflections about taking a directive or nondirective position in
order to influence change in therapeutic work with families
As outlined in part one, my early development as a therapist was influenced by training
experiences as a person-centred counsellor and as a clinical psychologist, encouraged to
use a science-practitioner approach to therapy. However later experiences of family
therapy approaches introduced me to concepts about a therapist taking a “not knowing”
position in therapy. As a result I have become interested in exploring how to usefully
position myself as a therapist in my work with children and their families. My early
reading of Anderson and Goolishian‟s (1992) paper encouraged me to begin by asking
families questions which aimed to facilitate them to build alternative narratives about
their lives, and to privilege their knowledge and experience above my own. However in
doing so I now realise I tended to work from a position of not giving advice or offering
ideas of my own to families.
In my current work context, families often request a referral to psychology (although
sometimes following the advice of another) asking for directive advice about how to
change their child. Typically families ask me to provide “behavioural management
strategies” they can use to “change” their child‟s behaviour or to help them feel more
“in control” of their child. Some families also ask me to help them change their
understanding of their child‟s behaviour or to “get to the bottom” of why the behaviour
is occurring. In general, families are not requesting “family therapy”. Instead I often
meet with families who have an expectation that as a Clinical Psychologist I hold a
position of expertise and will be able to provide them with new and different ideas or
solutions about their difficulties. Many families have worked with my predecessor, a
psychologist/behavioural specialist who used directive behavioural techniques in his
work with families. In this way, before our initial meeting, families have developed an
expectation they will gain something tangible from our meetings. Their expectation of
change is often defined in practical terms, for example advice and knowledge I will be
27
able to give them to “change” their child‟s aggressive behaviour. Working within this
context has challenged my early preference of taking a “not knowing position” as a
therapist and my beliefs about whether a directive or non-directive position is most
useful to facilitate the process of change for families.
Burnham (1992) discusses that advice giving can be perceived by a therapist as
contradicting constructivist notions such as „non-instructive intervention‟ which has been
embraced by family therapy approaches. However to always take a position with clients
of not giving advice, is in itself a form of advice and so the position contradicts itself
(Burnham, 1992; see also Cecchin, 1992). Further, any position that becomes
permanent regardless of context is likely to become less useful, as all positions can be
useful temporarily given a liberating context (Burnham, 1992). Burnham suggests
placing the apparent incoherence in giving directive advice to families, in the context of
“both-and”. Thus a context can be created for the therapist to become curious about
giving advice or being directive in therapy, e.g. when might it be useful to give advice?
How can I become oriented to the likely effects of taking or not taking a directive
position of giving advice?
Further, Karl Tomm (1988) writes that when clients are simply unaware of basic
information or do not have the knowledge or resources to answer coherently it can be
appropriate for the therapist to provide answers for them. In addition, Reder and
Fredman (1996) caution that stuckness can occur in therapy when there exists a
mismatches between client‟s expectations of help and therapist‟s beliefs about what is
helpful, for example, when a client seeks practical help from a therapist who adheres to
a non-directive empathic approach (see also Cecchin, Lane & Ray, 1994). Instead there
is a need for the therapist to join with the family‟s belief system so that a shared view
about therapy can be co-constructed (Cronen & Lang, 1994; cited in Reder & Fredman,
1996).
Conclusions Over the past three years, my experiences working with clients as well as my further
reading about second order cybernetic and narrative approaches to family therapy has
widened my ability to reflect further upon the influence of my position within the
therapeutic context. In particular I have been able to reflect upon my understanding of
what different families I have worked with have experienced as more useful? My
attempts to facilitate change from a position guided by my knowledge of structured and
directive family therapy and behavioural techniques or my attempts to facilitate change
from a position guided by my early interpretation of the “not knowing position”. In
clinical practice I have found that taking both directive and non-directive positions in
relation to change can be useful in working with families. On the basis of conversations
with many clients I have also reconsidered my earlier assumption that to make use of a
“not knowing position”, should exclude finding opportunities to usefully give directive
advice to families. Instead I have found more useful ways to consider whether to give
advice. For example, in clinical practice I have found ways to explore advice giving with
families and to frame my suggestions tentatively as ideas to explore rather than fixed
solutions.
Therefore the challenge remains for me as a developing family therapist, to negotiate
and co-construct viable and sustainable ways of being that fit with the family, myself and
also culturally sanctioned ways of being (e.g. within my organisational context and my
28
professional guidelines). This will require me to remain curious and “not to know”
about my client‟s expectations and my own, to enable therapeutic work to become a
process of discovery that is open to change. In doing so I will need to continue to
challenge myself to use questions that explore with families what they think will be
useful at a particular time rather than holding strongly to a position that giving directive
advice is not necessary or useful. In this way I hope I will be able to continue to
suspend judgement about what a family needs or which therapeutic position will be
more useful in relation to the process of change within the therapeutic system.
References
Anderson, H., & Goolishian, H. A. (1988). Human systems as linguistic systems:
preliminary and evolving concepts about the implications for clinical theory. Family
Process, 27 (4), 371 – 392
Anderson, H., Goolishian, H. (1992). The client is the expert: A not knowing
approach to therapy. In S. McNamee & J. Gergen (Eds.) Therapy as social construction, pg. 25-39. London, Sage Publications.
Burham, J. (1992). Approach – method – technique: Making distinctions and creating
connections. Human Systems. The Journal of Systemic Consultation and Management
Carr, A. (1999). The handbook of child and adolescent clinical pscyhology: A
contextual approach. London, Routledge.
Carr, A. (2000). Family Therapy: concepts, processes and practice. Chichester, John
Wiley & Sons.
Cecchin, G. (1987). Hypothesizing, circularity & neutrality revised. Family Process, 26
(4), 405-413
Cecchin, G. (1992). Constructing therapeutic possibilities. In S. McNamee & J. Gergen
(Eds.) Therapy as social construction, pg. 86 – 95. London, Sage Publications.
Cecchin, G., Lane, G., & Ray, W.A. (1994). The cybernetics of prejudices in the practice of psychotherapy. London, Karnac Books
Dallos, R., & Draper, R. (2005). An introduction to family therapy: systemic theory and practice (second edition). London ,Open University Press.
Egan, G. (1998). The skilled helper: a problem management approach to helping
(Sixth edition). Brooks/Cole Publishing Company.
Hayes, H. (1991). A re-introduction to family therapy: Clarification of three schools.
Family Therapy, 12 (1), 27-43.
Jones, E. (1993). Family systems therapy: Developments in the Milan Systemic therapies. Chichester, Wiley.
29
Partridge, K. (2000). Family problems. In L. Champion & M. Power (Eds.) Adult
Psychological problems: An introduction, pg. 175-199 (Second edition). London
Psychology Press.
Reder, P., & Fredman, G. (1996). The relationship to help: interacting beliefs about
the treatment process. Clinical Child Psychology and Psychiatry, 1 (3), 457-467.
Rogers, C. R. (1951). Client centred therapy. London.Constable
Selvini, M.P., Boscolo, L., Cecchin, G., Prata, G. (1980). Hypothesizing – circularity –
neutrality: Three guidelines for the conductor of the session. Family Process, 19 (1), 3-
12.
Sluzki, C.E., (1992). Transformations: a blueprint for narrative changes in therapy.
Family Process, 31, 217-230.
Tomm, K., (1984a). One perspective on the Milan systemic approach: Part I overview
of development, theory and practice. Journal of Marital and Family Therapy, 10 (2)
113-125.
Tomm, K. (1984b). One perspective on the Milan systemic approach: Description of
session format, interviewing style and interventions. Journal of Marital and Family Therapy, 10 (3), 253-271
Tomm, K. (1987a) Interventive interviewing: Part 1. Strategizing as a fourth guideline
for the therapist. Family Process, 26, 3-13
Tomm, K. (1987b). Interventive interviewing: Part II. Reflexive questioning as a means
to enable self-healing. Family Process, 26, 167-183
Tomm, K. (1988). Interventive interviewing: Part III. Intending to ask lineal, circular,
strategic or reflexive questions? Family Process. 27, 1-15.
30
An Exploration of Communication Theory and Therapeutic Practice
Damien Black: Senior Lecturer, Mental Health and Professional Education. Background in mental
health nursing and undergraduate and post graduate education. He is currently a student 2nd
year Bsc
Counselling
Throughout this assignment I take opportunities to reflect on my thoughts and feelings
as they appear, as opposed to a discrete reflective section. This is more expedient as it
avoids repetition of the material facts. Within this process I generally subscribe to a
reflective model advocated by Gibbs (1988) (Appendix 1.)
In compliance with the professional code of conduct (NMC, 2004) and the codes of
confidentiality of the family institute and the NHS Trust, details of the client have been
altered to protect her anonymity. Diane gave her consent to the use of this audio
recorded session as per the conditions outlined in Appendix 2.
Diane is a forty-six year old lady, who has been experiencing mild to moderate
depression for the past eighteen months. She is employed as a manager and has been
coping quite well with her job. She was born in South Wales and has lived there most
of her life. She lived in Sussex for a period of time during part of her six-year marriage
to Frank. They divorced seventeen years ago, which she says was always inevitable.
They had one daughter Joanna, aged 22, who now lives with her partner John. Diane
married Nick fifteen years ago and they have been very happy. Nick is very caring and
supportive of her and is an excellent stepfather. He is a very stabilising person for her.
She was very close to her father who had a very disabling stroke 20 years ago. Following
a four-year period he died. She was also very close to her mother until their relationship
gradually deteriorated during her father‟s illness. Her mother Joan she describes as an
emotionally needy person who has always been prone to depressive episodes and had
several periods as an in-patient. Joan had an affair following her husband‟s stroke and
against her father‟s wishes she told Diane. She traces tension in their relationship and
the status quo from that point. Also around the time of her father‟s death she had
feelings of despair and depression which she managed to overcome after approximately
two years. She has predominantly been feeling depressed again for over a year and has
sought help because she needs as she said in an earlier session “to become a whole
person again, for herself, Nick and her daughter”.
She has one older brother Jim (50) who has a long-term much younger partner and a
younger brother Stuart (43) who prefers same sex relationships and this is an “open
family secret”.
I will be focusing this assignment on the fourth session with Diane. A very prominent
feature in her interaction has been the emotionally disabling effect that her mother‟s
attitude is having on her and which she believes is causing her symptoms.
During the first session Diane remained very tearful and constantly apologised in spite
of my reassurances. The second and third sessions were similar when Diane would
begin by stating her determination not to cry. However as soon as she mentioned her
relationship with her mother, tears would follow and persist. It was clear by the fourth
session our formulation of her needs that these relationship issues were central to her
emotional fragility and general depressive symptoms.
31
She was longing for her mother‟s approval and was constantly seeking this. She had
excelled in her life in every other respect. Her mother never acknowledged this yet was
overtly praiseworthy of even the smallest efforts of her two sons and Jim‟s partner.
By the end of the third session she agreed to give some thought to the following issues
which might form the basis of session four.
To explore the deterioration of their relationship in terms of her feelings of
Joan‟s general and specific betrayal of her father.
To get a perspective on this in the context of her deteriorating relationship with
Frank, this is occurring around the same time period.
To explore, Joan‟s possible motivations for having an affair and why she would
disclose this to her (my hypothesis is that they were so close at this time it would
have felt a natural thing to do), and to view this in the context of the Diane of
today who would be approximately the same age as her mother was then.
This analysis and reflections are based on the first 30 minutes of a one hour session.
The session begins using phatic interaction largely surrounding an appointment that she
missed last session. Malinowski (1972) found that Trobiand islanders develop
conversations from the phatic phase progressing to more serious discussion. Burnard
(2003) suggests that small talk (phatic speak) underpins the forming of relationships
between client and counsellor on a session to session basis. This approach helped the
client to know that I was continuing in a warm friendly and non-judgemental manner.
Diane appears very comfortable as the session opens. I am very aware of the need to
remain person centred by listening and attending and promoting genuineness, empathy
and unconditional positive regard (UPR). Rogers (1957) mentions respect as
fundamental to UPR arguing this has to be present to allow appropriate conditions to
form the basis from which constructive change could emerge within a counselling
relationship. This view is supported by Egan (2002:46) who identifies respect as the
foundation on which all helping interventions are built.
Initially as I enter this session my intentions are inclined towards the issues as outlined.
Nevertheless in line with my intention of staying on Diane‟s agenda I ask;
“Is there anything in particular that you would like to talk about today”?
She takes the opportunity to suggest where she has got to. She states that she feels much
better and talks about her medication possibly having a positive effect as well as these
sessions. She metacommunicates about what she is about to say by stating she thinks a
great deal about what we talk about. Bateson (1955) identifies in communication it is
important to make it clear at all times what kind of situation or context one is in. If we
say (first) "this is play", we can (afterwards) allow ourselves to do and say things that
might otherwise be offensive. Such communication about the situation in which
interaction takes place, is called meta-communication. Watzlawick et al (1974:53) see
this as identical to the relationship aspect of a communication.
She defines the problem thus;
“I don‟t know what it is whether it is a problem with my mother or it is a problem with
how I behave around my mother, but I know I need to address that to make myself feel
better”. She goes on to express that she doesn‟t know how she is going to do this and
illustrates with an example how difficult she finds expressing her needs to her mother.
32
My response is to encourage her to talk, for example, finishing the sentence with her,
which also demonstrates empathic understanding. (Rogers 1961). This is quickly
overtaken by me doing at least two things. I want to link the previous sessions in the
context of Diane‟s definition of the problem but also to both remind Diane that we had
discussed other definitions of the problem and to offer this contrast again. I remark on
the fact that Diane and Joan do not communicate directly about how Diane feels but
from the perspective of their analogue communication, Diane infers that Joan must
know the impact she is having on her emotionally. Watzlawick et al (1974) citing the
work of Bateson identifies analogue communication, the discrete embedded messages,
as having more general validity that the spoken word (digital or more pure
communication). Basically my attempt to further define to the problem is by asking
how Joan would know this, if you have never spoken about it. I also wanted to
acknowledge the efforts Diane was making in giving a lot of thought to this relationship
dynamic and her search for possible resolutions.
Diane relays a recent example of her mother being inconsiderate and infers that
although it might to the observers (i.e. her brothers etc and her husband) appear trivial
“it is huge to me”. As she continues I am acknowledging the content of what she is
saying and continuing with minimal prompts which remains a constant feature of my
interaction. Burnard (1994), Nelson Jones (2005) sees these as evidence of active
listening. On reflection I do sound like I have a tendency towards my own agenda.
This is in the context of defining the minutia of the problem.
Prior to the breakdown of their relationship they had been very close or as Diane states
“It was really, really good”. She goes on to describe how her mother was quite strict
with all her children and was subsequently very proud of their good behaviour. She also
says that later in life her brothers rejected this but perhaps the desire to please her
mother persisted in Diane. On reflection I think I might have explored what made their
relationship really good and why her brothers later rejected her control while Diane
continues to accept it. She concludes this part of her interaction by saying she hated that
strictness. So in essence there is some construction of meaning in Diane to the stories
she tells about her perceptions of childhood. Pearce and Cronen (1980) developed the
Coordinated Management of Meaning (CMM) theory. According to CMM, two people
who are interacting socially construct the meaning of their conversation and this is an
inherent part of what it means to be human. There is a real sense of three people in the
room, me Diane and by proxy Joan. On reflection I think perhaps Diane has always
resented this aspect of her mother and is even more upset that, unlike her brothers, she
has not been able to move out of this child domain. Berne (1961:141) postulates that
each person is made up of three alter ego states. Our internal reaction and feelings to
external events form the 'Child' ego state. This is the seeing, hearing, feeling, and
emotional body of data within each of us. When anger or despair dominates reason,
the Child is in control.
Also on reflection, I also think I missed this part of our interaction because I was
thinking ahead to what the session might seek to cover, but I think Diane was relating to
lots of stories that were making her life meaningful. With this in mind, CMM suggests
that we tell stories about many things, including our own individual and collective
identity and the world around us. (Pearce and Cronen 1980)
33
As the session progresses I am listening and attending more completely. Whilst I still
encourage Diane to explore how she felt about her mother in the past, there was quite a
natural emergence of how Diane feels now. This also quite naturally led us into what
had been one of my intentions, to view the situation from the perspective of Diane now
being the age her mother was then. Clearly she had thought about this and had
concluded her thoughts in a very non-judgemental attitude and with greater
understanding of how her mother must have felt at the time. This I think was a very
therapeutic process for her.
