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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

Brooke, R [2000], Pathways into the Jungian World, London.Routledge,

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.

Jung, C. G. [1995], Memories, Dreams, Reflections, London.Fontana Press,

„Jung‟s Model of the Psyche – Part One‟ [2001]. Retrieved April 21, 2006, from

http://www.bbc.co.uk/

May, R, Angel, E, & Ellenberger, HF [1958], Existence: A New Dimension in Psychiatry and Psychology, New York.Basic Books,

Rogers, C. R.[ 1997], On Becoming a Person: A Therapist‟s View of Psychotherapy, London.Constable & Company Ltd,

Samuels, A [1985], Jung and the Post-Jungians, London. Routledge & Kegan Paul plc,

Stein, M [1998], Jung‟s Map of the Soul, Illinois. Carus Publishing Company,

46

van Deurzen, E [2005], Existential Counselling & Psychotherapy in Practice,

London.Sage Publications Ltd,

Yalom, I [1980], Existential Psychotherapy, New York.Basic Books,

Yalom, I [1991], Love‟s Executioner and Other Tales of Psychotherapy, London

Penguin Books,

Yalom, I [2006], The Gift of Therapy: Reflections on Being a Therapist, London

Piatkus Books Ltd,

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.

References.

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approach to therapy. New York: Basic books.

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Anderson, H., (1993) On a roller coaster: a collaborative language systems approach to

therapy. New York, Guildford.

Bakhtin, M., (1984) Problems of Doesoevsky‟s poetics. Theory and history of

Literature, Vol. 8.

Bakhtin, M., (1986). The problem of speech genres. Austin: University of Texas.

Baraldi, C. (1993) Structural Coupling: Simultaneity and difference between

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Blom, T., & van Dijk, L. (2007). The role of attachment in couple relationships

described as social systems. Journal of Family Therapy Vol. 29

Buber, M., (1965). The knowledge of man. New York: Harper.

Cronen, V.E., Pearce, W.G., & Snavely, L. (1979). A theory of rules structure and

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Falicov, C.J., (1998) From rigid borderlines to fertile borderlands: reconfiguring family

therapy, Journal of Marital and Family Therapy. Vol. 24.

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and J. Byng –Hall (eds) Multiple Voices: Narrative in Systemic Psychotherapy, London:

Duckworth.

Frosh, S., (1995). Postmodernism versus psychotherapy, Journal of family therapy. Vol.

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Gergen, K. J., (1991). The saturated self: dilemmas of identity in contemporary life.

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USA, Harvard University press.

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Suhrkamp.

Lysack, M., (2002). From monologue to dialogue in families: internalized other

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Maturana, H.R., & Varela, F. (1980) Autopoiesis and cognition. Boston: Reidel.

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library.

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Pare, D.A., & Lysack, M., (2004). The oak and the willow, from monologue to dialogue

in the scaffolding of therapeutic conversations. Journal of systemic psychotherapies,

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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

64

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

65

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

66

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

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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

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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

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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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