REPRINTED WITH PERMISSION from Guilford Press for the Journal of Systemic Therapies, vol 18, number 4, pp. 18-41.
Theories are often an object of contention in the family therapy field. Confused therapists can mechanically follow models, produce too many negative outcomes, or burn out. Theories are not to blame. Neither are therapists. It is the way in which they are related that makes for the quality of therapy. We have an ethical mandate to choose a model that fits our personal beliefs. This paper describes a process for creating our theories to fit ourselves.
When clinical practice is a reflection of one’s deepest values, one goes beyond doing therapy to being a therapist.
As a field, family therapy seems well defined. Authors perceive it as a separate discipline from other forms of psychotherapy (Framo, 1996; Lee & Sturkie, 1997; Shields, Wynne, McDaniel, & Gawinski, 1994; Stanton, 1988) especially given the increasing utilization of social constructionist, postmodern thinking (Bailey, 1996; Fruggeri, 1992; Gergen, 1991; Hoffman, 1988). The definition blurs, however, when it comes to specifying what it takes to be a family therapist. A good place to turn for an understanding of how to do therapy would seem to be theory because theories should provide focus for our work (Hardy, 1994; Taibbi, 1996). Instead, the subject of theory is a constant source of contention. For example, there is the decades-old debate on influence and power (Goolishian & Anderson, 1992; Simon, G. M., 1992, 1993, 1994; Simon, R., 1982). This is just one of many conflictual theoretical issues (Amundson, Stewart, & Valentine, 1993; Atkinson & Heath, 1990; Coyne, Denner, & Ransom, 1982; Golann, 1988; Goolishian & Anderson; Hardy; Keeney & Sprenkle, 1982; Shields, et al.; Watzlawick, 1982; Wilder, 1982). How can we know which theory to follow?
Complicating a lack of direction from theory is outcome research which may not distinguish among theories, philosophies, and techniques (Beutler, Machado, & Neufeldt, 1994). Outcome research provides very little information on how to do therapy (Lambert & Bergin, 1994; Beutler et al.; Orlinsky, Grawe, & Parks, 1994). That theory and outcome research do not clarify how to practice therapy is of more than academic interest. The distressing phenomenon of therapist burnout (Grosch & Olsen, 1994; Smith, 1995; Sussman, 1995a, 1995b; Wylie & Markowitz, 1992) may exist, in part, because we, as individuals, cannot define ourselves.
Being a therapist should follow from a clear understanding of the nature and purpose of theory, and, most importantly, how to choose the right theory (Berger, 1995; Taibbi, 1996; Rogers, E., cited in Grosch & Olsen, 1994)–a concept about which there is incredibly little in the literature. An understanding of the nature of theory and a review of both outcome and burnout research ought to provide a solution to defining ourselves as therapists, a solution allowing us to maintain our individualities. What they suggest, instead, points to the distinction between doing therapy and being therapists.
THEORY AS ETHICS
Confusion about the nature and purpose of theory
Given the state of conflict over theories and because outcome research does not demonstrate the efficacy of therapy models, there are iconoclasts nearly ready to discard therapy models and theories altogether (Miller, Duncan, & Hubble, 1997; Nylund & Corsiglia, 1994; Efran, Lukens, & Lukens,1990; Whitaker, 1976). There are those who consider new theories fly-by-night ideas unless the theories are empirically tested (Duncan, Hubble, & Miller, 1997a). There are those who object to a “slavish adherence” to tried and true models, an adherence which militates against developing a personal style (Efran et al., p. 142). The latter worry that although novice clinicians may be comforted by performing specific tasks, when they rigidly follow techniques they are reduced to mere roles (Jourard, 1971). Compromises between a purist adherence to models and jettisoning them completely include skepticism (Fine & Turner, 1991), irreverence (Cecchin, Lane, & Ray, 1993), and theoretical pragmatism (Stanton, 1988). However, without a systematic conceptualization of how the therapist chooses a particular path at a given moment, that therapist is open to charges of muddled eclecticism (Duncan et al.; Efran et al.).
Confusion about the nature of theory itself (Beutler et al., 1994; Held, 1992) and its concomitant ethics (Efran & Clarfield, 1992; Epstein & Loos, 1989) in a postmodern age compounds the issue of whether to retain theories. Some theorists worry that a postmodern theory of family therapy would lack universal ethics (Epstein & Loos) because postmodern thinking implies all views are correct, thus requiring high levels of personal responsibility (Efran & Clarfield; Epstein & Loos). Epstein and Loos think that therapists do indeed need to respect all views as equally valid and are concerned that some people would accuse them of nihilism for taking this position. Efran and Clarfield counter that therapists are entitled to have preferences. Nevertheless, the moment therapists decide on a right way to do therapy–an assertion of personal ethics–that would seem to make them realists (Held, 1992) rather than postmodernists. Because of this apparent contradiction, Wyschogrod (1990) wonders, “A postmodern ethics? Is this not a contradiction in terms?” (p. xiii). It is not, but philosophers rarely discuss and little understand postmodern ethics (Wyschogrod). It is a topic which could shed some light on the therapist’s choice of theory.
The primacy of personal preference
Ethical decisions appear to be rationally, logically determined (Wyschogrod, 1990). There is a problem with this understanding. The first human who needed to use logic would have been in trouble because logic had not yet been established. That is, “justifying the rules of logic would be impossible without the prior existence of a fully-formulated science of logic” (Wyschogrod, p. 131)–a logical impossibility.