I found myself in the interaction responding to Diane with a self disclosure about a
similar story in the context of reflecting my own thoughts about me being my mother‟s
age when my father died and consequently, finding it easier to empathise with her
possible emotions at the time. This was spontaneous rather than planned and it was not
overdone and was immediately and seamlessly related to Diane‟s situation. It appeared
to have the effect of encouraging further expression about how her mother‟s need to
rebuild her life had progressed to the acceptance of now as opposed to the rejection of
then. In particular though fleeting in some respects she recounts her brothers at the
time rejecting, for example, her mothers attempts to develop relationships with new
partners, arguing that her mother appeared to need her acceptance more so than any
other family members. So in this sense she is reflecting on her observations, at least, of
the wider network of relationships in the family. Later she also draws attention to how
her paternal aunts with whom she has remained in contact with have been rejected by
her mother. A point she is quick to suggest would place a wedge between her and her
mother if it were openly acknowledged.
Reflecting on the use of self disclosure, I was seeking to communicate to Diane my level
of understanding and empathy and to further build on our therapeutic relationship.
Mearns and Thorne (1999:91) acknowledge that the counsellor may have lots of
feelings and sensations flowing within them and suggests it is only those, which are in
response to the client that is appropriate for expression. This view is supported by
Roberts (2005) who says when using self-disclosure the counsellor should keep focused
on the extent that it will be useful for the client.
During some of the interaction I get a sense that I am creating varying degrees of
tension in Diane. I think this is because I am seeking to understand her truth about the
relationship between them. Certainly listening to the tape I can also perceive a very mild
challenge to her story as alternative views are offered. I aim to avoid the direct „why‟
type of question and rephrase to use the words „how come ……‟ If I am being very
critical of myself I think that Diane might get the impression that I am siding with her
mother. However it does appear to open up other possibilities in her perception of the
relationship as we explore it using different lenses and perspectives.
Towards the end of the selected interaction we have some considerable discussion
regarding the reasons for her mother‟s different relationship with Diane as opposed to
her brothers and Jim‟s past and present partner, “They have what I want”. She defines
the cause of this further by involving her father and his stabilising influence being no
longer present as a major issue. I encourage her to see this from different perspectives
and present these in the frame of “just my thoughts, to be accepted or rejected” (meta-
communication). By doing this I want to avoid appearing too challenging of Diane‟s
perceptions of the problem. I was intending the questions to be reflexive. Tomm
(2006) argues that the intention of this type of question is to open space for alternative
34
meanings that support healing or wellness in a manner that is respectful, invitational,
enabling and which will draw on the client‟s own propensity for change. The precise
nature of this change was something I had no idea about. Tomm suggests that these
questions will have a generative effect for the client and a creative effect for the
counsellor. These effects are not readily heard in the excerpt being considered but did
manifest later and in subsequent sessions.
During the years following her dad‟s death, she describes her mother as really going
through a series of hospital admissions for depression to the point where Joan needed
to “take responsibility for her life” Although my questions are intended to be reflexive
there is certainly still an orientation aspect to them.
Diane and Joan‟s interaction can be viewed in terms of pathologising interpersonal
patterns (PIP‟s). “A „PIP‟ is defined as a recurrent interpersonal interaction which
triggers or increases negativity, pain and/or suffering in one or both persons interacting,
or which results in deterioration of the relationship” (Tomm, 1988). Diane
seeks/desires approval from Joan but she perceives rejection when Joan is
inconsiderate, rude, does not involve her in family events or acknowledges her
achievements.
As I place myself in an outside „listening‟ role there is considerable complexity in
punctuating the ongoing sequences of their PIP‟s. Did Diane start the chain of PIP‟s by
judging her mother‟s behaviour at the time she had an affair, and did this judgement set
up a chain of behaviours in Joan that Diane perceives as negative and challenging.
My conclusions are that at this point in time it does not matter who started what, or
indeed, where the punctuation of the sequences of behaviour are, the overall
perception of Diane is that they are negative challenging and produce symptoms in her.
The view of their PIP‟s is supported by Watzlawick et al (1974) when they illustrate that
disagreement about how to punctuate sequences of events lies at the root of countless
relationship struggles and offer their example, you nag me because I am passive and
withdrawn and I withdraw because you nag me.
From a Cognitive Behavioural (CBT) (Beck 1989) perspective I did previously ask her
as homework to consider that it is she who allows her mother to cause her to feel the
ways she does and not her mother causing her feelings. In other words the activator
(her mother‟s behaviours and communications) to Diane is not the source of her
symptoms (consequences) but the ways she perceives them (beliefs or cognitions). It
was offered to Diane as an alternative way of seeing things and in later sessions proved
to be very efficacious.
Interestingly Joan as far as I can ascertain is possibly unaware that she occupies a
dominant relationship with Diane to the extent Diane perceives this. I think this
because in my communication with Diane I have tried to establish the validity and
reliability of Diane‟s perception of her mother‟s attitudes and behaviours towards her
yet she has not been able to verify this with her mother. This poses the real question
which I pose to Diane, “How do you know this is true”?
Bateson and Naven (1952) in Watzlawick et al (1974) referring to complementary
schismogenesis illustrate the assertive nature of Joan towards Diane and the submissive
response of Diane to Joan. This pattern of behaviour has insidiously developed and has
probably been reinforced by Diane‟s culturally determined views on her role as a
daughter. She has previously talked before about cultural expectations of women in the
micro society of the South Wales Valleys. Similarly we sought a perspective on how
35
mothers in this micro-society view their sons. We had discussed the possibility that her
brothers were being given prominence simply because they were male. However, we
had reached no conclusions on this. However, it was certain that Diane perceived an
inequality in the ways her mother treated her as opposed to the ways she wanted to be
treated.
If there was a difference in the way her mother perceived her brothers she had been
able to overcome this because she stated her brothers and her were so close that it was
of no consequence. So in the context of ideas expressed by Watzlawick et al (1974) the
content (digital) component of how her brothers are treated is lessened by the
relationship (analogue in nature) she has with her brothers.
I am aiming to remain non-judgemental with Diane. Yet at the same time, in spite of
my meta-communication reassurances, the intonation, pace and emphasis of my voice
or other non-verbal gestures facial expressions eye contact posture, in the analogue
communication context might be sending a different and even opposing messages to
Diane. I aim to redefine the relationship and my interaction by almost spelling out the
content yet Watzlawick et al (1974) argues that the more powerful relationship on
analogue aspects are difficult to suppress, (actions speak louder than words) and they
are more honest at least from the perspective that they do not have an opposing
negative value. They just are!!
On a wider notion I personally was of the opinion that my relationship with Diane had
become more congruent and empathetic. As relationships develop people feel more
able to release their empathy and acceptance (Mearns 2003:44)
References
Bateson G., (1955) http:/www.anthrobase.com/Dic/eng/def/context.htm
Beck A.T., (1989) Cognitive Therapy and the Emotional Disorders. New York.
Penguin Books
Berne E., (1961) in Nelson Jones R., (2006) Theory and Practice of Counselling and
Therapy. Fourth Edition, Page 141: London, Sage Publications,
Burnard P., (2003) Ordinary Chat and Therapeutic Conversation: Phatic
Communication and Mental Health Nursing. Journal of Psychiatric and Mental Health
Nursing. 10(6), 679-689
Egan G., (1998) The Skilled Helper: A Problem – Management and Opportunity
Development - Approach to Helping. (6xth Edition) Pacific Grove: Brooks/Cole
Malinowski B.K., (1972) The Language of Conversation - Phatic Communion
http://english.unitecnology.ac.nz/resources/resources/conversation/part1-C.html
(Accessed 4th Jan 2007)
Mearns D., Thorne B., (1999) Person Centred Counselling in Action. Second Edition.
(Series Editor; Dryden W) Sage London, Publications,
36
Nelson-Jones R., (2005) Introduction to Counselling Skills; Text and Activities. Second
Edition, London, Sage Publications,
Nursing and Midwifery Council (2004) The NMC code of professional conduct: standards for conduct, performance and ethics London. NMC, ,
Pearce W. B., Cronen V., (1980) „Communication, Action, and Meaning: The creation
of Social Realities‟. New York. Praeger:
Roberts J., (2005) One Day Workshop on Self-Disclosure, Cardiff Bay, Organised By
The Family Institute, School of Care Sciences, University of Glamorgan
Rogers C.R., (1961). On Becoming a Person. London: Constable
Tomm, K. (1988) Interventive Interviewing: Part 3; Intending to Ask Lineal, Circular,
Strategic or Reflexive Questions. Family Process, 27; Pages 1-15
Tomm. K., (2006) Workshop organized by „The Family Institute‟ University of
Glamorgan and subsequent workshop notes and handouts supplied by Dr Tomm.
Watzlawick P., Weakland, J.H., Fisch, R. (1974). Changing a system. Change, New
York. W.W. Norton,
37
Title: An inspired journey”
Anna Jenkins currently works as an administrator for the University of Glamorgan. When she wrote this
essay, she also worked as a bereavement support volunteer for the Merthyr Tydfil and RCT Branch of
Cruse Bereavement Care as well being a student on the BSc Counselling (Year 1)
Introduction
This essay will describe and compare two counselling approaches from two different
schools of counselling and therapy. I have chosen two approaches that resonate strongly
with me and are having a profound influence on the theoretical and philosophical basis
of my thinking as a trainee counsellor, at the moment. The first approach is the
existential approach, from the humanistic-existential school. The second is the Jungian
approach, from the psychodynamic school, which is more commonly practiced as a
form of psychotherapy, as opposed to a counselling approach.
My experience of working with bereaved people and personal experience in relation to
spirituality and holism, have led me to become interested in exploring these two
concepts as they relate to counselling in general. Consequently, in this essay I have
chosen to focus specifically on these areas in describing two counselling approaches.
I will structure the essay into three distinct parts. Initially, I will explore the existential
approach under the following three headings: an overview of the approach; the holistic
perspective of the approach; the spiritual perspective of the approach. I will proceed to
explore the Jungian approach under the same three headings. In the third part of the
essay, in order to convey a greater sense of the whole of both approaches, I will
compare them in a more general sense. I will conclude by summarising the main points
of the essay, as a whole.
Overview of the Existential Approach
Existential approaches to therapy emerged at the beginning of the twentieth century
when a number of psychiatrists began applying the thinking of existential philosophers
such as Kierkegaard, Nietzsche, Heidegger and Sartre amongst others (as well as
Husserl and the phenomenologist‟s) to their clinical work (Cooper, 2003; van Deurzen
2005). Daseinsanalysis (founded by Ludwig Binswanger and developed by Medard
Boss), was one of the first existential approaches along with Logo therapy, which was
founded by Viktor Frankl and many others followed (Cooper, 2003).
Whilst the diverse range of existential practices that exist today reflects the hugely
diverse and often contrasting spectrum of ideas on which they are based, all have one
shared focus; that of exploring, understanding and coming to terms with human
existence. Furthermore, they share the following fundamental concepts or assumptions:
the concept of human existence as an on-going process of change and transformation;
human existence as, unavoidably, intertwined with the existences of others; the
inevitability of anxiety, guilt and despair in facing the reality of existence - equally, the
value of these as sources of guidance for living; the concept of authentic living as
characterised by personal strengths and weaknesses and exercising freedom of choice
and individual responsibility in determining an authentic lived-experience based on
one‟s own values and beliefs (aware of the possibilities and limitations of existence); the
notion of time as lived-experience (Cooper, 2003).
38
To give an indication of the diversity found across existential approaches, I will outline
some key dimensions along which individual approaches variously sit in terms of
thinking and/or practice: phenomenological or existential; directive or non-directive;
use of descriptive exploration or explanatory exploration of client material; focusing the
therapeutic process on psychological or philosophical exploration; focusing on
individual or universal experiencing; encouraging clients to focus on subjective or
inter-worldly experiences; focusing on immediacy or non-immediacy in the therapeutic
relationship; approaching the therapeutic process spontaneously or by drawing on
specific techniques; pathologising or de-pathologising.
However, most existential approaches focus on the potential for well-being and growth
as opposed to pathology or cure (van Deurzen, 2005; Cooper, 2003). Different
existential approaches are, therefore, practiced in a variety of diverse and contrasting
ways; characteristically, however, most are philosophical, flexible and openly responsive
to the varied needs of individual clients and therapists.
The Holistic Perspective of the Existential Approach
Generally, and specifically through the use of aromatherapy, Reiki, homeopathy,
herbalism and meditation, I have developed an increasingly convincing conviction in
the concept of holism, which for me is a reminder of the interconnectedness not just of
the mind, body and spirit but of all things. Consequently, in exploring different
counselling approaches, I find myself drawn to approaches that feature a holistic
perspective.
As I see it, by enabling clients to explore the meaning of the entire context of their
existence, Emmy van Deurzen‟s (2005) existential approach is particularly holistic. It
focuses on clients‟ experience of the world on four interlinked and interrelated
dimensions, from which she believes clients form their world-view, as follows: physical (that of existence in relation to the givens of the natural, physical world including the
polarities of survival and death); social (that of existence in relation to the public world,
including the polarities of belonging and isolation), psychological (that of relationships
with ourselves and intimate others, and including the polarities of integrity and
disintegration); spiritual (that of existence in relation to ideals, philosophy and the
polarities of ultimate meaning against the threat of meaningless).
This framework provides a basis for clients to gain a broad, holistic perspective of their
lives. Clients are invited to explore all four dimensions in order to come to terms with
personal and universal limitations, confront tensions caused by the various polarities
and dilemmas within each dimension, and search for clarity, meaning, purpose, identity
and ideals in living.
Van Deurzen (2005) believes that meaning arises most fully from clients‟ conscious and
active engagement with their lives on all four dimensions. On the whole, however, all
existential approaches respect the autonomy of clients to determine what is meaningful
and beneficial to themselves as individuals: whether it is behavioural change, personal
growth or an altered belief system is up to the client
The Spiritual Perspective of the Existential Approach
In my work for Cruse Bereavement Care, since 2002, all of my clients have searched
for existential meaning including a search for ultimate meaning in their lives: all have,
spontaneously, explored their own, unique spiritual beliefs and/or experiences of
spiritual integration in their lives. This has made me curious about the part spirituality
plays in terms of exploring meaning in people‟s lives. Today I found a study into
spiritual beliefs and existential meaning in later life and the experience of older
39
bereaved spouses that concluded the following: „A remarkably strong association was found between strength of belief and adjustment to bereavement‟ (Economic and Social
Research Council n.d.).
A number of existential approaches acknowledge the spiritual dimension of existence.
However, van Deurzen‟s approach is one that specifically focuses on it. As mentioned
earlier, she believes that individuals experience the world on four interlinked and
interrelated dimensions, one of which is the spiritual dimension. She refers to
spirituality in the very broad sense of individuals‟ relationship to ideals, philosophy and
ultimate meaning, including abstract and metaphysical aspects of experience beyond
themselves. This very broad basis for acknowledging and exploring the spiritual
dimension of existence is one that I think most people are likely to relate to. In
describing the spiritual dimension, van Deurzen writes „This is the dimension of our
overall world-view and ideological perspective, which determines how we operate on the other dimensions and how we make sense of the world‟ (van Deurzen 2005, p. 92).
This view resonates with my own personal experience. I get a sense from my Cruse
clients, that looking at the ultimate meaning of existence is vital in helping them not
only deal with the death of a loved one and the consequent significant life changes that
that brings about but, also, to focus on the ultimate meaning of their own existence.
Another well-known existential psychotherapist Irvin Yalom (1980) notes that those
who have a sense of spiritual meaning generally experience a corresponding,
harmonising sense of personal meaning: he also notes empirical research findings on
meaning in life which corroborates the association between religious beliefs and a
positive sense of meaning (Yalom, 1980). Whilst spirituality is not consistently
acknowledged or addressed across existential approaches, Van Deurzen‟s approach
provides a broad framework for acknowledging and integrating the spiritual dimension
of existence in clients‟ lives.
An Overview of the Jungian Approach
Jungian approaches to therapy are based on analytical psychotherapy (also referred to
as Jungian analysis or psychotherapy), which was founded (between 1913 and 1918) by
Carl Gustav Jung. A student and colleague of Sigmund Freud for six years, Jung
eventually disagreed with Freud over the nature of the unconscious and developed his
own monumental approach to psychology.
To give a sense of Jung‟s ideas in this overview, I will provide a brief outline of the
central tenets of his original approach, as distinct from the various post-Jungian
approaches that have emerged since. On the whole, I will continue to focus on Jung‟s
original approach throughout this essay. Jung was keen to go beyond the confines of the
personal and was interested in the interaction between the conscious and unconscious;
he believed the unconscious to be a positive, creative force (In our time, 2004).
He divided the psyche into three parts: 1. the ego – the centre of consciousness and
organiser of our thoughts, intuitions, sensations, easily accessible memories etc.; 2. the
personal unconscious - comprising anything that is not presently conscious but could be
including complexes (accumulations of associations that have a strong emotional
content and influence); 3. the collective unconscious - a myth-inspiring level of the
psyche shared by all humans and composed of primordial configurations known as
archetypes. These are innate in the psyche, and have „the capacity to initiate, influence and mediate the behavioural characteristics and typical experiences of all humans‟ („Jung‟s Model of the Psyche – Part One‟, 2001).
