Introducing User-Friendly Family Therapy

Sigurd Reimers, Andy Treacher

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317799429
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

All too often the experience of users of family therapy is neglected in the theory and practice of family therapy as well as in the literature itself. In Introducing User-Friendly Family Therapy the authors describe in detail how the results of an action research project helped the professionals involved to modify their practice. They draw out the implications of the research for providing a genuinely user-friendly service and set the arguments for a more humanistic approach in the wider context of contemporary social policy.
Thought-provoking and practical in emphasis, this book places the user at the centre of the stage and insists that family therapy can only flourish if it becomes genuinely empowering and user-friendly.

Chapter 1

Introducing user-friendly family therapy

Andy Treacher and Sigurd Reimers

It is genuinely difficult to establish whether family therapists take much interest in how their clients (users) experience being in family therapy with them. Maybe they do take an interest on a day-to-day basis but, if so, this interest is rarely reflected in family therapy publications. As we will demonstrate in a later chapter, the number of publications which actually attempt to give users a voice by recording their thoughts and feelings about being in therapy is remarkably small.

To illustrate this lack of interest, it is worth turning to the massive (715-page) Volume 2 of the Handbook of Family Therapy, edited by Alan Gurman and David Kniskern (1991). Its index contains no mention of ‘client’, ‘clients, perceptions of or any related item. Looking under the broader topic of ‘family’ proves slightly more fruitful since there are two references to ‘family – goals of and therapist’s goals’ and ‘family – goals of individual members’. Both items give a hint that users may have a point of view that needs to be considered but the first reference is particularly poignant. It concerns a controversial facet of structural family therapy practice which involves therapists being invited to challenge users’ goals, on the basis that users only want to achieve symptomatic change, whereas structural family therapists are concerned with achieving deeper (structural) change in the family so that the symptoms are eradicated at a more basic level. Consulting Volume 1 (796 pages) of the same book (Gurman and Kniskern, 1981) also yields an interesting finding. There is, indeed, one reference to ‘client’ (‘client-centred therapy’) but ironically there is no such reference in the second volume, as we have already pointed out.

It is ironic and perplexing that family therapists have neglected their users in this way. Systemic theories, after all, stress such notions as feedback and circularity, and often take other forms of theorizing to task because they are considered to be ‘linear’ (unidirectional) in their thinking. The allegedly superior interactional theorizing of family therapy is assumed to be more sophisticated than other models which are dismissed because they concentrate on intrapsychic phenomena. Many theories of psychotherapy do suffer from major inconsistencies but we believe that this particular inconsistency has had, and still has, enormous implications for the development of the family therapy movement.

Anne Rogers, David Pilgrim and Ron Lacey (1993) in their pioneering book Experiencing Psychiatry – Users’ Views of Services, provide us with some important clues, which help explain such a startling gap between theory and practice. They point out, in discussing related examples, that there are several reasons why psychiatric patients’ views about their experience of therapy tend to be disregarded by the professionals who work with them. Since family therapy, as a movement, was initially dominated by psychiatrists, it is safe to assume that some of the movement’s basic attitudes towards users were introduced through the back door. There is no reason to believe that the professionals who initially developed family therapy ideas changed their basic attitudes to users. These would have reflected their class background and initial professional training and practice. Medical practitioners are traditionally drawn from a very narrow class base and medical training inculcates hierarchical attitudes, so it is not surprising that we discover that family therapists have consistently disregarded users’ views. Many of the original powerful opinion-makers within the movement brought a range of unchallenged reactionary assumptions and opinions into the movement. These key figures have influenced subsequent cohorts within the movement who have tended, in turn, to idealize them as ‘founding fathers’ (term used advisedly).

We would argue that family therapy research has been equally dominated by ideas that militate against researchers having a prime interest in the experience of therapy from the user’s perspective. This argument is supported by evidence from the work of Rogers and her colleagues. Taking the crucial area of schizophrenia research as an example, they point out that research priorities are upside-down from a user’s point of view. The Medical Research Council (a key funding agency in this country) has a list of priorities for research that totally ignores users’ perspectives. Their list of priorities is headed by ‘genetic investigations’ followed by ‘neuropathological studies of post-mortem brains’. Evaluation of services to users comes a poor eighth out of the ten cited priorities but user evaluation of services and treatment receives no mention whatsoever and yet approximately 1 per cent of British people are likely to suffer from schizophrenia in the course of their lifetime.