The first humans deciding to use logic had to initially formulate logic’s rules, and that required mutual consensus (Gaus, 1990); hence, use of logic to debate competing values is a socially agreed upon tradition (Wyschogrod, 1990). Winning a logical debate does not make the given values true; because logic arises from social contract, it cannot establish truth value. Each logically debated position begins with personal preference (Efran & Clarfield, 1992; Gaus). Indeed, theories are always based on values. The concern that therapy “does good and is done well” (Abroms, 1978, p. 3) is certainly a value, but so are mundane matters like deciding on problem definition and selecting goals (Aponte, 1985). The fact that personal preference is at the foundation of logic, and thus, the foundation of ethics, does not diminish personal preference’s importance.
We recognize that others, too, value their choices. Therefore, each person must
- “come to a proper understanding of his place in the larger scheme of things. Ultimately, one can only grasp anything from one’s own perspective. . . . To grasp valuing objectively is to . . . see some other parts of one’s system of beliefs and values . . . as non privileged vis-a-vis that of other people.” (Gaus, p. 201)
Personal preference, or what we value, has primacy in social interaction. That is, our preferences come first; then, under social consensus, we use logic as a vehicle for championing those values. Logic, as a servant of preference, cannot establish the truth of a given assertion. Moreover, we make our choices and other people make theirs; we recognize that to others, our values may be non-privileged. Ethics, then, lie not in logic, but in personal preference.
Ethics of the profession
Applying this discussion to therapy theory, we recognize that each position in the various debates derives from personal preference. Because logic itself is not primary in human valuing, there can be no resolution to our field’s many debates. Preferences prevail. As Harman noted, “We only fool ourselves if we think our values give reason to others who do not accept those values” (as cited in Gaus, 1990, p. 201). Our arguments, after all, are simply our way of punctuating our experience (Bateson, 1972). Regarding an aspect of theory that she liked, Hoffman (1988) honestly stated: “Even if [it] proved to be untrue, I would still want to believe it” (p. 120).
Contrary to a slide down into ethical relativism, this tug amongst personal preferences inoculates against it. Preferences, submitted for negotiation, insure that ideas unacceptable to the group will not long survive. It is not only all right to be zealous about our ideas, but that zeal is the energy that catapults them into the public domain for negotiation. There, they can be contested if they do not meet consensual ethical standards. In this way, debates represent our field’s informal system for maintaining universal ethics (in addition to the formal code of our professional organizations). Consequently, not only is it not necessary for the group to arrive at a watered-down, both/and understanding of issues at hand (Ravella, 1994), but such action precludes the vigorous debate required to maintain universal ethics. Of course, this existence of shared principles does not remove from us the obligation of personal responsibility.
The caveat is for the originator of cherished ideas to remember that they are not objective truth. In response to Held (1992), to prefer particular theories, even very enthusiastically, even to the point where they are firm beliefs, is not to make reality claims about them. Taking this position, while bearing in mind that others take the same position about their ideas, goes a long way towards cutting the acrimonious tone (Coyne et al., 1982; Wilder, 1982) of some of our debates. At the same time, recognition of the importance to others of their ideas does not mean that all views have equal validity. All views may not lie within the domain of shared values. Assuming, however, that there is nothing consensually unethical about a proposed idea, one still need not hold it to be as precious as one’s own. Nonetheless, respecting the view of the other reminds us of our context (Gaus, 1990; Sampson, 1993): In order to exist as individuals within society, we must engage in a dialectic between championing ourselves and, at the same time, maintaining a proper interpersonal humility.
A discussion about reality and validity would be wanting without reference to the place of science. If all observation is the product of choices on the part of observers, then that is true of science as well (Efran & Clarfield, 1992; Gergen, 1991). Science is not synonymous with objectivity (Gergen & Kaye, 1992), and as the outcome research section will show, may not even shed light on the question of what works. This is not a call to abandon research, but it is a reminder that, like all other ethical decisions, research choices begin with personal preference. Science, like logic, is not a path to truth.
Finally, we must address the charge made against those who would cling to someone else’s theory at the risk of stunting their own growth (Efran & Clarfield, 1992). It may be necessary for inexperienced therapists to have clear models to try out as preparatory to finding their own style (Hirschhorn, 1997; Whitaker, 1976). By following a model to the letter, therapists may be taking a first step in searching for conceptualizations that resonate with themselves. We have a reflexive relationship with our theories. They should guide and focus our work, (Hardy, 1994; Taibbi, 1996), but in choosing them, they, in turn, reflect our values.
A fundamental ethical action therapists must take is to exercise their preferences in how they conduct therapy. These preferences constitute their theories. When therapy goes wrong, it may not be a bad theory but the lack of fit between the therapist’s values and behavior. Efran et al.’s (1990) “slavish adherence” to models (p. 142) may be nothing more than the groping for direction by therapists out of touch with their own values. Clearly, the foregoing indicates that the value to be placed on a theory must derive from personal preference. However, the theories themselves do not contain instructions for deciding which one to pick, or for how to adapt them to oneself. Without guidance from theory, perhaps outcome research can shed some light in this area.
AN UNEXPLORED VARIABLE IN OUTCOME RESEARCH
Clinicians cite outcome research in order to make the case that theory should not rigidly guide the practitioner in doing therapy (Duncan et al., 1997a, 1997b; Miller et al., 1997). Such research indicates that the therapy alliance is the most important factor affecting change (Bachelor, 1991; Bordin, 1979; Marziali, 1984)–by implication diminishing the usefulness of theory. Supporting this conclusion is a finding that therapist use of varying models obtains comparable results (Lambert & Bergin, 1994). A closer examination of the research reveals, however, that Lambert and Bergin’s analyses of over 30 years of studies are mainly on psychodynamic and behavioral literature; where family therapy is included, there are no distinctions among models. Other major meta-analyses covering marital and family therapy experiments use general categories, non-specific to systemic family therapy (Shadish, Ragsdale, Glaser, & Montgomery, 1995). There may be an exception or two such as the Orlinsky et al. (1994) analysis which included one family-therapy intervention.