40
One of the innumerable archetypes is the Self, which is considered to be the central
archetype. The Self is super ordinate to the ego and expresses the unity of the psyche as
a whole. Complexes are the manifestation of archetypes in the personal unconscious
and exert a strong influence on conscious experience and behaviour. Jung saw the
dynamics of psyche as being generated by the oppositional and compensational forces
within it (conscious processes being compensated by unconscious opposites).
In essence, he saw the psyche as a dynamic system made up of two oppositional halves,
with an innate urge to synthesize the whole. Dreams, Jung believed, were spontaneous
self-depictions of situations in the unconscious attempting to counterbalance something
in the conscious mind. Jung distinguished psychological types into the following
function-types: thinking; feeling; sensation; intuition, and attitude-types into extroverted
and introverted (which, again, be believed were counterbalanced with unconscious
opposites). In the Jungian Approach, the goal of life is individuation (realising the Self),
by transcending the opposites, achieving one‟s potential and becoming whole integrated
and uniquely oneself (Samuels, 1985).
The Holistic Perspective of the Jungian Approach
The Jungian therapeutic process centres on the notion of engaging the innate healing
power of the client‟s unconscious towards the on-going formation of a unique,
integrated or whole self. This is achieved by fusing the opposites within, for example:
archetypes and instincts (regarded as psychological and physiological expressions of
psychic energy or libido); the ego and the shadow, the hidden or unconscious (both
good and bad) aspects of the individual; the anima-animus (the yoked opposites of
masculine-feminine); introvert and extrovert aspects etc.
Psychic unity or wholeness is understood to be achieved by a, largely unconscious,
psychological mechanism called compensation - the compensatory interplay between
consciousness and unconsciousness. This can be aided or abated by the conscious
mind attending or not attending to what is emerging from the unconscious. The
therapeutic process aids compensation and, therefore, the individuation process using
metaphorical and experiential means, for example: transference and counter-
transference between client and therapist; activation of the unconscious using dream
interpretation, and other forms of active imagination such as fantasies and various
imaginal art forms; amplification of the archetypal themes, which involves the use of
mythic, historical and cultural parallels in order to clarify the metaphorical content of
unconscious imagery (Fordham, 1978).
The ultimate task of individuating (realising the self) is a creative unifying of the whole
psychic system, by synthesising the two opposite halves to form a unified whole. In this
process, Stein explains, „the Self impacts the psyche and creates changes in the individual at all levels: physical, psychological, and spiritual‟ (Stein 1998, p. 194). The
Jungian approach emphasises the dynamic, holistic process of individuation as a natural
tendency to integrate consciousness and unconsciousness. In doing so, Jung believed
one „…..gathers the world to one‟s self‟ (Jung 1995, p. 415).
Hall and Nordby state „The mind of man is prefigured by evolution‟ (Hall & Nordby
1973, p. 39). Viewing the human psyche within the context of a larger evolutionary
whole, the Jungian approach, in effect, extends the focus of therapy beyond the
boundaries of the individual mind, body and spirit towards the more infinite and unitive
existence of the collective unconscious (Hall & Nordby, 1973).
41
The Spiritual Perspective of the Jungian Approach
Personally, I am particularly aware of my own mind, body and spirit whole when
meditating or communing with nature and, in such moments, I perceive my spiritual
essence, experientially. Both from personal experience and from my work with
bereaved people, it seems to me that focusing from a spiritual perspective enables one
to look beyond the fears and limitations of immediate existential problems towards
discovering inspirational meaning and solutions beyond the boundaries of one‟s
conscious worldly existence.
I think that the Jungian approach to counselling acknowledges this and provides an in-
depth means of connecting to the spiritual dimension of existence. This is
accomplished by providing a method for exploring and expanding one‟s consciousness
of existence, acknowledging and integrating the conscious and unconscious parts of the
whole, as described above.
Jung believed, as I do, that the spiritual dimension of existence is the essence of human
nature and he developed a dynamic conceptualisation of the physical, mental and
spiritual dimensions striving for unity and wholeness in each individual (Jung, 1995).
The individuation process strengthens the connection between these dimensions,
whereby the ego gives up its need for the persona (its mask, the face it presents to the
world) and begins to embody its whole, unique self, which Jung understood to be the
God image – a reflection of the Self. He stated “….the soul must contain in itself the faculty of relation to God…....the archetype of the God-image‟ (Jung 1995, p. 419).
Jung saw man as a psycho spiritual being and religion and spirituality as transformative
systems of man‟s wholeness (Jung 1995). In the Jungian therapeutic relationship, client
and therapist do not connect merely on a conscious level, but also aspire to connect on
an unconscious or spiritual level - the level of Self - enabling a unity of souls, that
become transparent to each other (Jung, 1995; Brooke, 2000). It occurs to me that
perhaps advanced empathy, also known as depth reflection, stems from this
unconscious level of connection between people.
Comparison of Existential and Jungian Approaches
Both the existential and Jungian approaches view meaning as vital to the fullness of
human existence and recognise the timeless universality of mankind‟s longing for
meaning. Conscious existential meaning is the predominant focus of existential
approaches. The Jungian approach also focuses on existential meaning; however, it
does so largely through the lens of collective or transpersonal meaning. Jung stated
„Meaning makes a great many things endurable – perhaps everything‟ (Jung 1995, p.
373).
On the whole, existential approaches emphasise individuals‟ conscious self-
determination of their existences and their becoming distinct, authentic individuals;
whereas, the Jungian approach focuses more on creative and holistic unconscious
influences as the primary determinant. Both approaches acknowledge and accept the
tension of opposites inherent in human existence, and focus on transcending or
synthesising these. The theory of psychological opposites is central to the Jungian
approach, as described above in 2.2. Jung wrote, „Nothing so promotes the growth of consciousness as this inner confrontation of opposites‟ (Jung 1995, p. 378).
42
Existential approaches focus on transcending the paradoxes of existence, for example:
survival and death; belonging and isolation; integrity and disintegration; meaning and
the threat of meaningless. Both van Deurzen (2005) and Yalom (1980, 1991, 2006)
speak passionately about transcending the opposites and paradoxes of existence leading
to clients engaging purposefully in life. It seems to me that the process of
acknowledging and synthesising the dichotomies of existence produces an effect similar
to the effect of the core conditions of the person-centred approach to counselling
(considered essential elements of the therapeutic relationship in many therapeutic
approaches); that is, enabling clients to become more accepting of who they are and
more empathic and authentic (Rogers, 1997).
The Therapeutic Relationship and View of the Person
Both existential and Jungian approaches have a strong belief in the therapeutic value of
the client-therapist relationship. In both, the therapeutic relationship is based on a
dialogue between the client and therapist. Presence, mutuality and authenticity between
client and counsellor are characteristic features of the therapeutic relationship in both
approaches. Both approaches stress the importance of therapists not imposing their
views on clients. In both approaches, the therapist‟s role is largely a facilitative one;
ultimately, facilitating clients in determining their individual, authentic existence.
Van Deurzen (2005) emphasises the professional nature of the therapeutic relationship.
May‟s view of the existential relationship is „as “one existence communicating with another”, to use Binswanger‟s phrase‟ (May et al., 1958, p. 81). The Jungian approach
shares a similar view with therapists aspiring to connect with clients on both conscious
and unconscious levels, without the need for a professional façade. The view that both
client and counsellor are changed by the therapeutic process, and that all interactions
between them are relevant is shared by both approaches (Samuels, 1985; Yalom, 2006).
In the Jungian approach, transference and counter-transference are a significant part of
the therapeutic relationship and process of therapy. Existential approaches generally
reject the notion of transference and instead focus on the here and now of the
therapeutic relationship. Both approaches respect the individuality of each client, as
evidenced by their focusing on and valuing clients‟ individual subjective experiences.
The existential approach combines this with focusing on universal, existential givens as
well; and the Jungian approach includes the collective unconscious influence on
subjective experiences.
Both approaches focus on the potential for well-being and growth as opposed to
pathology or cure (van Deurzen, 2005; Samuels, 1985). Jung felt that the individual‟s
story was more important than diagnosis (Dryden, 1996). The existential approaches
concur with this view. Both approaches recognise the on-going process of change and
transformation within clients and view clients‟ difficulties as informational resources
with the potential to promote growth and transcendence, ultimately. In terms of the
therapeutic relationship, despite the Jungian approach coming from the psychodynamic
school of counselling and therapy, it appears to have more in common with the
existential-humanistic school than the psychodynamic school.
43
The Goal of Therapy
In terms of the goal of therapy, the existential and Jungian approaches are distinctly
different yet they share some similarities. The existential approach seeks to assist clients
in understanding and facing the complexities and dichotomies of their finite lives in the
world and their relationship with it. In doing so, clients focus on facing up to the
conflicts and anxiety, which, according to Yalom and May, are caused by the ultimate
existential concerns of death, freedom, isolation and meaninglessness (Cooper, 2003);
van Deurzen (2005), on the other hand, focuses on these in a more general sense.
In essence, the existential approach emphasises self-awareness, self-determination and
freedom of choice through the lens of the conscious, finite worldly existence of the
individual. The Jungian approach, on the other hand, centres on the psychological and
psycho spiritual development of the individual, and on harnessing the creative and
transformative potential of the unconscious (transpersonal) dimension of existence.
Focusing on the psyche‟s innate urge towards individuating, the main goal of Jungian
therapy is to assist clients in consciously moving towards the goal of understanding and
developing the innate potentialities of their psyche, which transcends the individual self.
Viewing the human psyche within the context of a larger evolutionary whole, the
Jungian approach looks beyond the boundaries of the personal towards a more infinite
and interconnected worldly existence.
As clients learn about archetypes, they discover their similarities and connection to
mankind as a whole. Samuels illustrates this point by describing the archetypes as
having a „profound social communicative function‟ and as a source of empathy in
relationships (In our time, 2004). As I see it, there are underlying similarities in the
overall goal of both approaches.
The goal of the existential approach is exploring issues of existence, meaning and
purpose, and one‟s unique response to these. The goal of the Jungian approach is
about consciously working towards reconciling the positive and negative dichotomies
within the psyche in the on-going formation of a unique, integrated or whole self.
Ultimately, both approaches focus on the individuality and intentionality of existence.
Personally, I think that the Jungian approach has a more expansive and holistic view of
who we are.
The Breadth and Essence of Approaches
The existential and Jungian approaches are similar in that they are both immense in
scope and depth; neither is a single cohesive discipline, each comprises a multiplicity of
theoretical variation and therapeutic practices under one broad umbrella of ideas. The
existential approach is devoid of psychological constructs or theories of personality.
Cooper explains „at the heart of an existential standpoint is the rejection of grand, all-
encompassing systems; and a preference for individual and autonomous practices‟ (Cooper 2003, p. 2). The Jungian approach was deliberately developed by Jung as an
open system of theory, which was influenced by Eastern and Western religions,
anthropology, parapsychology, mythology and alchemy (Samuels, 1985). Jung believed
that many theories were needed to get „even a rough picture of the psyche‟s complexity‟ (Jung, cited in Samuels 1985, p.267).
It seems to me that, on the whole, both approaches are (to a large extent) open systems,
reflecting the very broad and complex basis of ideas from which they emerged and
continue to be influenced. Jung‟s original approach focuses predominately on the
unconscious (or spiritual) dimension of existence believing this dimension to be the
44
essence of who we are, which is a view I share, wholeheartedly. Many existential
approaches focus largely on the conscious, physical and psychological dimensions of
existence, to the detriment of not recognizing the whole (conscious and unconscious,
physical, psychological and spiritual). Van Deurzen‟s approach, however, attempts a
holistic balance in acknowledging and synthesising the whole including the spiritual, but
with much less conviction in its overall significance than the Jungian approach. Whilst I
recognise and appreciate the breadth of focus in both of these approaches, for me a
combination of the two would create a truly holistic context for counselling.
Conclusion
I set out to first describe the existential and Jungian counselling approaches, in turn,
starting with an overview before focusing on their respective holistic and spiritual
perspectives. In order to convey a greater sense of the whole of these two vast
approaches, I then intended to compare the approaches in a general sense.
In describing the existential approach, the diverse and often contrasting spectrum of
ideas within the discipline was evident. Furthermore, it became obvious that although
all approaches share the central focus of exploring concerns rooted in the individual‟s
existence, together with some fundamental concepts and assumptions, different
existential approaches practice in a variety of diverse and contrasting ways.
It was noted that van Deurzen‟s approach provides a holistic perspective by focusing on
the physical, social, personal and spiritual dimensions of existence, and that
comprehensive meaning is thought to stem from clients‟ active engagement on all four
dimensions. The fact that a number of existential approaches acknowledge the spiritual
dimension was noted, as was the fact that van Deurzen specifically addresses this
dimension in her approach, and recognises its impact on all the other dimensions of
existence.
In describing the Jungian approach, the depth and breadth of the approach was
apparent, as was Jung‟s complex view of the human psyche. The central tenets of Jung‟s
original approach were outlined, including the three levels of the psyche, the
psychodynamics of activity and the interrelation of the various parts, and the life-long
goal of the psyche to achieve wholeness.
This was followed by an overview of the therapeutic process as it relates to the
reconciliation of oppositional forces within the psyche and the unification of the whole
psychic system, which it was noted extends beyond the individual to the larger collective
or evolutionary whole. The Jungian approach was acknowledged for providing an in-
depth means of exploring the spiritual dimension of existence and the aspiration of
Jungian therapists to connect to clients on an unconscious (spiritual) level was noted.
In comparing the two approaches, the following similarities between them emerged: the
significance of meaning as vital to the fullness of human existence; transcendence of the
tension of opposites inherent in human existence; many similarities in the style of the
therapeutic relationship and view of the person, including a shared view on
psychopathology; the shared focus on the individuality and intentionality of existence;
the broad and diverse basis of both approaches; the spiritual and holistic perspective of
both approaches.
The following differences in the approaches were noted: the significant differences in
their focuses on meaning being derived from consciousness (existential) as opposed to
unconsciousness (Jungian); opposing views on the notion of transference and counter-
transference in the therapeutic relationship; the general focus on conscious self-
determination (existential), as opposed to unconscious Self-determination (Jungian); the
45
relatively superficial focus on the spiritual dimension of existence (existential) as
opposed to an in-depth focus (Jungian).
In conclusion, it is clear that the existential and Jungian approach each focus on a
distinct determinant of existence. The existential approach focuses on the conscious
existential self as the determinant; whereas, the Jungian approach focuses on the
collective unconscious as the primary determinant. Personally, I think that there is
more collaboration between consciousness and unconsciousness than is recognised by
either of these approaches.
Finally, when I wrote my first position statement, I ended it by expressing my
anticipatory excitement about discovering and developing my own individual, integrative
approach to being a counsellor, writing this essay has been an inspired part of that
journey for me.
References
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Cooper, M [2003,] Existential Therapies, , London. Sage Publications Ltd
Dryden, W [1996,] Handbook of Individual Therapy, London.SAGE Publications
Ltd,
Economic and Social Research Council n.d., Spiritual Beliefs and Existential Meaning
in Later Life: The Experience of Older Bereaved Spouses. Retrieved 30 May 2006,
from http://www.esrcsocietytoday.ac.uk
Fordham, M [1978], Jungian Psychotherapy: A Study in Analytical Psychotherapy, John
Chichester Wiley & Sons Ltd,
Hall, C & Nordby, V [1973]. A primer of Jungian psychology, New York.Mentor,
In our time [2004], radio programme, BBC Radio 4, UK, 2 December.
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May, R, Angel, E, & Ellenberger, HF [1958], Existence: A New Dimension in Psychiatry and Psychology, New York.Basic Books,
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Stein, M [1998], Jung‟s Map of the Soul, Illinois. Carus Publishing Company,
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van Deurzen, E [2005], Existential Counselling & Psychotherapy in Practice,
London.Sage Publications Ltd,
Yalom, I [1980], Existential Psychotherapy, New York.Basic Books,
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47
Title: Theories of change in the field of systemic psychotherapy: A
Critique
Mark Hendy is 46 and lives with his wife and family in Swansea. He is employed by Sure Start to work
with fathers and is a student on the MSc Systemic Psychotherapy
Introduction
Being as it is, within the “true” nature of systemic thinking to connect and reflect, rather
than to polarize and defend; its evolution is unavoidably influenced, for better or worse,
by some of the major scientific, social and philosophical themes of our time, as well as,
for therapists, by the desire to do better clinical work. Consequently
practitioner/theorists in the field of systemic psychotherapy have re-evaluated and, in
some cases, radically developed many of the original foundations and concepts. Writers
describe “paradigm shifts” that have ushered in new epistemology and subsequent
theories of change, in turn generating a rich diversity of methods and techniques useful
to the field, and in non-therapeutic “human systems” settings.