Even in the general area of psychotherapy, there is a dearth of studies of particular models, and these do not differentiate theory from intervention. This is problematic because therapists with purportedly similar philosophies often use different techniques (Beutler et al., 1994). Coincidentally, therapists presumably using the same treatment obtain different outcomes–even when pre-trained under supervision (Lambert & Bergin, 1994). Of pertinence to this paper is the finding that “preferred therapies produced more improvement than their less favored counterparts” (Lambert & Bergin, p. 158).
In an attempt to control for divergent outcomes, training to standardize treatment is often accomplished with therapy manuals. For inexperienced therapists who are not sure what theories they like, this may be a boon. However, one study (Lambert & Bergin, 1994) shows surprising results: As the therapists became better trained, they exhibited worsening interpersonal behaviors. My hypothesis is that doing therapy to the letter may create a disparity between actions and one’s philosophy of relating to people, an easy pitfall which demands active challenge (Hardy, 1997). Duncan et al. (1997b) illustrate how even seasoned clinicians can fall into this trap.
A Beutler et al. (1994) study seems to support this hypothesis. In it, less actualized therapists effected more positive changes in their clients. Perhaps the “conflicted therapists” (p. 248) listened better to their clients’ positions because they were confused themselves. This could have been as therapeutic as systemic family therapists’ non-expert stance (Goolishian & Anderson, 1992). Summarizing these two experiments, when personal values did not fit the interventions, the therapy deteriorated. When the clinician was genuine, in spite of not following the prescribed interventions, the therapy was a success.
One way of viewing these conclusions is to toss out models (Duncan, 1997a, 1997b; Efran et al., 1990; Nylund & Corsiglia, 1994; Miller et al., 1997; Whitaker, 1976) in favor of Rogers’ (1961) personal characteristics of warmth and genuineness, which outcome researchers call the common factors, and often use as placebos to test against specific interventions and no-treatment controls. Unfortunately, the meta-analyses reveal that these placebo studies are so flawed as to be unusable (Lambert & Bergin, 1994). In spite of unclear results with placebos, Lambert mentions in a personal communication to Miller et al. that clients neither appreciate nor mention interventions. I would not expect them to, but that does not implicate their effectiveness. In fact, one often-used principle of therapy requires the intervention to be unconscious (O’Hanlon, 1987).
I actually experienced the exception that Lambert believes does not happen (Hirschhorn & Chenail, 1997). I had three visits with a couple, sent them a letter following their termination, and did a follow-up interview eighteen months later. To my surprise, when I asked to what they attributed the improvement in their perspective, they quickly replied, “The letter.” This leads me to suggest more widespread use of follow-up interviews on specific interventions with clients (Shilts, Filippino, & Nau, 1994; Todd, 1997) to determine if Lambert’s assumption is correct or not.
Therapist-related negative effects (Lambert & Bergin, 1994) and a lack of correlation between amount of clinical experience and client improvement (Beutler et al., 1994) do not bolster the case for keeping therapy models. My own professional history supports this point. Even though I have been working in the therapy field since undergraduate days thirty years ago, I had intensive training in behavior modification, and many clients commented on my sincerity, warmth, and listening skills, nevertheless, until five years ago, I did not meet my own standards. There was one couple, for example, who couldn’t stop fighting, even in my office. They liked me so much that they were crushed when, after a year in which I saw no change in their mutual hostility, I referred them out. My experience, common factors, and thorough knowledge of a model did not help.
These discouraging findings actually support the ideas I am presenting. It is not enough to say that a particular theory is good or a particular therapist is competent; there must be a fit between the two. Behavior modification works well for many therapists, not just because it is good, but because these clinicians like it. It did not work well for me. Lack of fit may result from not thinking about what one prefers, being compelled by the nature of the research project to act differently from the preferred way, or being inexperienced. Outcome research needs to pinpoint the variables which make the theory fit the therapist. Presumably, a therapist who does not choose correctly could burn out, so an examination of the research in this area might help us gain a better understanding of this vital relationship.
THE DISTRESSING PHENOMENON OF BURNOUT
In a search for the experience of the therapist, the burnout literature at first looks promising. There is a recognition (Grosch & Olsen, 1994) that burnout may stem from more than being overworked, underpaid, unappreciated, and other contextual factors. Disappointingly, there is little research on therapist characteristics (Beutler et al., 1994) with the exception of those that focus on pathology (Grosch & Olsen; Sussman, 1995a). Smith (1995) calls this the “psychotherapist’s disease.” It is a product of a pathologizing worldview, part of a “professional culture that often leaves little room for the clinician’s humanity” (Sussman, 1995a, p. 4).
It would seem that with an increasing recognition of the postmodern role of family therapists (Lee & Sturkie, 1997), it behooves us to isolate more human, non-pathologizing factors such as therapist job satisfaction. Nevertheless, a recent survey for the American Association of Marriage and Family Therapists on psychotherapists’ practice patterns (Doherty & Simmons, 1996) had not a single comment on this. Only a small number of researchers focus on therapist well-being. Taibbi (1996), whose position comes closest to mine, tells therapists that theory should fit “the basic you” (p. 7); however, he does not explain how the therapist knows which theory will accomplish that.
The preceding sections of this paper assert that the essence of being a therapist is the ethical act of using personal preference to choose one’s theory and then acting upon one’s choice. We conclude from the theory section that problems might not emanate from the theories themselves. The outcome and burnout research literature do not indicate that the problems are necessarily in the therapists either. When therapists mechanically follow models, they are merely doing therapy–and not necessarily very well. Neither theory nor research tells us how to look for the right fit.
A POSTMODERN DEFINITION
“We ask children: ‘What do you want to be when you grow up?’ Notice that the emphasis is not on doing, but on being” (Sussman, 1995b; p. 15). Without guidance from theories or research, how can we help clinicians to be therapists–that is, develop their own style (Berger, 1995; Efran et al., 1990; Whitaker, 1976)?
Duncan et al. (1997), whose work indicates that they are good clinicians, may only think they discarded theory. It could be that they learned the theories and their accompanying interventions very well–and then forgot them (Atkinson & Heath, 1990; Keeney & Sprenkle, 1982; Whitaker, 1976). Bateson (1972) points out that the essence of skill is to practice something so well that one no longer thinks about it. At that level, artistry can occur. The artistry of being a therapist means “that formal training and life experience have melded together in a seamless whole” (Wylie & Markowitz, 1992, p. 30).
To avoid charges of being too abstract or vague (Coyne et al., 1982; Efran et al., 1990), here is a workable definition of this artistry: In grammar, the verb to be is called the copula because it connects the subject and the predicate. For our purposes, the copula links the individual’s behavior at a given moment in a given therapeutic relationship with the theory that he or she espouses. Thus, we can think of a model of therapy as customary patterns of conversation, a recognizable personal style, or use of specific techniques. Theory is the rationale for using such patterns, style, or techniques. If the clinician practices a technique because it embodies a deep conviction, the practitioner is no longer merely using the technique, but rather the technique has become part of who that therapist is.
My understanding of normalizing (Hoffman, 1988) can serve as an illustration of the difference between doing and being. If a therapist reading original Milan work (Selvini Palazzoli, Boscolo, Cecchin, & Prata, 1980) selects positive connotation as a strategy in order to “find the ‘bomb’ that would blow the family system out of the water,” it is a mere technique, and, as such, it may turn out to antagonize the family (Hoffman, 1988, p. 121); I would consider that doing therapy.
Selvini Palazzoli was herself highly successful (Hoffman, 1988) and I believe this was so because she really did perceive families as engaging in “psychotic games” (p. 120) and genuinely wanted to help divest them of these; in following her model, she was being a therapist. Others following her lead but who do not envision family behavior in that way would just be doing therapy. In the above example, therapists can use various terms–normalizing, reframing, positive connotation, logical connotation–which all mean about the same thing. The intent behind the behavior distinguishes a technique that reflects one’s own cherished beliefs from a technique one merely uses mechanistically.
REACHING FOR THE INTANGIBLE
I present here a four-step process for reflexively scrutinizing–and improving–the copula, the link, between therapist and practice which calls the former into being. The first step, writing our histories (Andersen, 1992; Cantwell & Holmes, 1995; Epston, White, & Murray, 1992), is an attempt to reconstruct the preferences we believe we once had. We can gain inspiration from authors who have been courageous in sharing their private stories (Brewster, 1992; Hoffman, 1988, 1992; Jourard, 1971; Minuchin, 1974; Rogers, 1961; Watzlawick, 1982; Whitaker, 1973). Our final stories may change as we ponder them (Cecchin, 1992; Epston et al.). That is the beginning of the reflexive process described here: Our present experience changes our recollection of our past histories, and our histories affect our future life choices. No wonder the passion with which some writers defend their theories–they are defending the meaning they give to their very lives.
The second step is to write a statement of one’s therapy credo, necessary in order to bring to light disparities between one’s behavior and philosophy, a problem Hardy (1997) calls segregated thinking. The writing creates a new view of oneself which can lead to yet additional understandings (Cecchin, 1992). Growth toward being a therapist is such writing, plus reading new ideas, raising questions within oneself about one’s work (Turner & Fine, 1995), being brutally honest about the congruence between one’s stated beliefs and one’s actions as described in the history, and permitting oneself to change. Considering the elements of one’s own model in light of a subjective history is the next step in the reflexive process: A personal credo has as much influence on the construction of one’s history as the latter has on developing the model.
Those not in the habit of introspection can be assisted by excellent self-reflective exercises (Fine & Turner, 1993; Piercy & Sprenkle, 1988; Rambo, Heath, & Chenail, 1993; Taibbi, 1996) and descriptions of others’ personalized therapy theories (Atkinson & Heath, 1990; Hoffman, 1988; Keeney & Sprenkle, 1982; Real, 1990; Whitaker, 1973). This exercise is not meant to develop a new model of therapy for others to now follow; it may or may not be a pure version of an existing one. The purpose of this step is to create the distinctions that allow us to compare our historical choices to a personal philosophy of being a therapist.
Step three requires that the therapist film a therapy session, transcribe it, compare the words with the analogic behavior in the film (Latz, 1996), and compare these to the analyses of the above steps. We can reconstruct the meaning in our historical choices and we can alter our philosophies, but video removes us one step from ourselves. As we watch our words, tone, and body language, we have the luxury of contemplating the extent to which our filmed behavior is in accord with our stated philosophies of therapy.