This essay will briefly map some of the wider context for these historical shifts. It will
look at the influences of post-modernism and go on to explore the tensions between
constructivist and social constructionist positions, as they relate theories of change and
to specific techniques. The significance of language in systems theory is addressed from
the different perspectives of narrative, dialogue and the coordinated management of
meaning. Finally it will consider ways in which apparently irreconcilable views about
change are being coordinated positively, leading towards better work with clients
without the need to abandon models and positions.
Systems theory
General systems theory was born in a climate of therapy dominated by theories of
change that centred on pathologizing the internal workings of the individual. Systemic
metaphors, derived from the world of mechanistic science, provided an oppositional
view; that change for an individual may be achieved through acting on features of the
relational system that the individual was connected to, usually the family, and that
limitations in the family could be causing the malfunction/symptom in the individual.
Many new techniques were developed that helped therapists work on problems that
might exist in, for example, the structural hierarchy or behavioural sequences in the
family, different aspects of whatever they considered to be wrong with the internal
workings of the family.
By the mid 1980s however, ideas that challenged traditional views about objectivity were
finally gaining influence in the field of systemic psychotherapy. The forces of post-
structuralism, post-modernism and the weight of the feminist critique of family therapy
practises could not be ignored. Ultimately, the notion of an “outside” observer position,
a hallmark of what is described now as first order family therapy, became untenable. A
metamorphosis occurred that produced an exciting alternative paradigm based on the
understanding that objective reality was unknowable. This demanded relinquishing the
certainty of secure positivistic ideas about how to fix families. In its place grew an
acceptance that therapeutic change would need to occur within the unpredictable
nature of collaboration. The therapist could no longer presume to “work on”; instead
the challenge became how to “work with”.
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Second order positions
As the field of systemic psychotherapy continues to re-organise around this second
order position, the practise and ontology of clinicians diversifies. Though remaining
true to the commitment to collaborative work with families, different emphases have
produced such contrasting ideas about change to a point that some commentators have
argued that the “systemic” metaphor does not adequately contain them. This will be
returned to later.
Though it would be impossible to offer a definitive map of everything that has shaped
current thinking, certain ideas deserve particular mention as their influence has been,
and continues to be, visible in the developing systemic landscape.
Constructivism
Of special significance is the epistemology of constructivism. In its simplest form it was
part of the force that contributed to the shift away from objectivity, from observed to
observing systems. It convincingly argued, with biological evidence, that externalities
could only be known through our individual innate mental and sensory structures and
that it is these structures that determine the understanding of and response to
interaction with the outside world (Maturana & Varela 1980).
Therefore, if the “knowledge” of the therapist is purely a personal construct that has
inherently no greater authenticity or truth than that of the client(s), it raises questions
about the value of simply telling a family what to do, and the goal of therapeutic
endeavour must include becoming part of the network that therapy is occurring in. This
also draws attention to the biases and “self” of the therapist. These ideas found
resonance in the post modern thinking that was gathering influence in the field even
though they originated from within the modernist world of scientific discovery and
“fact”.
Post modernism defies definition, other than to say, whatever it is, it is not modernism.
Whether it is viewed as a political, social, literary or an epistemological position, and it
is all of the above, its impact and influence in the field of systemic psychotherapy,
though controversial, cannot be underestimated. Some of the implications will be
addressed more fully in a later section, but it requires a brief mention in this context
because of the way it provided a critical framework that supported the transition to a
second order position within psychotherapy. By nature, post modernism is a critique.
As such, it promotes investigation into the space between two positions; events etc. over
the analysis and evaluation of the single, and, as such, is
“characterised by uncertainty, unpredictability, and the unknown. Change is a given and
is embraced”. (Anderson 1997).
Epistemologies and Truth
As a critique, post modernism depends on the concept of epistemological investigation
- the theory of knowledge (Rivett 2003), allowing truth to be reconceptualised, away
from its overarching, singular and static position of omnipotence and set within specific
limits. These parameters contextualize and relativize the “truth” so that, if the
parameters change, the so does the truth.
An idea contained within these post modernist themes is that of social constructionism,
another major influence on the systemic field. Drawing from freedom allowed by the
post modern perspective, social constructionism posits that truths, and indeed all
49
knowledge and meaning, is constructed by members of a social grouping from the
representation of its experience, especially through language, culture and dialogue. The
“truth” of these meanings is limited to the specific context of the social system.
Profoundly different from constructivism, this epistemology offers a description of
knowledge whose locus is completely embedded in the social interaction between
interpreting entities as opposed to within individual perception and structure (Gergen
1994).
From these initial influences and related ideas, contemporary theories of change have
centred on the process of story telling, or narrative making, taking in to account the way
that language, culture and dialogue act as meaning generating entities.
“Narrative is now widely regarded as a prime organising framework for experience, the
means by which we construct our views of ourselves and our lives.” (Paré, 1996)
However, different emphases on the meaning of language, hermeneutics, in therapeutic
interaction have produced contrasting methods and explanations, depending on the
interpretation and bias of the practitioner.
Narrative therapies
Though Michael White and David Epston, for example, describe their current work as
a “narrative” approach to family therapy, (White and Epston, 1990) their theoretical
position is significantly different from others who might use similar terminology. While
retaining some aspects of their previous work with externalizing problems, White and
Epston‟s practise moved away from a “modernist” deficit based model and started to
focus on externalizing the “lifestyle” around the problem.
This challenged the negative sense of personhood that was almost unavoidably part of
the totalizing diagnostic label worn by the client. A “problem saturated” narrative, due
to its position as the dominant discourse, produces a loss of personal agency, thereby
becoming a problem in itself; even though it is in reality only one of many narratives
that might accurately or usefully describe a situation or a person/family.
The therapist‟s role, and, some would argue, ethical responsibility (Pare & Lysack,
2004), is to ask questions that bring suppressed stories into the open, privileging
“unique outcomes” that contradict, deconstruct and dis-empower the dominant view.
Therapy is able to produce new meaning and knowledge that remains coherent with the
clients‟ lived experience. Alongside this, in recognising and exploring ideas of
dominance, the mechanism of suppression and power, White has drawn from the
writings of Foucault and introduced a level of political and social ethics into his work.
“At times this practise of therapy includes a form of political action at what we might
call the local level.”(Michael White, 1995.)
Through the meaning generating ability of language these previously unspoken
conversations have a transformative effect and challenge the abuses of power.
The use of “narrative” as an element of therapy is also found in the work of Harlene
Anderson, as developed from her collaboration with Harry Goolishian(1988), although
it occupies a different position and has produced different methods and techniques. In
her “collaborative language systems approach” (Anderson, 1993) she takes a post
modern view that similarly recognises the construction of self as social and therefore
language dependent.
Anderson too sees problems being maintained in language, but identifies that the
therapeutic system itself is a language and meaning generating system, organising and
50
being organised by the problem, and therefore is, literally, part of the problem. To
attempt to resolve this, or at least reduce its effects, Anderson has designed an approach
that she describes as a “conversational partnership”, a flattened hierarchy in which no
definition of therapeutic goals or direction is offered by the therapist, and the client
becomes the teacher. Change occurs in a flexible dialogic space that the therapist takes
responsibility for maintaining, allowing the problem system to dissolve rather than
become more fixed in a system organised around finding solutions. Therapists‟ ideas
and expertise from outside of the session are seen as unhelpful and Anderson
advocates a “not-knowing” position.
“ the therapist exercises expertise in asking questions from a position of “not-knowing”
rather than asking questions that are informed by method” (1992).
This position, which has attracted much comment, is seen by Anderson as creating the
level of mutuality between the participants that is key to enabling the dialogic process.
The dialogic process is an important feature of social constructionist thinking, as can be
seen from Martin Buber‟s (1965) explanation that personal growth is
“not accomplished in relation to oneself, but instead in the dialogical relation between I
and the other” (Rober 2005)
Dialogics
This approach clearly contrasts with the intention and practise of Michael White. The
dialogic understanding of narrative thinking is based on theories of change that are
different, though not mutually exclusive, to the externalizing approach.
Dialogue maintains the “space of possibilities” (Searle 1992, as quoted in Anderson,
1997) in the therapeutic system, the space to explore and create new meaning together,
and is not necessarily synonymous with conversation. Two opposing politicians, for
example, may converse but they are likely to do so in a monologic way, consequently
unable to generate new meaning in each other. The conversations between teacher and
pupil or doctor and patient produce new knowledge in the pupil and patient but only as
a duplication of the already existing authoritative knowledge. Dialogue has not
occurred.
The requirements for a dialogic relationship are complex, fragile, even risky, possibly
experienced as feelings of love (Seikkula & Trimble 2005). For the therapist, the ability
to remain in dialogue requires moving from the safety of a meta-position to a place
engaging with the complexity of the inner voices that create her own sense of
distinctness and identity. This is because dialogue is new meaning found in difference, it
does not exist in “sameness” and is not produced by psychodynamic empathy; it does
not expect the therapist to “step into the shoes” of the client.
It is enabled rather by a genuine engagement of the therapist with her own
“outsidedness” (Bakhtin 1986) which she finds reflected in the questions of her inner
dialogue. The shift between engagement with external “actual” others and the internal
“virtual” others for both client(s) and therapist(s) creates a new language within a new
context, with new possibilities for change (Seikkula & Trimble 2005).
Internalised others
Another technique that successfully shows how these theories of change integrate and
function has been developed by Karl Tomm. “Internalized other interviewing”
addresses the internalized evolving “self-story” (McAdams & Janis, 2004), as a narrative
made up of different descriptions about the self. The client is asked to speak from the
position of a significant “other” thereby allowing the client to “more fully appreciate not
51
only the other‟s perspective but also how the thoughts, attitudes and feelings of another
person can be part of who they are.”(Hurley, 2006)
The “polyphony” (Bakhtin, 1984) of inner voices that populate the “self” are brought
into an internal dialogic space, and by asking reflexive questions, the therapist can
encourage the generation of new possibilities (Tomm,1987). According to Wikipedia
“Reflexivity is considered to occur when the observations or actions of observers in the
social system affect the very situations they are observing”.
As the client observes the externalized internal dialogue in a reflexive way, change is
taking place. Though more directive in style than the “not-knowing” position of
Anderson, this technique demonstrates how self healing is achievable through engaging
with the “dialogic self” (Lysack, 2002).
Both narrative and dialogic ideas engage with the contextual nature of meaning that is
so central to social constructionist thought. Whether in the style of White‟s directive
questioning to reveal unique outcomes, or within a non-directive collaborative language
systems approach, there is recognition that the same action or event can have multiple
meanings that are dependent on the context.
Coordinated Management of Meaning
The management of these meanings is part of how the process of change takes place
and a tool has been developed to provide a framework for mapping this combination of
meaning and context called “Coordinated management of meaning”, or CMM
(Cronen, Pearce et al 1979). Developing from its origins as a general theory of
communication in the 1970s it now resides within the broader theory of social
constructionism and has become a practical theory of change that has influenced and
been incorporated into a range of methods and techniques.
By using a hierarchy of meaning, usually, but not always, consisting of six levels
(content, speech acts, episodes, relationship, life scripts and cultural patterns) CMM
organises social meaning into levels, each level contextualized by the levels either side
of it. Communications between participants contain different levels of meaning that
generate the hierarchy according to the regulative (action) or the constitutive (meaning)
rules within the communication.
Thus it is possible to infer that there are two reciprocal forces are at work, producing a
self-referential structure. These are the “implicative” force, acting on the level above,
and a stronger, “contextual” force coming from the level above, which defines the
meaning of the level below. The hierarchy is not fixed and is subject to reversal if the
implicative effect is greater than the contextual, at which point a different or new
constitutive rule is incorporated into the hierarchy. Change in meaning and behaviour is
unavoidable as the system adjusts to coordinate to its new rules.
From a therapeutic perspective, questions to family members identify the hierarchy of
meaning and “By engaging in communication with the family and focusing on the
connections between different meaning-providing levels, the therapist becomes part of a
reflexive process through which new meaning can be co-created through
language.”(Mongomery, 2004)
As post modern systemic thinking has become more established it appears to be
becoming more inquiring about ideas from beyond the systemic framework. The way
that the above example of CMM has been drawn out from Communication Theory to
52
be applied within systemic psychotherapy illustrates how useful this can be. In this
example compatibility might not be an issue, as communication is a fundamental part of
mechanics of social constructionism and the therapeutic system.
Current systemic thinking, however, is also successfully exploring, developing and
adopting ideas about change from other fields that might seem less compatible, being
possibly considered more “individualist”, modernist or even unrelated in their purer
forms. Before closer consideration is given to some of this ideological “cross-
pollination”, it is necessary to outline some of the reasons behind this sort of
development.
Postmodern lenses
The critical freedom of post modern thinking itself, which invites self-reflexivity and
debate, brings with it a resistance to the notion of standing still, “foundationlessness” is a
characteristic trait (Falicov 1998).
Post modernism is a lens about lenses (Hoffman 1990) that is inevitably turned on
itself, producing philosophical and pragmatic questions. However, there continues to be
a persistent uncertainty about the uncertainty that is implicit within generic post modern
ideas and a concern that this uncertainty may be unhelpful to the therapeutic process.
Along with this, reflections from practise suggest that the post modern/social
constructionist psychotherapeutic “box” with its emphasis on collaboration, language
and meaning making, may not completely do justice to the diversity contained in the
reality of human experience and its hopes and needs (Flaskas 2002).
The following illustrations show how some post modern ideas, may not be conducive to
good therapeutic practise. The idea of new stories and meaning being always useful is
an assumption that tends to accompany narrative approaches to change. There are
however occasions when the relativism implied by a new story or new understanding
about the story is not useful, that therapy and healing come from staying with, rather
than moving away.
One context where this has been noted is with survivors of trauma. “The success of this
piece of work depends not on the therapists‟ ability to generate new stories, but on their
capacity to stay with the family‟s experience of the real” (Frosh 1997)
Structure and stories
The source of family experience may not be contained primarily in language and social
constructs. In an earlier paper Frosh (1995) makes the point that it can be in the
breakdowns and insufficiencies of language that reality is known and experienced.
The interest in story/meaning making would supplant actual interest in the experience
of the client, given that it can be relativised at different levels of context, reducing the
centrality of the subject. “In this layer of ideas, the interest in any external reality fades,
and is replaced by the interest in the process of the “making” of reality through social
construction in language.”(Flaskas 2002).
Another concern focuses on arguably the most important structure relevant to systemic
psychotherapy, the family itself. As can be seen from this essay, though social
constructionism and post modernism enable consideration to be given to both the
wider meaning of context and context of meaning, and to new ways to conceptualise
“self”, they do not necessarily contribute to a framework from which to consider the
uniqueness of the social construct that the family is (Minuchin, 1998).
Identity presents another difficulty for the social constructionist as it appears to be
synonymous with the internal socially constructed narrative (Gergen,1991). If identity is
only the product of others‟ descriptions of ourselves, then what part do “real” factors
such as genetics play, and why are some situations more easily changed than others?
53
Linares (2001) suggests that there may still be a need for a separate concept of
“identity” alongside the narrative construction of self.
The individuals place
In attempting to address such complexities, theorists are reconsidering ideas about
subjectivity and individual therapy that might have seemed at odds with the very essence
of systemic principles at its inception and even more incompatible with the move
towards a second order position.
Psychoanalysts, social scientists, geneticists and developmental psychologists are
bringing useful and often controversial ideas to the field. This has led to questions of
the “but is it systemic?” type, but beyond that, they are addressing a much more
significant question which has central relevance to this title.
How do systemic psychotherapists adequately describe the connection between change
in the interpersonal social system and change in the intrapersonal psychic system? In
the search for more robust theories that engage this core issue, interdisciplinary
cooperation is engendered.
Attachment theory
An example of this is the recent paper by Blom and van Dijk (2007), a social scientist
and a psychiatrist respectively, which discusses attachment theory in a social
construction framework. They usefully describe both psychic and social systems as
“symbolic” systems, and as such are based on meaning relations. All systems are, in
essence, organised and “structured” forms, whether inanimate, biological or symbolic.
As a step towards understanding how the elements of the structure relate across the
psychic and social divide it is important to notice what exactly it is that is being
structured. Following from Luhmann‟s ideas (1984), they suggest that
“social systems are basically structured processes of communication…..Psychic system
refers to structured sequences of mental events, such as thoughts, feelings and images.”
The difference is fundamental and irreconcilable, and yet, at the same time, the two
systems are totally interdependent, unable to exist without each other. The therapeutic
conversation occurs in the social system using language that becomes structured into
communication which, in turn, utilizing the theories and ideas already discussed,
produces new meaning.