The fourth step calls for feedback focusing on the degree of fit between the theory and therapist. Whether one is a trainee or a seasoned therapist, supervision and consultation (Grosch & Olsen, 1994; Todd & Storm, 1997a, 1997b) as well as peer support (Berger, 1995) can provide invaluable feedback. Often, high quality supervision may attend to a supervisee’s personal and emotional reactions (Atkinson, 1997), but the supervisor’s job can go beyond this level of personal exploration to helping supervisees exercise their theoretical preferences (Todd, 1997) as an expression of their values.
Step 1: A history
When I was a preschooler, my parents prophesied that I would become a lawyer because I was headstrong and opinionated, and I liked to argue so much. However, although I was a champion debater in high school, that was all in fun. I never really cared for an adversarial way of relating to people. I still have strong opinions, but my love for argument evolved into a fascination with analytical process, and the focus of my analysis was people. Since fifth grade, when I queried of a diary, “Why do people act the way they do?” I was captivated with the mysteries of interpretation and symbolism in behavior. In college, I was smitten with Freud.
Maybe wearing dental braces for too many years gave me a kinship with underdogs, or maybe it was my late father’s extraordinary kindness that taught me empathy. Perhaps this empathy motivated me, as an undergraduate, to set up a program in which psychology students visited patients in a state mental hospital, a program good enough to make it into the city newspaper two years later (“Students form,” 1970).
My experience was an eye opener–and it horrified me. The psychiatrists believed that chronic patients do not get better, and because they don’t make much sense, it is pointless to listen to them. It is but a short step from this hierarchical position to one of total disrespect (Hellerstein, 1994), an attitude I found duplicated in Israel where I conducted undergraduate research on mental hospital environments (Schwarz, 1968). I came to believe that the Freudian certainty as to the meaning of behavior was the source of that disrespect, and I rejected it. My initial attraction to Freudian interpretation was altered by my contact with its application. This was the first instance of experience altering my preferred theory.
I later entered a masters degree program in behavior modification (Ayllon & Azrin, 1968) because behavior modifiers seemed more optimistic about the potential for change than did traditional medical model adherents, and they took action in helping their clients (Hamerlynck, Davidson, & Acker, 1969). However, in my masters studies, I was greatly disturbed by my observation that institutionalized clients could lose their individuality as therapists carried out agency goals (Bijou & Ribes-Inesta, 1972). Although I had been attracted by behavior modification’s efficacy, my enthusiasm was quelled by what seemed to be mechanistic in its application, a lack of soul.
I switched masters programs in midstream to a Rogerian-oriented (1961) one and finished my degree, but the debater in me could not sit still to just listen and reflect. Where was there room for my voice in the Rogerian paradigm? In my zeal to offer my clients a voice, would mine have to be lost? My experience with the three major schools of psychology illustrates the reflexive relationship between one’s history and one’s theory. I was attracted to each school because of specific features, but I ultimately modified my choice when practice led me to experience a dissonance between my beliefs and the behavior required by that model. My change in theory necessitated changes in behavior which, in each case, required that I re-examine my values.
Upon completion of my degree, I retreated from the field for a number of years, until, by chance, I came across non-normative systemic therapy philosophies (de Shazer, 1984, 1985; Fruggeri, 1992; Hoffman, 1988, 1992). I was intrigued by social constructionist thinking. Here at last, clients would be given respect and a voice to prove it (Hoffman), but I would not lose mine (Abroms, 1978; Aponte, 1985; Cecchin, 1992; Cecchin et al., 1993; Epstein & Loos, 1989; Rambo et al., 1993). I felt, in my doctoral studies, that I had come home.
Step 2: Personalizing theory
My history points the way to a fit with social constructionist theory and not with any of the three major schools of psychology. To develop my personalized theory, I had to re-examine my history. Consideration of my beliefs led me to highlight parts of my history that I had previously thought unimportant. For example, I came to see that my desire to express my own voice in my clinical work was foreshadowed by the delight I took in high school debate. Emphasizing parts of my history led me to recognize the importance of other aspects of theory. For example, I came to see that early learning of empathy meant that if my voice was important to me, then so must be the voices of my clients. To be theoretically consistent, my opinions should never overshadow that of my clients. Re-tooling one constantly led me back to the other, the reflexive process.
Such musings can help one to construct a coherent personal theory of therapy. I defined models earlier in this paper as customary patterns of conversation, a recognizable personal style, or specific techniques. Armed with this definition and a first look at one’s history, a therapist can examine his or her characteristic way of working and ask what principles lie behind the behavior: That defines one’s theory.
Non-normative, social constructionist therapy satisfies four fundamental requirements for the theory that reflects the professional choices I have made. First, unlike the medical model or Freudian interpretation, it is non-hierarchical in that the therapist is not an expert and there are no underdogs. Rather, the uniqueness of each client and his or her way of handling life is as respected as that of the therapist. Second, unlike Freudianism, which standardizes interpretations, and behaviorism which focuses more on behavior than significance, it presents a rich opportunity for the creation of meaning. Third, unlike Rogerian work, the therapist actively participates in that creation (Epstein & Loos, 1989; Greenleaf, 1997; O’Hanlon & Wilk, 1987; Rambo et al., 1993). Fourth, because meaning is the product of both therapist and client, we are free to develop optimistic, positive meanings, in contradistinction to both the medical and Freudian models. These four aspects of my preferred theory allow me the thrill of perceiving patterns and sharing them without having to claim them as received truth; they are just my ideas, my vision. These four constraints on my chosen theory can help draw distinctions within the domain of known social constructionist models.
Regarding the first component of my individualized theory, a non-expert position, I shy away from normative thinking which implies that the therapist knows best how a normal family should function (Minuchin, 1974; Simon, 1992, 1993, 1994). Thus, I would not enjoy doing structural work, however much I deeply admire Minuchin. For the same reason, even non-normative strategic therapy, with all its brilliance, has a flavor for me of outsmarting clients (Fisch, Weakland, & Segal, 1982) and therefore seems hierarchical, however one-down the authors may insist they are. Because I am so passionate about a non-expert position, I relish normalizing clients’ behavior. It reduces the gulf between my world and theirs (Amundson et al., 1993). From my perspective, normalizing is not a reframe; it is my original frame. It is akin to Hoffman’s (1988) “‘logical construction’ of the problem . . . used, not as a particular intervention, but as a total stance” (p. 122).
One indication of respect for the client is to allow one’s sensitivity to the client to guide one’s work no matter how much a specific technique is a reflection of one’s core beliefs (Cecchin et al., 1993). This is strikingly applicable to the tension between stability and change. I believe clients predominantly come to therapy for change (L Shilts, personal communication, February, 1993). That is why I do often use solution-focused interventions. Even so, I recognize that there are times when they do not want it (Becker, 1996). I therefore allow for a switch from change to stability.
The second constituent of social constructionist thought that attracts me is the generation of meaning. Perhaps it is a throwback to my enjoyment of symbolism and interpretation in Freudian psychology, or perhaps it is a rejection of the behavioral exclusion of meaning, but I would rather work with changing the client’s perception of the problem in order to resolve it (Goolishian & Anderson, 1992) than work with changing behavior. I agree with the notion that it can be helpful to gently challenge people’s unclear premises by “introducing doubt wherever possible” (O’Hanlon & Wilk, 1987, p. 56). However, my approach is more straightforward, less strategic, than that of O’Hanlon and Wilk; I don’t have a list of tactics to call upon in order to accomplish this. This is one reason why I do not consider myself predominantly solution-focused. I see de Shazer’s model (1985, 1994) as a conveyor of hope, I often give solution-focused homework assignments (Hirschhorn, 1998), and I sometimes use the miracle question and scaling techniques; however, the intervention which appears at the end of de Shazer’s sessions is often more clever than one I could produce, and its certain presence has a formulaic air that, with all its elegance, seems too planned for me.
This leads me to the third factor of social constructionist thought that I have been using as a yardstick for determining the best-fitting theory for me, my own participation in the meaning-making. de Shazer is so respectful of his clients’ voice, what he calls text-based reading (1994), that his own voice is usually heard only briefly, at the end-of-session intervention. I am simply too talkative for that.
The fourth element, a positive outlook, is another reason why I prefer normalizing clients’ behavior. This orientation may also explain why I like to incorporate humor into my work (Cecchin et al., 1993; O’Hanlon & Wilk, 1987; Waters, 1992).
These four features do not point to a pure model. They seem to be an amalgam of the non-expert stance, some techniques of de Shazer (1984, 1994), the addition of my own voice so as to construct positive, healing frames (Epstein & Loos, 1989; Greenleaf, 1997; Hoffman, 1988; Rambo et al., 1993), a gentle challenge to client presuppositions (O’Hanlon & Wilk, 1987), and a dose of humor. It seems to me that the case to follow illustrates a non-hierarchical stance, the introduction of new meaning through my normalizing the identified person’s behavior, and a positive outlook as exemplified in both the normalizing and the use of humor.
Step 3: Excerpts from a two-session case
I chose the transcript to follow, taken from a case I saw in 1994, because it portrays my therapy philosophy and how it suits me, it is brief, and it was videotaped and transcribed as suggested in step three. The Rutherfords1 came to a university training facility 2 where I was the therapist on the case working with a team behind a one-way mirror. The family consisted of the parents, Lester and Betty, and Jason, 16, the source of their concern. As a baby, Jason cried incessantly. At age two, his parents took him to a neuropsychiatrist. From that point onward, Jason saw a succession of therapy professionals from whom he received various diagnoses including hyperactivity and depression. Jason seemed to have done well for the previous two years. Lately, however, his grades began to slip, and he became uncommunicative. His parents interpreted his lack of communication as a sign of depression.
(1) Betty: Basically, he does not communicate, you know. Sometimes, he will, and you know, he’ll talk about–but mostly, he very rarely says what he thinks or what he feels.
(2) Therapist: When did the communicating stop?
(3) B: [pause] It never really started. Know what I mean?
(4) T: Well, when he was 11 months old, he communicated pretty loudly.
(5) B: Yeah.
(6) Lester: Mmmm.
(7) T: Right? You’re telling me he did a lot of crying, and he was letting you know something.
(8) B: Yeah. Exactly.
(9) T: So, I’m wondering when it stopped.
(10)B: Ahha. [pause] That’s a good question.
Lines 1 and 3 indicate the family’s position that their son does not communicate. In lines 2, 4, 7, and 9, I enter their worldview by agreeing that he does not communicate, but I also challenge their presupposition that this is Jason’s nature. By normalizing crying, I also convert it from the helplessness of depression to the power of a baby that wants to be heard. In spite of my desire to present the baby’s behavior in a positive light, I offer my frame as a question; I do not want to impose my view on the family. As a question, rather than an interpretation, I express my curiosity and leave open the possibility that I started on the wrong track. Questions also provide clients an opportunity to really ponder their situation in a new way. In lines 8 and 10, the family verbally and non-verbally conveys their agreement. Had I not witnessed that confirmation, I would have backed off and taken a different path. A few minutes later, they give me another opportunity to normalize. Betty refers to her son’s behavior in line 11:
(11)B: And he’s doing it to bug me, you know?