Biology, communication and change
In the light of Maturana‟s observations (Maturana &Varela 1987) that autopoietic
systems that can only produce what they are made up from, how does this new meaning
within the socially constructed system produce change in an individual organism, when
both are structurally determined and self-referential closed systems? In other words,
what is the relationship between thought and communication?
“The theory of structural coupling seems a promising way to explain how individual
autonomy can be based on communication, avoiding the harsh debates between
individual constructivism and social constructivism” (Baraldi 1993).
The concept of structural coupling is one way to describe this relationship. In brief,
structural coupling occurs when two structured events happen simultaneously. The
social system structures a communication event in tandem with the structuring of
thought or mental event in the individual psychic system.
54
Change occurs in both systems, autonomously. The purpose of mentioning this
concept in this essay is not primarily to explain the mechanism, but rather to use it as a
metaphor for the evolution of both systemic theory and other therapeutic theories are
as they engage with theories of change. The theoretical structures remain fundamentally
different, autonomous from each other, while at the same time, producing greater
shared understanding together.
Conclusions
This essay has considered theories of change in systemic psychotherapy and how they
have and continue to develop. Starting from the early systemic metaphor it has shown
how transitions have occurred that brought the field into the influences of post
modernism and social constructionism.
Using the notion of narrative it has been demonstrated that different approaches to
change are compatible with post modern thinking. The centrality of dialogue in the
production of meaning is explored along with its particular application with the
“internalized other interview”.
CMM has been shown to be a useful framework from which to consider meaning.
Some of the concerns have been discussed about the outcome of the influence of post
modern ideas on the practise of systemic psychotherapy. Finally, structural coupling is
used as an example of collaboration between different disciplines and as a metaphor to
show how theories of change are being currently developed.
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Blom, T., & van Dijk, L. (2007). The role of attachment in couple relationships
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57
Counselling in the context of an ethical dilemma.
Sian Smith works in mental health and has recently started a job as a Primary Care Gateway Worker.
She now takes that role in the Gwent Healthcare Trust.. She is undertaking a Bsc Counselling with the
Family Institute.
A man is referred for counselling following a disclosure to his GP that he has been
sexually abused as a child. In the course of my work with him he tells me that this happened when he was 10 years old and that the perpetrator is his older brother. He tells me that his older brother has remarried a woman who has a 10 year old son. My
client does not want to inform the authorities. (This is a hypothetical situation allowing me the opportunity to explore ethical perspectives in Counselling).
Introduction
I have chosen to do this question within the context of primary care, therefore there are
statutory obligations which need to be considered and the impact on client care that
these may have. Ultimately, child protection is of concern as potentially a child is at
risk. Issues which require consideration include; ethics, codes of conduct, legality,
autonomy, confidentiality, and the therapist‟s personal development and their ability to
find ethical solutions. Also the client themselves in relation to the impact abuse has
had. These all require to be thought of in relation to the therapeutic relationship with
the client. Fundamentally in addressing the above issue as the client does not wish to
inform authorities about potential abuse, the therapist is left with an ethical dilemma. In
view of the potential negative long lasting effects of child abuse, this subject requires
careful, sensitive thought, from all aspects.
Relationship, risk and purpose
Initially the counsellor would need to develop a therapeutic relationship with the client,
whilst setting boundaries and contracting. Bond (2000), points out that this is not easy in
practice; as the client may be vulnerable and distressed. The NHS could seem a
daunting minefield for a client being seen for the first time.
It may be required to explore some of the issues regarding the alleged abuse, and the
degree of risk posed by a potential perpetrator. The survivor of abuse was aged 10
years, when the alleged abuse occurred; therefore what was his understanding of abuse
and what constituted it? It may be significant how old his brother was at the time; and
whether the alleged abuse occurred as part of normal childhood inquisitiveness/ sexual
development. Alternatively was the abuse more violent in nature and therefore more
serious. All these factors require exploration with the client. Jones (2000), suggests that
if it is clear that abuse did occur it is easier to deal with, and more difficult if the client is
confused. The client themselves may be unsure and unclear; therefore this needs to be
sensitively explored. It may also be of significance if the client has previously disclosed
the abuse to anybody else.
In order for counselling to proceed there is a need to explore the purpose of
counselling with the client regarding their aims and goals, Jones (2000). As the
counsellor has been requested not to break confidentiality, the counsellor needs to be
aware that working within a primary care context may be governed by various codes of
58
conduct. The issue of confidentiality is complex in a public funded organization, (Potter
2002). Each trust has its‟ own child protection procedures which require consideration.
Working within the context of primary care, results in working collaboratively with a
multi disciplinary team, this process needs to be sensitively explained to the client; that
health records and information are exchanged, and that concerns may need to be
shared.
If information has not been shared, it has been noted by Palmer-Barnes (2001), Scori
(1999); that there have been incidents where statutory authorities have been involved,
and professionals have not worked collaboratively resulting in sad consequences.
It is not within the scope of this essay but needs to be acknowledged, that different
health care trusts have different policies as to whether a client is seen primarily for
sexual abuse work. It may be that unless there are other factors in the client‟s
presentation, that it is suggested that they seek assistance from other organisations,
where they could possibly receive a better service. It needs to be acknowledged that
there can be difficulties surrounding the pathologizing of mental health patients
(Laungani 2002). Clients may be having a normal reaction to an abnormal occurrence.
The client‟s capacity to make an informed decision about not informing the authorities
about potential abuse needs to be considered; as the client is being seen in a health care
setting, it needs to be considered that their decision may be affected by their mental
state.
Codes of Ethics
As a counsellor working within primary care may be subject to various professional
ethical codes, for the purpose of this essay I am going to focus on the British
Association of Counselling and the implications this has working within a health care
setting.
It is the clause, „‟Responsibility to those at risk of serious harm‟‟ (BAC 1197:B.3.4.1,
cited in Jones 2000) that results in an ethical dilemma for the counsellor and how this is
addressed; as by adhering to the above principle the counsellor is going against the
clients wishes and would be breaking confidentiality, thereby loosing the clients trust.
Jones (2000) verifies that if counselling is being provided by a public funded
organisation there is an obligation to pass on information. In line with BAC, Nursing
and Midwifery Codes and local trust guidance; professional codes imply it is alright to
break confidentiality if a child is at risk.
However Bond (2000), points out that the BAC puts emphasis on client autonomy. He
also goes on to add that though the BAC puts emphasis on the client‟s right to
confidentiality, this cannot be viewed as an absolute right issues regarding children.
A client‟s trust in a counsellor may be dependant on the availability of confidentiality
within the situation, without trust it would make it difficult to proceed, thus leaving the
child open to abuse.
Codes of ethics can appear to make the situation confusing for the counsellor. It has
been argued that ethical codes have been established to protect the public interest, to
protect professions from outside regulation and to police its‟ members. They also
provide a structure for accountability and redress should clients have cause to complain,
also to provide a structure for the public to have faith that they are receiving a
professional service, (McLeod 2000). The negative side of them is that they have been
established without public consultation and serve to protect the governing bodies which
they represent (Hannabuss 1998, Kitchener 1982). It can also be viewed that ethical
codes are reactive rather than proactive (Corey1993).
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Counsellors may interpret the codes wrongly. It has been argued that a code of ethics is
dependant on the subjective mood of the counsellor (Gibson 2005), and that ethical
codes do not necessarily promote ethical behaviour and awareness (Pattison 1999).
Also Palmer-Barnes (2001) explains that counsellors may never break a code of ethics
but treat clients in a way that „brings the profession into disrepute‟, she goes on to say
that by doing this they are keeping to the rule of law not the spirit of the law.
By sticking to the codes of conduct, and notifying the relevant authorities the therapist
could potentially make the situation worse. This could be for various reasons: - the
counsellor may not have gathered enough evidence; the situation could potentially
explode having disastrous consequences for the client and their family; and child
protection agencies are not always able to stop abuse, as the family may close ranks with
the threat of social services involvement. Alternatively if the counsellor did not consider
the codes, they could leave a child open to abuse.
Counselling and Morality
It could be argued that the counsellor could potentially be making a moral judgement,
by informing authorities about potential abuse. So for the counsellor, to not practice
defensively, Clarkson (1996), recognises there is a need to recognise and make value
judgements explicit, and not impose them on clients.
It needs to be acknowledged that the counsellor may be taking undue risks, by ignoring
a dangerous situation and not taking appropriate action. It can be argued that:-„‟Ethical issues arise when there are no existing guidelines to give us direction on personal values and judgements.‟‟ Pg. 44 (Rosenbaum 1982b cited in Kitchener 1984)
A difficulty of not having guidelines, is if the counsellor is looking for guidance, is trying
to defend a particular stance or if colleagues or the law disagrees with an outcome which
a counsellor arrives at (McLeod 1998). A code of ethics cannot have all the answers for
every situation; but they can give an overview of what should be done ethically.
A dilemma for counselling is the need to be non judgemental. But a client may be
choosing to make a decision which from the counsellor‟s point of view is morally
wrong. The counsellor is then forced to make a decision based on their moral
judgement.
Hare (1981), argues that intuitive moral reasoning based on someone‟s prior ethical
knowledge and experience are necessary when immediate answers are required for
dilemmas (cited in Kitchener 1984). He goes on to say that if the situation is beyond a
counsellor‟s experience there is a need to have a critical-evaluation level of moral
reasoning. This enables the person to have an ability to think about ethical situations;
professional codes form the basis of this, leading on to ethical principles and ethical
theory. Kitchener (1984) identifies the core principles of autonomy, non-maleficent,
beneficence, justice and fidelity which she terms ethical principles and adds another of
self interest, which can be applied to the current dilemma. I will discuss autonomy in
more detail later on.
As beneficence refers to the promotion of human welfare (McLeod 1998); from the
clients perspective it could be viewed that by maintaining a therapeutic relationship and
not breaching confidentiality the counsellor will have worked within a framework of
beneficence. But for the child this would not be the case, therefore the principle of
non-maleficent needs to be considered. However it could be the case that the
counsellor could be thought of working in a non-maleficent way if by not disclosing to
appropriate authorities the overall situation deteriorated for both the client and the
child. Kitchener (1984) acknowledges that ethical principles are not absolute, as the
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discussed scenario highlights. But she goes on to say that they are always morally
relevant and give us consistent advice about what moral issues need to be considered.
It has been suggested by McLeod (1998) that when dilemmas such as the one described
present, they can be resolved by utilitarian ideas. As Palmer-Barnes (2001) points out to
act in a utilitarian way entails working out the most likely outcomes and which would be
the most beneficial in the circumstances. But this could potentially ignore the client‟s
wishes and go against the ethos of counselling to promote growth in the client.
If ethics is considered from a consequential or teleological view; whereby the end
justifies the means; depending on what outcome the counsellor hopes to achieve.
Should the counsellor choose to preserve the safety of the child; the counsellor could
break confidentiality and the child would be safe. However this could have
consequences for the therapeutic relationship. From a dutiful or deontological view
whereby actions are either intrinsically good or bad; the counsellor may decide to not
break confidentiality but would have to live with the possibility of a child being abused.
Ethical pluralists, take a stance between these two options. They could form a
consequential point of view; by not breaking confidentiality, as the outcome may not be
satisfactory for various reasons. But work within a deontological view, with the belief
that the client will make the right decision on balance.
Gabriel L (2001) uses the term „ethical literacy‟, to describe the development a
counsellor may go through to describe how they move from a lower level of ethical
functioning to a higher level. She reflects that a counsellor moves from a position of
adhering to practice guidelines, seeking support from colleagues and supervision to
develop their own internal system. Gabriel feels that reflection is needed in order to
have an understanding of how values and beliefs have an effect in ethical decision
making.
To be ethical according to Pattison (1999) requires critical reasoning, to actively choose,
question judge and not mindlessly conform. So in order to „unpack‟ the given scenario
in its complexity, it may be that the counsellor has to deal with some difficult feelings.
For the counsellor to practice ethically it may be helpful to look at the legal position
regarding the scenario and the obligation to break confidentiality.
Legality
The Children‟s Act 2004; section 11 places a statutory duty to make arrangements to
safeguard children; it places emphasis on services working collaboratively and to share
information, (Goldthorpe 2004). From a health care perspective, there is a requirement
to make appropriate agencies aware of child protection concerns, and to share
information, (Daniluk 1993). The McColgan case as documented by Scori (1999),
illustrates how when services have not worked together; adult survivors successfully
brought about a civil liability lawsuit against authorities who failed to protect them
against abuse from their father.
Alternatively under the Human Rights Act (HRA) with regard to confidentiality if a
client is receiving a service from a public body, a client not only has a private law right
of confidentiality, but under article 8 of the HRA, they have the right to respect for
private and family life; they also have the right to data protection. However if a public
body fails to take adequate protective measures to prevent abuse it is a violation of
article 3(prohibition of torture). As article 3 is an absolute right and cannot be restricted
by the state, it overrides article 8 regarding confidentiality as it is a qualified right,
(Costigan 2004).
If the therapist were to break confidentiality the client would find redress under private
law, the human rights act and under data protection; if it were discovered that no abuse
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had occurred and the counsellor had acted with defensive practice. Alternatively if it
was discovered that a child was in danger the client would have no redress for
confidentiality being broken.
The Client‟s Autonomy
In order for the counsellor to practice ethically it is necessary that the client is
instrumental in this. Therefore it is important to look at the concept of autonomy.
Corey (1993) feels that the: - „‟goals of therapy are a process of problem solving, not just
to solve problems.‟‟ pg 32. In order for problem solving to take place the client should
be in an autonomous position, (Bond 2000). BAC guidelines advocate client‟s seeking
control over their lives, so the counsellor needs to be aware of the power balance within
the relationship. It has been argued that counsellor power makes the concept of
autonomy difficult (Bond 2000 et. al.).
In order to address this difficulty one aspect can be demonstrated by the concepts of
un-conditional positive regard and taking a non-judgemental approach to counselling as
advocated by Carl Rogers; it is hoped that through this process the client develops self
determination.
Taking a non-judgemental approach entails, as Rogers terms „being with the patient‟
and not taking a directive approach. He feels that by taking this approach, it results in
growth for the patient, therefore moral growth (Gibson 2005).
However is the concept realistic? Johnstone (1999) argues that being non-judgemental
is difficult to achieve; faced with potential child abuse as the counsellor is potentially
forced to make a value judgement. Gibson (2005) contrasts this with saying that the
relationship between a non-judgemental counsellor & client is fundamentally a moral
relationship based on the client‟s un-conditional worth as a moral agent.
The Philosopher Immanuel Kant: - „‟…prioritises autonomy but recognises that one persons right to autonomy may conflict with another.‟‟ pg. 94 (cited in Bond 2000).
From a utilitarianism perspective, it is felt that there should be respect for another‟s
autonomy, but that a person should be mature enough to make their autonomous
decisions. This stance may be difficult within the practice environment as clients may be
seen with other presenting factors, which would have an impact on their capacity to
make decisions.
It can be argued that if the concept of autonomy were always followed it would result in
our obligation to never prevent harm, (Kitchener 1984). There may be a cut off point
when the;-„‟ risks get too great, and action needs to be taken when there is clear &
imminent danger‟‟ Pg. 16, (Daniluk 1993). An indicator of this could be when the client
is not showing growth within the counselling relationship, and they are unable to
acknowledge the risks.
As the concept of confidentiality is difficult to uphold, the best way forward appears to
be to work within a framework of trust, Palmer-Barnes (2001); this facilitates the client‟s
confidence within the relationship. She recognises that; - „‟…due to the culture there is no such thing as absolute confidentiality‟‟ pg. 146. The new ethical framework is not
specific about requirements for confidentiality in the therapeutic relationship. (Potter
2002)
Cohen (1992) feels that: - „‟... obtaining clients consent is the best way of resolving legal and ethical disclosures over confidentiality.‟‟ pg 158 (cited in Bond 2000).
There are as Jones (2000) points out conflicting priorities of confidentiality and duty of
care to the client; and doing the most good and causing the least harm within the
counselling relationship whilst protecting children at risk.
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As there are limits to confidentiality; Daniluk (1993), states that it may be helpful to
engage the client in reporting. In order for this to occur as previously stated the client
needs to have developed a moral stance within an environment of trust and
containment.
McLeod (2000) recognises that all counselling is concerned with dialogue between
conflicting and contrasting moral positions. In order to for this to occur it may be
helpful to acknowledge the effects, that childhood sexual abuse has on the clients; and
the counsellors ability to work with this dilemma. Due to the nature of the effects of
childhood abuse, counselling may be seen negatively by the client and emphasises the
client‟s inadequacy and separation, (Bollas 1991). Initially it is important that the client
feels understood and that the abuse can be dealt with and talked about. Kennedy (1996)
believes that if the client has the right kind of therapeutic environment they are better
equipped to resolve the experience, thus protecting them from further mental health
difficulties. The reason the client is seen in Primary care, is to prevent deterioration.