(12)T: His job is to make you frustrated.
By using the word “job,” I introduce the idea that as a normal teen, Jason must bug his parents. As the discussion proceeds, the boy begins to cry. The family states that his depression was never “this bad.” At this point, I take a break to consult with the team. We see Jason’s behavior as a reflection of his parents’ concerns for him and I proceed with this thought:
(14)T: One observation that we thought, for what it’s worth, is kind of interesting is that you, Jason, are, or had been, on Medication because you’re anxious. And yet, what’s so interesting is that everybody, all the family members, have been very, very anxious about Jason.
[Betty and Lester nod heads]
(15)T: It’s not just one person that’s anxious in the family.
(17)T: And this started when he was 11 months old. And that feeling of overwhelming concern to make it right hasn’t changed. . . . Now, his life is more complex, he’s a young man, and surely the things that he might need soothing for are going to be more complex. And so much more the frustration: You can’t soothe him. . . .
(18)B: We know that you can’t make everything in life right because life is like that, but we want him to learn how to take frustration in stride is what we want him to learn. How to take it and not to take things so to heart, you know. . . .
(19)T: But you know what I’m seeing here, Betty, that strikes me, is that you’re not able to take the frustration you have seeing his frustration to heart yourself either; it’s so difficult–
(20)B: Ahhh. That’s true. That’s true.
(21)T: . . . You can’t take your frustration at his frustration easy–you take it to heart also. So naturally, he would take it to heart also. He has an example of a very, very sensitive and caring family that takes things to heart. And he sees you taking him to heart: He takes things to heart, too.
(22)L and B: So it becomes a vicious circle.
(23)T: I don’t know that it’s a vicious cycle. You see, my perception is not necessarily a vicious one. I see you as loving, caring, concerned people, all of you. A concerned, sensitive family.
(24)B: Yes, we are. We love him very much. He’s so special to us.
(25)T: And I see it only as each person’s caringness that’s coming out in your frustration at things not being just right.
(26)B: Notice, in line 14, as I introduce the frame of shared family concern, I shun an expert position with the expression, “for what it’s worth,” and I present the ideas as “kind of interesting,” rather than received truth. I reinforce the frame in lines 15, 17, 19, 21, 23, 25. The family’s body-language following line 14, and verbalizations in lines 16, 20, 24, 26 let me know that they accept this frame. In line 22, Lester and Betty appear to me as though they would stop pathologizing Jason by incriminating themselves. I contradict them in lines 23 and 25, giving my own voice the same degree of respect I give theirs (Epstein & Loos, 1989; Greenleaf, 1997). Betty accepts it in line 26. The family opens the second session by stating how pleased they are with the previous one because it permitted a catharsis for Jason. In as much as the concept of catharsis is not part of my theory, this is a good example of how clients are not generally aware of the intended nature of interventions and will supply their own meaning to what happens. However, their lack of awareness of my intention does not diminish the potency of the intervention. They elaborate:
(27)L: I think Jason has improved very significantly.
(28)T: How so?
(29)L: The way he’s behaving and uh, the relationship.
[Jason grins, to which Betty giggles]
(30)T: [to Jason] you may not smile! No smiling allowed here now! . . .
(31)L: Yeah, and I think we have a relationship much more open and frank and friendly.
(32)T: Uh-huh. You were saying that you were able to talk to him much more.
(33)L: Yeah. Yeah, we were playing tennis and he was talking to me and I asked him questions–
(34)T: Did he whip you?
(35)L & B: Yeah!!
(36)T: What was the score?
(37)L: That’s incredible, yeah.
(38)B: He said, “Boy!” he said it’s as though, you know, “Boy, he beat me so–“
(39)T (to Jason): Good for you! You show him.
(40)L: Even, even in that regard.
Mmhm. . . . That’s what it is.
I am not satisfied with a global statement of improvement, but want specifics. Line 29 alludes to an overall behavioral improvement, especially in the area of Jason’s relationship with his father. Lester elaborates this in lines 31 and 33. Out of curiosity, I ask about the game in line 34 and get amazed responses from his parents. If we go back to line 12, the reader will notice that I support Jason in taking a playful one-up position to his parents. I believe he chooses play to establish his normalcy and adulthood with them. The laughter in the session indicates that this too is play (Bateson, 1972), thus making another one-up stance permissible.
(41)B: You know, I think it was good for him to have a good cry over all these things.
(42)T: Yeah, we all need that sometimes.
(43)L: Even though, last time he didn’t say anything much, either, but I think it helped him to get it–
(44)T: He said it in his own way.
(46)B: Ahhh. Okay. Now. So, I don’t have to worry so much about his being–
(47)T: Oh, I think you should keep worrying, Betty! What would you do if you weren’t a worrier?
Line 41 is fascinating because Betty herself switches from pathologizing to normalizing. In line 44, I again present my own perspective, this time with Lester, whose response in line 45 implies that he accepts it. The joke in line 47 serves three purposes: It normalizes Betty’s behavior; it teases her gently for it so that perhaps she will worry just a little less; and it maintains a humorous tone which conveys the message that there is no serious problem here.
A follow-up phone call four months later revealed no new symptoms of depression. Betty expressed concern over Jason, which is to be expected. She followed my parting message by allowing herself to worry as an expression of normal parental concern. A three-year follow-up found Jason claiming he had had no depression, no Medication, and no other problems since being seen at the clinic. He had selected a vocation, is both studying it in vocational school and working while finishing high school, and had made plans to continue his career after school. His parents apparently stopped worrying because they took a three month vacation, leaving Jason to govern himself.