Bollas (1991) recognises that clients who have experienced childhood sexual abuse may
perceive that they are being harmed by their recollection of memories.
The relationship again
Therefore there is a need for the counsellor to work at the same pace as the client and
not to force issues. This is borne out by MacCarthy (1988) who recognises that working
too quickly can result in the client not feeling contained with the consequence that they
could „act out‟ or terminate treatment. Campling (1992), writes that clients may respond
defensively, to anything reminiscent of abuse, to intrusive questions or coercion. She
goes on to say, clients who have been abused as children may not have developed their
vocabulary to express how they are feeling, therefore present differently to how they are
actually feeling. She feels if their confusions are reacted to with control it can evoke
powerlessness. Therefore there is a need for the counsellor to be clear and explain
thoroughly, each step of the counselling process. Campling (1992) also reflects that: -
„‟…clients may respond to the world with despairing acceptance‟‟. It may be tempting
for the counsellor to respond with action; however the client may perceive this that they
are being pushed into doing something against their will.
MacCarthy (1988) feels that clients require:-„‟… clarity and clear boundaries from the therapist‟‟pg.117. Kennedy (1996) also suggests the counsellor could be viewed as a: -
„‟…constantly failing environment the client may wish to control‟‟ Pg. 158. The client
may perceive that the counsellor is not helping, as they may be experiencing strong
emotions. The client may respond by „acting out‟ their feelings, which the counsellor
may need to understand and contain.
Disclosure
Due to issues surrounding disclosure the counsellor is not in a position to be directive;
they could facilitate the client to be aware of all angles to the difficulty. Should the client
choose to disclose according to MacCarthy (1988), the consequences often realises the
victim‟s fears within the family, society, and legal process and health response. It is
important to explore the effects of disclosure with clients. Also the impact on the legal
system should they want to proceed further. It may be pertinent that they were both
children at the time. A difficulty regarding disclosure could be that clients may feel they
were responsible for the abuse and therefore unable to acknowledge that another child
may be at risk, Jones (2000)
Disclosure can have devastating effects for the client within their family as the:-
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‟…the silence of incest years is nothing compared with the deafening & lifelong silence that can descend within the extended family after disclosure‟‟ pg.118, (MacCarthy
1988). The impact of disclosure regarding the client‟s relationships needs to be
explored in counselling. Daniluk (1993) suggests that disclosure and gaining family
support could be potentially healing.
Should the client decide on a court case it could potentially have an empowering effect
on the client as there would be some form of restitution. Breaking their silence can be a
potent therapeutic strategy as the survivor can gain personal control and power
(Daniluk 1993, Scori 1999). However this needs to be balanced against the emotional
effect on the client as the alleged perpetrator is a sibling. Severing contact with the
abuser could result in feelings of guilt for the client. Alternatively if the perpetrator is
acquitted, ultimately if they have abused the client is left with the emotional trauma of
being disbelieved. MacCarthy (1988) affirms if the end result is a court case:-„‟…the ultimate humiliation is a full legal process, culminating in acquittal‟‟ pg114. The abuser
is potentially then able to abuse again. Scori (1999), points out that clients who are
experiencing the effects of PTSD as a result of abuse, often find a court case difficult
due to the reoccurrence of symptoms. It is important to acknowledge that due to the
client‟s vulnerability, the balance of power may shift from client to therapist when
dealing with abuse, therefore it is important to maximise the client‟s autonomy.
To practice ethically, it is important to be honest, by strictly working to practice
guidelines, every issue might not be considered, resulting in defensive practice whereby
the client and other people involved are left feeling betrayed. Foucault makes the
statement that:-„‟…ethics is the kind of relationship you ought to have with yourself... and which constitute himself or herself as a moral subject of his/ her actions‟‟ pg. 41
(cited in Hannabus 1998).
So to work ethically a counsellor is required to have a sense of where they stand
morally. From my previous argument regarding unconditional positive regard it can be
viewed that a counsellor may be able to view the client with unconditional positive
regard as their own moral agent, it is then possible to display to the client skills of
congruence and empathy.
In order that the counsellors own needs are not invested and problems don‟t become
the client‟s it is important to consider the therapists personal development. As Johns
(1996) points out, awareness of self and others is the crux of personal development.
She suggests that development and growth are:- „‟…influenced by our implicit attitudes, values, constructs, perceptions and needs.‟‟ pg 7.
Gibson (2005) argues that if counselling is not morally based, counsellors are free to do
as they please. Gaining insight into irrational beliefs and emotional disturbance,
Holmes & Lindley (1991) feels leads to moral development (cited in Johns 1996).
According to Ashcroft (2001), clients are more concerned with the personal and moral
qualities of the practitioner. He goes on to say that it is a key feature of the ethical
framework which emphasises the personal dimension of counselling and
psychotherapy.
In order for a counsellor to develop ethical practice for the given situation; Gabriel
(2001), uses the term „ethical literacy‟, to describe the process whereby a counsellor
needs to hold and contain the situation whilst developing skills, knowledge and support.
By becoming ethically minded the counsellor is then able to find ethical solutions,
Conclusion
In writing this essay I have been relating it back to myself and my own personal
development and practice. Before I started on the course I was feeling burnt out. Since
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starting on the course I have had the time and space to think about my own personal
development and my values and assumptions. I am ashamed to say that the above
scenario if related to a client I was seeing in my work would have left me with a heart
sink feeling. This stance is verified by MacCarthy (1988) who observes that incest
victims are often feared by professionals, and: - „‟…that statutory agencies project onto clients by isolating, and ignoring their treatment needs while protecting their own position.‟‟ pg. 118. What could be helpful for the above client and their difficult
scenario is a feeling of containment. There are many aspects to promoting this;
understanding where the client is coming from and allowing them time and space.
There could be a danger of the client seeking direction and the counsellor wanting to
give it. This should be avoided as it would not facilitate the client‟s development and
could potentially be open to interpretation. There is also a need for the counsellor not
to feel pressured by the needs of the organisation. Hopefully if some of these aspects
are considered, the client will reach their own conclusions. The counsellor needs to be
continually mindful that they are dealing with a potentially difficult scenario in that they
are balancing the needs of the child, client and the environment that they are working.
At any time the counsellor needs to be aware that they may be forced to break
confidentiality if the dangers of potential child abuse become too great.
References
Bollas, C., (1991) The trauma of incest. London Free association Books:
Bond, T., (2000) 2 ed. Standards and Ethics for Counselling in Action. London Sage:
publications
Campling, P., (1992) Working with survivors of child sexual abuse. British Medical
Journal, 5:12 pgs.305-30-6
Corey, G., Corey, M., and Callanan, P., (1993) Issues and Ethics in the Helping Professions Pacific Grove CA: Brooks/Cole
Costigan, R., (2004) Why bother about the Human Rights Act? Counselling
Psychotherapy Journal, Dec: 42-61
Clarkson P., Murdin L., (1996) When rules are not enough: the spirit of the law ethical codes. Counselling, February; pg 31-35
Daniluk, J., Haverkamp., (1993) Ethical issues in counselling adult survivors of incest.
Journal of Counselling
Gabriel, L., (2001) A matter of ethical literacy, Counselling Psychotherapy Journal, July
pgs 14-15
Goldthorpe, L., (2004) Every child matters: A legal perspective. Child Abuse Review,
vol.13: 115-136
Gibson, S., (2005) On judgement and Judgementalism: how counselling can make people better. Journal of Medical Ethics, Oct.Vol.31 (10),575-577
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Hannabuss, S., (1998) Ethics in Counselling, Education Today: vol. 48; 1: 41-46
Jones, C. (2000) Questions of ethics in Counselling & Theory Milton Keynes Open
University Press
Johns, H., (1996) Personal Development in Counsellor Training ,London: Cassell
Johnstone M., (1999) On becoming non-judgemental: some difficulties for an ethics of
counselling; Journal of Medical Ethics; 25:487-491
Kennedy, R., (1996) Bearing the unbearable - working with the abused mind.
Psychoanalytic Psychotherapy. Vol.10 No.2 143-154
Kitchener, K., (1984) Intuition, Critical Evaluation and Ethical Principles: The Foundation for Ethical Decisions in Counselling Psychology The Counselling
Psychologist 12/3, 43-55
Langani, P., (2002) Mindless psychiatry & dubious ethics. Counselling Psychology
quarterly, Vol.15, No.1, pgs 23-33
MacCarthy, B., (1988) Are incest victims hated. Psychoanalytic Psychotherapy Vol.3,
No.2, 113-120
McLeod, J., (2000) An introduction to counselling. Milton Keynes, Open University
Press
Pattison, S., (1999) Are professional codes unethical? Counselling 10(5) Dec., 374-380
Palmer-Barnes, F. (2001) Values and Ethics in the Practice of Psychotherapy and Counselling Milton Keynes, Open University Press
Potter, V. (2002) Ethical framework for good Practice in Counselling & Psychotherapy: Review of Introduction Process Counselling Psychotherapy Journal, March: 26-27
Sgori. S., (1999) The McColgan Case: Increasing Public Awareness of Professional
Responsibility for Protecting Children from Physical and Sexual Abuse in the Republic
of Ireland. Journal of Child Sexual Abuse. Vol. 8/1 113-131
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Title: A critical evaluation of cognitive behavioural therapy Author: Adrian Perkins
Adrian is a participant on The Post Graduate Diploma in Family and Systemic Therapy year two but
at the time of writing this essay was on – Year 1 .He is a child care / family law solicitor and volunteer
counsellor with Cardiff Concern Christian Counselling Service. His particular area of interest is
relationship counselling.
Introduction
The National Service Framework for Mental Health cites Cognitive Behavioural
Therapy („CBT‟) is the first line treatment of choice for a wide range of psychiatric
disorders (London HMSO 2000). It has become the default psychotherapy for the
public sector mental health services. Christine Padesky (2004) describes CBT as
providing a high probability of success and low relapse rate through the use of
empirically proven methods to achieve goals in a brief time period. Yet CBT does have
its critics and some leading cognitive behavioural therapists are looking beyond the
traditional CBT model. In this essay I will aim to consider some strengths, limitations
and uncertainties in relation to the use of CBT and comment upon the future of CBT
in the context of the wider world of psychotherapy.
Over four decades ago, Aaron Beck developed the cognitive therapeutic model for the
treatment of depression as a response to his conclusions about the way human beings
function: how people think and give meaning to events, affects their emotions and
behaviours. The initial cognitive model has been developed by Beck and others to
combine with the behavioural therapeutic model so that behavioural changes
consolidate cognitive change. From these beginnings CBT has developed in the United
Kingdom to its position as the treatment to beat in the psychotherapeutic world.
Since Beck‟s initial work with the cognitive model a wealth of outcome studies purport
to provide evidence for the efficacy of CBT. Even its critics recognize that it has much
in its favour. Jeremy Holmes (2002) describes it as „an attractive, efficient therapy that is
relatively easy to learn and deliver and produces good results in many instances.‟
The breadth of application of CBT
Government endorsement of the use of CBT is significant as an indicator of its
credibility and value. The National Service Framework cites CBT as the treatment of
choice for depression, eating disorders, panic disorder, obsessive-compulsive disorder
and deliberate self harm. The Department of Health goes further in its more recent
guideline on the subject, adding agoraphobia, generalised anxiety disorder, post
traumatic stress disorder, bulimia and chronic fatigue (Department of Health (2001)).
The above is not an exhaustive list. For example, CBT is the treatment of choice for
patients suffering from schizophrenia. Neil Rector (2005) reports that „Considerable
scientific support now exists for the efficacy and effectiveness of CBT in schizophrenia:
meta-analyses of RCTs conducted on CBT have concluded that CBT effectively treats
positive symptoms of schizophrenia, reduces relapse, and enhances recovery during the
acute phase (2-5).‟ Further, cognitive and behavioural interventions such as exposure
and cognitive restructuring are reported to be effective with adult survivors of rape or
sexual abuse (Foa et al (1991)), reported by Ross and Carroll (2004).
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The nature of the therapy
A wide range of techniques are available to the cognitive behavioural therapist, for
example: in vivo exposure, imaginal desensitization, problem solving, relapse training,
assertiveness training. Overarching application of these techniques is the guided
discovery for the client of how they reason, the meaning they attribute to events and the
emotional and behavioural consequences which follow. The role of the therapist is to
take the patient through this process of guided discovery, collaborating with the patient
for them to discover alternative meanings and responses.
The process is structured, optimistic in its outlook and involves the active involvement
of the patient. It is a process that lends itself to the development of a positive alliance
between the therapist and the patient. The importance of the therapeutic alliance is
emphasized by Horvath and Symonds (1991) – a good therapeutic alliance is the best
predictor of outcome in psychotherapy.
CBT also has the advantage that a course of therapy is usually prescribed to take place
over a relatively short timescale with a limited number of sessions and any suitably
trained person can carry out; its application is not limited to medical professionals.
These features of CBT contribute to its cost effectiveness, a significant consideration for
NHS Trusts, faced with the responsibility to treat patients on a limited budget.
Notwithstanding the above, there are generally recognized limitations in the use of
CBT. It is not a modality which is suited to every patient. The approach, method and
techniques involved do require some logical analysis on the part of the patient, mental
capacity and an ability to concentrate; further, an ability to undertake tasks set by the
therapist e.g.: completion of dysfunctional thought record.
By way of example, complexity can also impact upon the usefulness of CBT: Linehan
(1993) has argued that „standard cognitive behaviour therapy for patients with
conditions as complex as borderline personality disorder is unlikely to be effective.‟
By way of further example, lack of mental capacity in a patient can preclude the
application of CBT. McGowan, Lavender, Garety (2005), researching the use of CBT
with psychosis, found that the psychotic patients concerned failed to make progress
using CBT. The suggested explanation was firstly, flawed information processing due to
cognitive or neurological factors; and secondly, the inhibition of the development of the
therapeutic relationship due to difficulties in reaching a view of shared goals and
understandings.
The feminist psychotherapist, Helen Graham offers an alternative and scathing critique
of the CBT approach. She describes the „Western obsession with performance‟,
suggesting that CBT falls into the category of „manly active techniques that make them
[men] feel that they are doing something to make their clients well. She goes further,
suggesting that the „technical behaviour‟ impresses clients and is a manipulation of them
by the therapist. „These therapists‟, she says, „are mainly attending to themselves‟.
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The evidence base for CBT
„The extensive and long standing empirical support enjoyed by cognitive behavioural psychotherapy does give it a clear….advantage over other psychotherapy approaches.‟ Grant et al (2004).
CBT lends itself to application of the evidence based medicine model („EBM‟). Its
focus on symptom change means that it is suited to Randomised Control Trials
(„RCT‟). It follows that meta-analyses in the form of systematic reviews and a wealth of
evidence from individual RCTs purport to provide a firm evidence base for the
application of CBT.
CBT‟s position as treatment of choice in the National Service Framework arises from
the framework‟s classification of evidence. CBT is supported by „level 1‟ evidence for
most diagnoses – at least one RCT and one systematic review.
Taken at face value, the research evidence based on the EBM model gives robust
support to CBT as an efficacious modality of therapy.
Challenges to reliance upon the current evidence base for CBT
Is the evidence base as good as is made out? A number of uncertainties arise. There
are questions in relation to the conduct of the research within the EBM model. An in-
depth meta-analysis is beyond the scope of this essay. However, a note of caution is
merited; assertions about efficacy and effectiveness should not be taken at face value.
Reference to an RCT does not of itself mean that the research outcome is reliable. For
example, closer scrutiny may reveal that the RCT was not undertaken „double blind‟
and perhaps without a „no treatment‟ control group when the circumstances indicate
that this was necessary. In relation to a study into the use of CBT for psychosis,
Bolsover identified that the RCT was not assessed „blind‟ and did not include a no
treatment control group.
The use of the EBM model may indicate efficacy in relation to the specific patient
sample under clinical conditions. This is not the same as proving effectiveness of CBT
„in the outside world‟. „Efficacy in RCTs is no guarantee of effectiveness in the field,
and effectiveness in the field is no guarantee of effectiveness in the individual patient‟
(Chiesa and Fonagy, 1999; Wells, 1999, cited in Williams (2002). The design of RCTs
in itself will have an impact on outcome. Williams identifies significant design features
in this regard: Trials usually have an upper age limit of 64 years. Women of child
bearing age or women who are pregnant are often excluded. Patients with mixed
diagnoses are excluded. Williams observes that „It often appears that those who are
motivated to cooperate in RCTs are not a typical cross-section of our patients.‟
There would appear to be a dearth of evidence from long term research studies into the
effectiveness of CBT. This also creates uncertainty about the claims made for CBT.
Even if evidence were to arise from appropriately conducted RCTs involving a typical
cross section of society, measurement of the effectiveness of the therapy for a particular
disorder arguably needs to take into account relapse rates in the long term.
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The measurement of the success of therapy – should it be limited to measurement of
symptom change?
In my view, this is the central issue arising within a critical evaluation of CBT. If we
accept the primacy of CBT amongst psychotherapies due to the quantitative research
evidence based on the EBM model, we are arguably accepting the premise that
successful therapy can be measured by reference symptom change.
CBT has traditionally placed itself squarely within the medical model. A person
referred for CBT is described as patient with a set of symptoms. This is a scientific
model based on objectification of truths, which in turn is based on quantitative research.
The psychodynamic psychotherapist might criticize the purist CBT approach for failing
to address a person‟s issues in sufficient depth to bring about lasting change.
The family and systemic therapist might level criticism based on a failure to consider
the narrative. „Narrative of illness provides a framework for approaching a client‟s
problems holistically and may uncover diagnostic and therapeutic options (Greenhalgh
(1999), cited in Williams (2002). Further, CBT fails to assess and address the impact of
relationships and „systems‟ on the patient. „Humans have evolved as social animals and
they exist in complex social systems in which social relationships and ties are
paramount and intimately linked to mental health (Erlbaum (2000)).
The challenge to the proponent of CBT is to demonstrate that the approach does not
lead to the cognitive behavioural therapist treating a set of symptoms rather than a
person in the context of their experiences and attributes – for example, race, religion,
gender, sexuality, culture, relationships.
The difficulty for the proponent of CBT in seeking to demonstrate the above is that the
quantitative evidence based model does not reflect the impact of CBT on non-
symptom related factors. This means that the research evidence upon which CBT relies
to maintain its pre-eminence is only of value in so far as it relates to the symptoms
identified. It fails, however, to provide a measure of success or failure of CBT in
helping an individual in his search for wholeness within his social, cultural and family
context. Specifically, for example, according to Hinshelwood, evidence from a RCT is
„almost completely helpless to assess relationship change‟
The risk is that CBT practitioners are trapped within the confines of the „positivist
research paradigm‟ reflected in its reliance upon the EBM model. Atkinson et al (2001)
states:
„It is singularly unhelpful to all concerned if disciplines become too tightly classified and
circumscribed according to styles of research. It is too easy to assume that disciplines
like economics or psychology are exclusively categorized by quantification and positivist
epistemologies….As far as we can see this unfortunate state of affairs characterizes
mainstream contemporary cognitive behavioural practice‟.
I find myself in sympathy with the view of Lyddon and Weill (1997) who state:
70
„A broadened evidence based agenda would speed the paradigm advancement of CBT towards an evolving position where personal meaning making and narrative of clients and practitioners are accorded much greater respect than is presently the case‟. In my view, therapy should not be limited to addressing symptom change; and the
measure of success of therapy should not be limited to consideration of symptom
change. If CBT is to maintain its credibility and value, cognitive behavioural
practitioners will need to demonstrate that CBT deals with individuals holistically and
in context.
Changes in the practice of cognitive behavioural therapy- the post CBT world
Perhaps the good cognitive behavioural therapist does look beyond the symptom
related paradigm and considers the patient in context. On the other hand, perhaps
many cognitive behavioural therapists maintain a purist approach based on the
reductionist medicalised model.
It does seem to me likely that practice will be significantly influenced by the method of
measuring outcomes. For this reason, it is my view that the proponents of CBT would
do well to consider an alternative research design model – one which incorporates a
blend of quantitative research dealing with medical symptoms and qualitative research
to measure outcomes in relation to the individual in context - a change in the symptom
related paradigm to incorporate a social constructionist perspective.
The usefulness of qualitative research is increasingly accepted in health care research.
(Williams 2002)). The challenge in this respect will be to ensure that qualitative
research develops in a way which will withstand the criticism of the EBM movement
and have credibility across the fields of psychology, psychiatry and psychotherapy. If
outcomes in CBT do take into account the long term effect on the person in context,
this will in itself be a catalyst for the development of a more holistic approach to CBT.
This will mean cognitive behavioural therapists adopting an integrative approach to
their practice.
There are promising indicators that leading cognitive behavioural therapists recognize
the need to develop an integrative approach to CBT practice. Research from Hardy,
Shapiro et al (1998) in Sheffield supported Gotlib and Hammen‟s interpersonal
cognitive model of depression. This model focuses upon the importance of assessing
and treating all aspects of depression in response to individual contexts. Standard CBT
interventions are used in conjunction with interventions which propose a response to
interpersonal issues and offer the client the opportunity to experience their emotions
within the therapy sessions.
Dr Corrine Gather of Harvard Medical School has developed a novel cognitive
behavioural approach to remediating social functioning deficits in schizophrenic
patients. This approach focuses on harnessing the patient‟s motivation to identify and
pursue life goals. This is in contrast to the traditional approach of targeting symptoms
first to remove barriers to improvement. This would appear to be a shift away from the
symptom related paradigm.
71
Linehan has modified traditional CBT treatment by placing a greater acceptance on
validation and acceptance and nurturing the therapeutic relationship rather than change
(Lau and McMain (2005)). Linehan‟s model, developed with a view to the treatment of
patients with multiple disorders who exhibit extreme behavioural dysregulation, is
known as dialectical behavioural therapy („DBT‟). In a similar vane, Teasdale, Segal et
al (1995), cited in Lau and McMain, have sought to integrate CBT with Zen Buddhist
„mindfulness techniques‟, known as Mindfulness based Cognitive Therapy („MBCT‟),
with a view to treating depressive relapse.
MBCT and DBT require further research, but both reflect an acknowledgement at
some level of the need to look beyond the limitations of the traditional CBT model.
Rasmussen (2005) brings yet another possibility to the debate over the integration of
traditional CBT with other models. He proposes integration with Theodore Millon‟s
personologic model – thereby giving recognition to the importance of personality upon
a person‟s individual resources to meet the challenges which life brings.
For my own part, from reading literature in relation to CBT within the wider context of
a diploma course on Family and Systemic Therapy, I have become convinced of the
vital importance of integrating CBT with a model or models which facilitates change for
the client as an individual in context - and which recognizes the importance of social
and family relationships in either nurturing or undermining progress made in therapy.
Conclusion
There is a weight of evidence which supports the contentions of the proponents of
CBT about its usefulness in treating a wide breadth of psychiatric and psychological
difficulties. It finds favour with health politicians and those in mental health services
who are accountable for the way in which public money is spent – it is marketed as cost
effective in that CBT is seen to produce measurable positive results for patients within a
reasonably brief period of time.
However, CBT‟s pre-eminent position in the world of psychotherapy is open to
challenge. Fundamentally, the evidential base upon which its success is measured
encourages a blinkered view. The quantitative Evidence Based Medicine model offers
empirical data on outcomes in the use of CBT. The use of this „best evidence‟
quantitative model is to be valued within limits. There is value in research which
demonstrates the impact of CBT on symptom change. However, the limitations of this
evidence needs to be recognized. It offers evidence about specific symptom change
rather than evidence about the patient as an individual in context.
There is a need to recognize the limitations of the evidence base upon which traditional
CBT has relied for so long. In my view, the government and mental health services
would do well to invest in research into alternative research design models. The aim
would be to identify a model which integrates the EBM model in so far as symptom
change is concerned, with a qualitative research model which takes into account the
impact of CBT on the patient as an individual rather than merely a set of symptoms.
A change in the way outcomes are evaluated would, in my view, be likely to encourage a
healthy development in the practice of CBT – a shift from the patient / symptom
72
paradigm to an approach which takes a holistic view of the person as an individual. This
integrative approach may be less attractive to those whose aim is to produce statistics to
prove cost effectiveness based on empirical data but in my view, is more likely to meet
the holistic needs of the public which the government and NHS are there to serve.
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74
Title: Following the Threads: Bateson to Ecosystemic Therapy Author: Cathy Huxley
Cathy wrote this essay as part of her intermediate year of training at the Family Institute,
University of Glamorgan. She won the Association for Family Therapy Student essay
competition[2007] with this essay which will be published later this year in Context. Cathy is
currently a Family Worker for Turning Point, the substance misuse counselling and support agency,
in Worcestershire and preparing to begin her qualifying level of training at The Family Institute.
„A human is part of the whole – called by us, universe… He experiences himself, his thoughts and
feelings, as something separated from the rest, a kind of optical illusion of his consciousness. The
delusion is a kind of prison, restricting us to our personal desires and to affection for a few persons
nearest to us. Our task must be to free ourselves from this prison by widening our circle of compassion to
embrace all living creatures and the whole of nature in it‟s beauty‟.
Albert Einstein (in Heaven, 2001, p389).
Discovering Bateson
I arrived at systemic therapy from psychology - a „science‟ with the usual academic
tendency to emphasise the views of those nurtured within its own discipline and to
embody „expert‟ knowledge with its own language and conventions…
So to encounter the influence of Gregory Bateson on systemic thinking and practice
during my second year of training has been an especially rich experience.
This may be particularly so because like Bateson, I have crossed over from one
paradigm to another (Bateson, 1972/2002; 1979/2002). My first training ground was the
English language, philosophy and religion. I trained and worked as a journalist, I spent
long periods of time studying Buddhism & new age spirituality and travelling. When I
enrolled on a psychology degree course in my 30s, „academia‟ and the world of work
that sprang from it, seemed to say that my personality and life experiences were of no
consequence. Tutors on the course told me to forget everything I had ever learnt or
believed in. Cognitive and behavioural psychology was influential at this time and it was
a world of experiments, statistical analysis and dead-cold empiricism.
However, through Bateson, who started as a scientist and embraced a more aesthetic
approach to the study of living processes, I am now enjoying the other side of the
debate. Strangely enough, it feels a little like Bateson‟s favourite T.S. Eliot quote – in
which the poet returns to the place he first started from and sees it as if for the first time
(Bateson, 1979/2002, page ix {in forward}).
Reading Bateson, his tendency to be obscure and to quote poetry annoyed me at first.
He was supposed to be a scientist wasn‟t he? How presuming to wander from his
domain! But that of course was his point…that the western world had conceptualised
different „disciplines‟ as separate and discrete, whereas his overarching vision, gleaned
from a lifetime‟s experience of biology, genetics (his father‟s discipline) and
anthropology, (and latterly, psychology – with his work on schizophrenic families at
Palo Alto), was that just as many species of plant and animal co-existed
75
interdependently, so also was knowledge a set of interdependent systems of thought
which should necessarily speak to each other‟s paradigms and principles.
Bateson was a thinker who thought in wholes rather than in parts. He seemed to have
the ability to see how things connected, whether ecological systems, political, social or
family. He saw that natural forces, behaviours or patterns tended to hold true on micro
and macrocosmic level. This gave him a clue as to the way in which all living creatures
were ultimately connected through eco-system, planet and galaxy etc and (more
controversially) how these patterns may influence and order human relationships and
behaviour. He saw pattern and process in the human social world. He saw relationship
and metaphor in the natural.
He also felt that there were other ways of „knowing‟ than by scientific methods. He
seemed to have an intuitive understanding that the artist‟s or the poet‟s vision of reality
was as profound as the scientists, even though it might not be wholly conscious or have
a demonstrable chain of logic. He was frustrated by the narrowness and „obsolescence‟
of logical scientific thinking, which he felt, was contributing to the destruction of the
planet and human systems. He argued for change to the way academics thought about
the world and the relationship of human beings with other species and the planet. “Do we…foster whatever will promote in students…those wider perspectives which will bring our system back into an appropriate synchrony or harmony between rigor and imagination?…As teachers, are we wise? “(Bateson, 1979, p243; in Burns, 1995; p341).
Bateson believed that the way in which „knowledge‟ was being divorced from the
philosophy of existence was causing a huge number of problems in the world including
the exploitation of resources and of people “A world of distrust, vulgarity, insanity, exploitation of resources, victimization of persons and quick commercialism” (Bateson,
1979, p204).
Bateson had been strongly influenced by the 1960s intellectual revolution in America
but felt that instead of building on current philosophical debates, the way in which
knowledge was taught actually seemed to have returned to Cartesian, dualistic (mind v
matter), and „objective‟ methods.
He believed that splitting things into parts and examining them separately from each
other as scientists had traditionally done, was a kind of reductionism that offered a
picture of the world which was less than the sum of its parts. He felt it resulted in a
disjointed and unnecessarily dispassionate understanding of things.
He also objected to the way that science was anti-aesthetic and exclusively quantitative
and felt that systems theory (also cybernetics, holistic medicine, ecology and gestalt
psychology) offered better ways of understanding biology and behaviour (Bateson,
1979/2002, pp203-204).
These ideas, published in the1970s (Bateson, 1972/2002, 1979/2002), were timely
insights when the scientific paradigm was at its zenith of prestige and power in the west.
Traditionally, scientists have believed man could control the natural world. This was
still being taught in the early 1990s. My psychology class learnt that the function of
psychology was to study, understand, control and change human processes. I also
remember a rather shocking „fire and brimstone‟ lecture against „new age thinking‟.
Intuitive jumps were not allowed, only results painstakingly gleaned from many years of
„objective‟, quantitative research and analysis.
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Naturally, Bateson has become a father of the ecology movement, and especially „deep
ecology‟, which encompasses a more spiritual and aesthetic approach to the natural
sciences and encourages holistic rather than linear, planetary rather than human-
centred thinking. However, he was also an early leading light in the development of
systemic theory and cybernetics. His ideas have given systems therapists a philosophical
base for their own theories about relationships and group behaviour.
Early understandings
In my early studies I noticed that he was quoted in family therapy papers with
astonishing regularity. Yet he had expounded a great number of theories - many written
in an obscure style and hard to decode. I was a new to the field; I struggled to
understand why this was. To me, Bateson was an enigma and his relationship to family
therapy, intriguing.
I began to realise was that it was partly a matter of being in the right place at the right
time. Bateson was one of the theorists who stood at the crossroads of the mid 20th
century debate „…between rigor and imagination…‟ (Bateson, 1979; in Burns, 1995), or
logic and intuition, and that he signposted a way forward. His ideas were absorbed by
many different schools of thought including the newly emerging paradigm of systems
theory. Other fathers of our field who added to the cogency of the debate included von
Bertalanffy (Johnson, 2001), Maturana and Varela (Leyland, 1988; Rosenbaum &
Dyckman, 1995; Speed, 1991) & Buber (Inger, 1993).
The concept of treating a family group was a radically new therapeutic intervention in
1950s-70s America. Therapeutic concepts based on treating the individual were (and
still are) the favoured treatment base. The very novelty of this new concept helped its
dissemination amongst practitioners and appealed to those who were disillusioned with
mainstream practice, looking for a challenge or who entertained intuitive systemic ideas
and later on, those interested in the new movement in physics which spoke of
connection and pattern between living systems.
In the late 1970s and early 1980s, radical scientists and thinkers such as „quantum‟
physicist, Fritjof Capra, gained inspiration from Bateson‟s ideas and began to publicise
them more widely. As the 80s ticked by, other scientists joined Capra, sensing a release
from old Cartesian bonds. In addition to Capra‟s own ideas, encapsulated in The Tao
of Physics (1975) and Uncommon Wisdom (1989); scientists such as James Gleick‟s
Chaos Theory, (Lovelock, 1988), James Lovelock‟s Gaia Hypothesis, (Lovelock,
1979/91) and Rupert Sheldrake‟s Morphic Fields & Morphic Resonance, (Sheldrake,
1981/1995) published and found popularity amongst „non-scientific‟ readers. These
theorists were amongst the first wave of scientists to build upon and access foundations
created by Bateson and likeminded thinkers and to create popular awareness that
science was no longer to be contained by Newtonian logic.
The Gaia Hypothesis theorised that human beings were much more closely connected
with the natural world than they had assumed under the old scientific order; that the
earth, the planet itself, far from being „controlled‟ by the superior mind of man, had
some sort of consciousness and homeostasis which kept all living systems in balance
with one another. In the Chaos Theory, Gleick demonstrated patterns of connection
which were profoundly elegant and inclusive within the natural world which, repeated
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themselves from macrocosm to microcosm. This put human beings alongside animals,
plants and even molecules into close, dependent relationship.
Sheldrake‟s ideas on „morphic resonance‟, that living systems have memory systems and
access to non-conscious awareness (wisdom or knowing), are a natural evolution of
Bateson‟s theories of „mind‟.
Gleick, Lovelock and Sheldrake are the most currently popular of many scientist-
philosophers who have shown how it is possible to cross over from the hermetically
sealed world of „empirical truth‟ into the world of the artist and philosopher, making it
legitimate for science to discuss previously unthinkable ideas which play with the idea
that relationship rather than logic, rules the world…
U.S INFLUENCES
In America, scientists like David Bohm and Herbert Frohlich developed a new „physics
of the self‟ derived from the link between quantum reality and consciousness. Just like
Bateson, they intuitively grasped a quantum reality in which matter and mind are seen
as two sides of the same coin. “Their theories (offered) the basis for a world view that transcend(ed) the old dichotomy between nature and culture and impose(d) the constraint of the natural upon the ultimate success of the cultural”(Danah 1991).