Upon reviewing the tape, I asked myself whether I thought my work was consistent with my philosophy. I noted more humor in it than I remembered to be there. I was pleased to find my voice seemed equally balanced with that of the family. This segment of transcript reveals the four features of my way of working that are so important to me: a non-expert position, a focus on meaning, my own voice, and a positive stance. It seems an accurate reflection of my espoused theory. Had my conclusion been otherwise, I would have been compelled to either alter my theory or my behavior. Changes, however, are difficult for all of us, therapists being no exception. That is why step four is so important.
Step 4: Feedback
It is of interest that the features of my chosen theory can also be found in the work of Rambo et al. (1993), of whom Rambo and Chenail have been my mentors. Did my personal model come to resemble theirs because they taught me, or did I choose the program at which they taught because its philosophy best resembled mine? Here too, one can find a relfexive process at work. Because of the good fit between my theory and theirs, my professors would seem to be an accurate source of feedback.
At the end of our first year of doctoral training, we were required to write a theoretical and clinical self-evaluation for discussion with faculty. As I look over mine, done five years ago, I am intrigued to note that many of the issues of importance to me in this paper were on my mind back then. In my preliminary self- evaluation, I was concerned with avoiding the expert position, the degree to which my own frames belong in the therapy conversation, and acquiring technical skill. These supervisee-determined issues later served as the focal point for supervision discussions of my clinical work (Cantwell & Holmes, 1995).
Recently, I asked a respected colleague to view the videotape containing the transcripts contained in this paper while bearing in mind the following questions:
1. What theory, model, or components of models would you say I follow?
2. Would you classify me as strategic or non-strategic?
3. What would you say is my overriding aim in these two sessions?
4. Would you say my own voice is prominent here or not?
5. Would you say I take a knowing position?
My colleague (J. Becker, personal communication, June 24, 1998) saw components of a number of theories in the tape: Milan (Selvini Palazzoli et al., 1978), because I remain neutral; Mental Research Institute (Fisch et al., 1982), because I ask questions relating to the interactional pattern; languaging (Goolishian, & Anderson, 1992) because I allow the talk to flow without pushing it in one direction or another to a large degree; O’Hanlon’s solution-focused (O’Hanlon, & Wilk, 1987), because I spread the symptom through the family; and narrative (Epston et al., 1992), because I attempt to restory the family’s view of themselves. She acknowledged that my interest in the pattern was not strictly MRI because I do not follow it up with attempts to break the interactional cycle, and that the Milan element is small because my questions are not circular.
Regarding question two, my colleague pointed out to me that it is difficult to classify what is strategic because any plan, such as to positively connote behavior (Selvini Palazzoli et al., 1978), could be considered strategic. She handled questions 4, 5, and 6 as follows: She saw my therapy goal as de-pathologizing the symptom and restorying the situation. She thought my voice was not too prominent but pointed out that this question requires comparison to others in order to rate degree or amount.
This response to my work prompted me to question the congruence between my theory and my behavior in two areas. The first area is that I thought that I eschewed strategy, but my colleague seemed to feel that a consistent search for positive frames is a strategy. Understanding the sense that clients make of their behavior is a precious part of my philosophy, one that I would not want to give up, but seeing myself as strategic produces a dissonant image of myself. Although a thorough discussion of the meaning of strategy is beyond the scope of this paper, my initial conclusion to this challenge is that I agree with Flemons who said that because he presents frames that he truly believes (D. Flemons, personal communication, October, 1991) instead of using them because they will have a particular effect on the client (Selvini Palazzoli et al., 1978), he does not consider himself strategic.
The second concern raised by the feedback is directed at the tension within me between enjoying sharing my own thoughts while not wanting to be hierarchical. It would seem from my colleague’s comments that my voice is more dominant than I want it to be. It may be that as I cogitate on this point longer and walk into the therapy room thinking about it, I might revise my theory to allow for a louder voice. Perhaps I will find that as client trust and therapist-client mutuality grow, a stronger therapist voice does not result in a hierarchical relationship. On the other hand, I may decide to change my behavior in the service of keeping my theory consistent with my beliefs (Hardy, 1997). My colleague’s feedback gives me a direction for self-supervision (Todd, 1997).
Self-evaluation cannot help but examine the degree of fit between one’s actions and one’s theory. The process is recursive: New understandings of theory shape re-examinations of one’s history, philosophy, and clinical work, and those re-examinations may influence one’s theory. Interestingly, the review process for this paper provided another opportunity to reflect on my theory and practice.
Ethical behavior means making choices. Being therapists, as opposed to following someone else’s prescriptions or acting out of habit, requires soul-searching to be sure that we choose every intervention based on our deepest values. Out of context, neither theories nor therapists are good or bad. It is the copula, the link joining them, that brings them into being. Research to substantiate this premise is needed. Is being a therapist, regardless of theory, related to client outcome? Is it related to therapist burnout? Have I left out any parameters for being? Could a well-trained, experienced person make the ethical choices necessary to be a therapist and still not do a good job? How do the theoretical variables discussed here relate to others of importance in the literature? Are there models which lend themselves more readily to being than others? Would a particular kind of problem require abandoning one’s best-fitting theory? Our field, which prides itself in its unique relational foundation, needs to further investigate the relationship between clinicians and their espoused theories
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- Names and distinguishing features of family members have been changed to protect their confidentiality.
- The clinic to which this family came is Family Therapy Associates, the training facility connected with Nova Southeastern University.