The ripples of these new ideas spread out amongst the systemic fraternity in America
and Bateson became one of their favourite „quantum‟ philosophers. Ironically however,
it was for his (now unfashionable) ideas on paradoxical communication and the „double
bind‟ theory in schizophrenic families that he was lauded at the time. He worked on a
10 year project with schizophrenic families at Palo Alto and his ideas on
communication and relationship influenced John Weakland, Jay Haley, Don Jackson,
Paul Watzlawick, Virginia Satir and others at the Mental Research Institute in
California. Their work together on styles of family communication coalesced into
structural and strategic therapy.
Structural therapy became synonymous with Virginia Satir who used the technique to
re-align relationships and open up communication between individual family members.
The work of Salvadore Minuchin has recently re-popularised and developed these
ideas in his own style.
Strategic therapy took the view that the therapist had to outmanoeuvre the pathological
games displayed by families with problems or „problem members‟. This pioneering
strategic approach was also influenced by the work of psychiatrist and hypnotherapist,
Milton Erickson. By the end of the1980s, family therapy in America was
overwhelmingly strategic or contained strategic elements that combined Bateson‟s
philosophical approach and ideas about communication with Erickson‟s rather directive
interventions.
In other parts of the world where it has taken root, Bateson‟s legacy has affected
different results. However, it is in Italy where his philosophy and ideas have been used
to the most ground-breaking effect.
The Milan Team In Italy, family therapy training and practice was centred in Milan. The Milan therapy
team, made up originally of Mara Selvini-Palazzoli, Giuliana Prata, Gianfranco Cecchin
and Luigi Boscolo, have been cited as the natural heirs to Bateson‟s ideas in the
systemic world. This is mainly because they were less caught up in the Ericksonian
techniques than therapists on the other side of the Atlantic, and were freer to interpret
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Bateson‟s philosophical ideas in a purer form. Mara Selvini-Palazzoli later wrote that
Bateson‟s „Steps to an Ecology of Mind‟ played an important role in the team‟s
movement from a psychoanalytic to a systemic mode of thinking. The team worked as
family therapists in isolation from others so that they could „…avoid at all costs any eclectic contamination by other conceptual models‟ (Gelcer, McCabe & Smith-Resnick,
1990 p11).
Working with anorexic and schizophrenic „families‟, they used and developed much of
Bateson‟s earlier ideas on paradox in the „variant method‟ in which each family is given
a unique „prescription‟ to counter the family game „…whose rules cannot be changed by those involved‟, (Krause, 1993).
In the late 1970s and early 80s, the Milan approach hot-housed pioneering and
experimental systemic theories, such as circularity (engaged communication), neutrality
(being open), the importance of hypothesising, and identifying the family „game‟ or
„games‟; and counter paradox (a way of strategically manoeuvring the family out of its
paradoxical situation). They even started to involve community participants (who dealt
closely with the family), in therapy in true Batesonian style. Towards the end of the
team‟s life, the „variant‟ changed into the „invariant‟ method. This „prescription‟ (which
often provoked individuation for the „identified patient‟), delivered as if unique, but
actually the same given to each family, proved to be successful in anorexic families.
Finally the team broke up to pursue different theoretical ideas; Selvini Palazzoli and
Prata staying as a team, working on the invariant prescription and returning to older
strategic ideas and Boscolo and Cecchin embracing the new paradigm of social
constructivism without „neutrality‟, „manoeuvres‟ or (latterly) hypotheses!(Bertrando,
2004).
Cecchin and Boscolo talked about staying curious rather than forming hypotheses and
started to wonder if the therapeutic conversation itself was enough. They even talked
about „not knowing‟ what was therapeutic, since they could not possibly know the
outcome of any deliberate or inadvertent intervention. They took the Batesonian idea
of the larger „system‟ consisting of the therapeutic team of clients and therapists and
looked at how it was constructed in order to discover the optimum intervention.
In an interview with Paolo Bertrando, Cecchin commented that after the two halves of
the team broke up, he and Boscolo arrived at a limit of their theories. “The basic idea
remains, nothing exists outside relationships…Human beings exist only in relationship with someone else. Without relationships, no person exists. This is a very useful prejudice…when we see an individual in therapy we always wonder which persons around her, make this person the person who she is…” (Bertrando 2004, p219).
Cecchin was described by Boscolo as a „deconstructionist‟, happy to deconstruct the
client‟s own stories about themselves and then leave them on their own to create or not
to create a new one.
Cecchin added to this: “Today, we have come to the point where we don‟t mind any more whether we are effective or not. In a post modern condition, you try to follow a coherent method but you cannot have any idea of it‟s efficacy”‟(Bertrando, 2004, p220).
It is interesting that in following Bateson‟s ideas the original Milan team arrived at such
different places, one half more interested in what worked in the therapy room, the
other embracing post-modernism and taking deconstructionism as far as it reasonably
seemed to go.
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Post-modernism
Currently the family therapy field is also reaching the limits of constructionism and
there seems to be a number of concerns about the ultimate usefulness of this as the
only paradigm within the therapeutic field (it fits uncomfortably with others – despite its
inherent openness to other views). And followers of the older schools of thought are
wondering how it can be used in conjunction with strategic or structural practices.
On top of this, a third cybernetic order which acknowledges social inequality as a given
rather than a construction (Dallos & Urry 1999), is becoming a more fashionable
approach in family therapy.
“...third (order) cybernetics shares with the second cybernetics an emphasis on meanings as central to family dynamics and experience. However, the meanings
shaping interactions are now seen as not just personal and idiosyncratic but as shaped by realities of the culture in which we are immersed” (Dallos & Urry 1999, p166). They
state that it is still accepted that we can never know the „world out there‟…but in
contrast, a „social constructionist‟ approach suggests that this world is real, both in the
structures and actions and in shared systems of meaning or discourses. Cultural ideas
are acknowledged in creating family life and experience. Power is also acknowledged as
an inherent part of social interactions, although meanings and identities are seen as
dynamic and fluid.
Bateson described power as a cultural „myth‟ but was never a pure constructionist and
did not refer to himself as a constructionist. „His ideas were “precursers of current contructionist ideas” (Krause, 1993). He emphasised meanings over „information‟ but
as an anthropologist would surely have understood the two–way relationship between
individual and culture as a dynamic and creative one, translated by context. I think he
would be comfortable with the third order or social constructionist viewpoint as closest
to his own.
Connecting new approaches Systemic therapists have recently become interested in Rogerian empathy as a useful
technique (Wilkinson, 1992; Anderson, 2001; Bott, 2001). As usual, systemic therapists
have looked to the foundation theories laid by Bateson and found that his concepts of
pattern and connection may be useful in considering how we understand empathy
systemically (Bateson, 1979/2002).
“Therapy occurs in the context of relationships, between individuals, between systems; if we locate empathy „in‟ the therapist, only one part of the therapeutic system, we are ignoring the process, the patterns of interaction between therapist and client(s). Bateson‟s principle of „double description‟ which is helpful in conceptualizing relationships between family members is equally helpful in viewing the therapist-therapy
team-client(s) relationship (Bateson, 1979; p133; Keeney, 1983; pp37-38), so that we begin to notice patterns of interaction and connections between people.” (Wilkinson,
1992, p194).
A natural development of Bateson‟s theories in systemic theory has been an exploration
of network theory. Over time, therapists have experimented with incorporating
neighbours, friends, professional family workers etc into the therapy room with the
family (Erickson, 1974; Haber, 1987) and several families together (Asen, 2002). Haber
talks about using children‟s friends in therapeutic meetings as a „neglected resource‟. There are also a number of studies looking at the social fit between families and the
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wider systems of work or school (Renshaw, 1975; Greif, 1994; Desivilya, 1996).
Renshaw‟s study found that organisational and family systems were „interdependent‟,
Greif talks of mutual support amongst African American parenting groups, while
Desivilya talked about the struggle of servicemen‟s families with the military
organisation.
Creativity has always been a part of the systemic approach but with the softening of
family therapy approaches in second order cybernetics, creativity was more welcomed
and understood to be a natural part of therapy. Allowing clients to play, use their
intuition, connect to each other through the language of the imagination and the
emotions is becoming good practice. Bateson felt that emotions and intellect were
intimately connected but different levels of thought. He understood their task in
communicating between the levels of mind in an individual and within a group
(Bateson, 1979; p464: in Burns, 1995; p329).
Essentially, Bateson‟s views on the arts and on the use of imagination and play in the
therapy room were positive, especially given his views on communication between the
disciplines, the correlation of art and science and his approval of intuitive thinking.
“Artistic skill is the combining of many levels of mind – unconscious, conscious and external – to make a statement of their combination” (Bateson, 1979; in Burns, 1995,
p331). Liz Burns goes on to say that many therapists have followed Bateson‟s suggestion
(Bateson, 1979; p464: in Burns, 1995, p329), and „looked directly to artists and poets for help‟. As a result we have therapists using art as a medium of communication
(Rubin & Magnussen, 1973; Morgan, 2003); also writing and narrative (Byng-Hall,
1998) play therapy, (Arad, 2004), psychodrama and ritual (Seltzer & Seltzer, 1983),
literary analysis as metaphor (Burns, 1995) and use of dreams (Sanders, 1994).
Humour has been flagged up as a harbinger of organisational flexibility in the therapy
room (Bateson, 1972, in Jones & Asen, 2000). Like creativity, Bateson believed that
humour was trans-contextual, cutting through paradigms of reality and „allow(ing) disparate contexts and learning levels to be put together‟ to enable change (Jones &
Asen, 2000, p64).
Narrative Therapy or storying, where no one story is dominant and each member of
the family has an equal voice, is a creative development of constructionism. Seeing
humans as „storying creatures‟ using mythology, script and story to explain and co-create
the group (Byng-Hall, 1998; Dallos, 2006), therapists can help to re-write unhelpful
stories or merely „witness‟. Bateson himself felt that story or metaphor/symbol was a
stronger and more direct language than that of logic (Bateson, 1979/2002). He believed
it was the language of the natural world and as such is powerful as a therapeutic
language to connect different mind states and organisational levels within the family.
Another new development links attachment theory to systemic practice, an interesting
confluence of Bowlby‟s theories of relationship with Bateson‟s ideas of the natural
connection between living systems (Akister, 1998; Dallos, 2006).
Dallos (2006) has recently connected all three therapeutic theories, systemic therapy,
narrative therapy and attachment theory, seeing that all are: “…drawing out links between patterns of family relationships and how these shape different forms of internal
81
worlds, including the narratives we develop about ourselves and others and in particular the narratives about feelings, relationships and attachments” (Dallos 2006, p2).
Future Directions
In recent systemic writing there seem to be several areas of interest that spring from a
Batesian perspective. For example: emotions as markers of success in therapy (Krause,
1993; Seikkula & Trimble 2005), personal development for therapists (Real, 1990; Abu
Baker, 1999; Rosenbaum & Dyckman, 1995), and an acceptance of empathy as a
relevant feature of the systemic approach (Anderson, 2001; Bott, 2001).
Jurg Willi (1987) talks of „co-evolution‟ where individuals work in therapy towards
mutual healing. There are also some spiritual approaches; Taoism is discussed in
Seltzer & Seltzer (1983) and Rosenbaum & Dyckman (1995), which makes Batesonian
sense since Taoism talks about the patterns and principles of nature and also the
connection of complementary opposites. Rosenbaum & Dyckman (1995), talk
intriguingly about „eco-systemic‟ practice and connect modern cybernetic thinking,
Taoism, Zen and social ecology into their theories, echoing Bateson‟s interest in Zen
and his theories on the immanent, impersonal and potentially collective nature of
„mind‟ (1972/2002). And given Bateson‟s holistic ideas, it may be that family therapy
will draw closer to the currently „new age‟ mind-body debate in the near future.
Healing the Planet
Ecology, the idea that man is part of a natural system (not in charge of it) and therefore
has a responsibility to himself and other species to keep it in good order, has
permeated every aspect of modern academia, family therapy no less. “There is no point
in liberating people if the planet cannot sustain their liberated lives or in saving the planet by disregarding the preciousness of human existence not only to ourselves but to the rest of life on earth‟”(King, 1990, p121: in Totton, 2003, p14).
There has been a recent debate in the Journal of Marital and Family Therapy on
whether systemic therapists have the right or duty to extend their practice to planetary
responsibility. Following a conference in which there had been a debate on ecological
and social responsibility, Scott Johnson wrote to the journal, stating his belief that such
views displayed „messianic tendencies‟. There was immediate support for the wider
debate from such old campaigners as Monica McGoldrick (McGoldrick, 2001) and
Carlos Sluzki (Sluzki, 2001). Kenneth Hardy (Hardy, 2001) commented: “as a family therapist, I believe that I should cease to serve as therapist when I become unwilling or
unable to assume the position of activist. I do not believe that promoting the cause of human rights is inconsistent with helping couples and families ameliorate distress in their lives…One of the major perils of segregated thinking is that it makes it impossible for us to see the connectedness of all matter”. ‟ And Bateson is mentioned as a leader
in the field who, in connecting the human and natural worlds, has also alerted human
beings to their responsibilities to the planet (as well as the dangers of irresponsibility).
Allowing the Planet to Heal Us
This stance is in line with a new movement, „Ecopsychology‟ (Totton, 2003).
Totton describes psychologists and counsellors making use of the natural world both in
a real sense and as a metaphor to promote a sense of well-being and healing.
Totton talks about the new trend towards therapeutic gardening and „ecological grounding‟ (therapy out of doors…!) for clients as a therapeutic intervention.
“We are all part of the organism of the Earth…when we do not acknowledge this connectedness…we become lost and paralysed. If we were to express the wells of
82
emotion so many of us hold about the ecological catastrophes and social injustices in the world…we would release not just the tears and anger – but streams of caring and creativity”‟ (Glendinning, 1994: p162; in Totton, 2003, p17).
The idea is that we have lost touch with rhythms and sensitivities that keep us healthy.
From an anthropological perspective, humans have always had a close connection with
nature with a great deal of interdependency and emotional involvement. As Bateson
was well aware, in traditional societies, nature tends to be scripted and given narratives
that depict and explain phenomenon in a more human centred way. However, since
the industrial revolution, the western world has been increasingly divorced from the
patterns and rhythms of the natural world. Westerners have taken refuge in a more
protected and species-specific environment where temperature, light, communication,
movement, the rhythm of the day, are all controlled and separated from nature and our
own biology.
In 1995, I reviewed the current literature regarding therapeutic wilderness experiences
mainly in America where they were pioneered (Huxley 1995). Most therapeutic groups
reported increases in self-confidence and well-being and of increased ability to re-
cooperate from stress, also enhanced learning ability, better social interaction and
increased feelings of empathy. This continues to develop as a fringe therapy – and has
recently become popular in the UK. Bateson‟s theories fit in very neatly to wilderness
programmes. It is tempting to think that he helped to inspire them.
Another interesting development close to systemic therapy is that of working with
animals as collaborators in the healing process. In 1999, the Family Therapy Networker
published a story by Garry Cooper that tells the story of a New Mexico programme
called „Ride for Pride‟ treating „delinquent‟ youngsters. “Equine therapists claim that the 4,500 specially trained therapeutic horses establish a conscious, mutual relationship with their clients through their physical power, intelligence and temperament which builds trust, empathy, responsibility and humility” (Cooper, 1999; p11).
Conclusion
It is not possible to do justice to the many threads of thoughts and the seeds of new
connections which have arisen from Bateson‟s revolutionary ideas. Yet he continues to
be a cornerstone of our „faith‟ His ideas are like golden threads which seem to connect
family therapy and systemic theorists through time and paradigm.
And just as the hero, Theseus, needed Ariadne‟s thread to find his way through the
Cretan labyrinth, perhaps we need to follow those threads of Bateson‟s ideas in order to
understand not only where systemic therapy has come from but also where it might be
going.
Guhen Kitaoka, an English NLP practitioner, has predicted that Bateson will one day be recognised as „another Einstein of the 20
th
century‟. (http://www.creativity.co.uk/creativity/guhen/bateson.htm). “However, while British born Bateson is a founding father with a unique and lasting contribution to family therapy, he does not appear to be as openly lauded in the UK as in America and Italy. Why is this”? Should Bateson be taught discreetly as part of systemic therapy‟s dusty past or do his
theories still speak to us with vitality and relevance?
83
And if we are involved in our own personal and professional debate ‘…between rigor
and imagination…’ (Bateson, 1979), can Bateson’s ideas still help us through the
modern labyrinth, the ‘moral maze’, towards better and more reflective practice.
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