According to Rogers and her colleagues, there are four major reasons that explain why users’ views have been traditionally disregarded within the mental health services:

1 Professionals feel entitled to disregard users’ views when they do not coincide with their own.

2 Psychiatric users are viewed as continually irrational and hence incapable of giving a valid view.

3 Patients and relatives are assumed to share the same interests and, where they do not, the views of the former are disregarded by researchers.

4 Professionals give partial credence to the clients’ perspectives provided that they fit in with their (expert) view.

We know of no specific research that has investigated family therapists’ underlying attitudes to their users but unfortunately the prima-facie evidence all points to the fact that family therapists, despite pretensions to the opposite, are just as likely to neglect user perspectives as any of their professional colleagues. Most models of family therapy try not to pathologize users’ behaviour but there are often striking contradictions within such models that create genuine uncertainty about their basic user-friendliness. For example, strict adherence to the original formulations of systems theory led to the neglect of the role of consciousness (and self-reflexivity) in determining behaviour. Users’ experiences could therefore be ignored as epiphenomena that were of little importance to therapists intent on achieving change at a systemic level.

In Chapter 9 we will explore research that has attempted to correct this major weakness in the development of family therapy. In fact our computer search of the literature produced a remarkably small catch. The studies we discovered were interesting and important but there is no coherent body of research which can be safely mobilized in order to answer many of the tantalizing questions that a user-friendly approach would want answered.

Many of the studies we will review hark back to John Mayer and Noel Timms’s classic study The Client Speaks: Working Class Impressions of Casework (1970). Significantly Mayer and Timms’s book contains the following salutary quotation which is used as an epigraph:

The confusion between the interest which a person himself has or takes, and the interest which a second person has or takes in him, is one of the pitfalls of parentage, teaching, religion and all varied forms of professed benevolence. In order to discover whether professed benevolence is really independent benevolence, ask the beneficiary rather than the benefactor.

R. B. Perry, Realms of Value

In our view, the family therapy movement is dominated by the views of the benefactors not the beneficiaries. There is, as yet, no sign of an organized user movement which could articulate the views of users and ex-users of family therapy and hence redress the balance. And yet the family therapy movement, in professional terms, goes from strength to strength. In Britain there are now about 1,400 members of the Association for Family Therapy but in America, where the movement is particularly strong, there are now 17,000 therapists affiliated to the American Association for Marriage and Family Therapy. The majority of practitioners work in private practice. Family therapy is highly commercialized and family therapy ideas and methods are often sold like any other product.

Against this background it is timely to attempt to redress the balance and to attempt actively to counter the ‘invisibility’ of the users of family therapy. The primary aim of our book is, therefore, to help to contribute to a perspective in the family therapy movement that has been largely ignored because of the impact and fashionableness of models which too readily absorbed the alienating and dehumanizing facets of systems theorizing. This alternative perspective insists that therapy needs to be viewed as a co-operative project between user and therapist which takes seriously users’ experience of family therapy.

As John Carpenter and Andy have pointed out in a previous book, some models of family therapy have tended to adopt approaches to therapy that stress the exact opposite:

One common way to think about therapy is to consider it as a form of combat. Thus, the therapist, an heroic figure, pits himself (the pronoun is always male) against the many-headed monster ‘resistance’ and, by dint of subtle strategy and tremendous technique, eventually succeeds in becoming its master. Alternatively, it is like a game of chess, of move and counter-move, in which one side attempts to outwit the other and so force surrender.

(Carpenter and Treacher, 1989, p. 1)

Models of therapy that adopt these types of metaphor have naturally contributed to a tradition in family therapy which has ignored users’ experiences of therapy. Fortunately changes are continuing to occur within the family therapy movement so that theorizing of this type is clearly on the wane, but it is curious how little attention the newer models of family therapy (like the ‘second-order approaches’) have paid to users’ opinions about therapy.

The basic ideas that prompted us to write this book are quite simple – as family therapists we became increasingly aware that our own day-to-day practice still reflected many of the weaknesses of the original models (structural and strategic family therapy) which our original trainers had taught us. What we lacked was any basic understanding of how users experienced therapy.

We had first met because we were both members of the Bristol branch of the Association for Family Therapy and the Bristol-based Family Therapy Co-operative. By happenstance we also briefly worked together (1986–1987) because we were both part-time members of the Chippenham Child and Family Guidance Clinic. While working together we were able to share a lot of ideas about developing a new approach, but since we also worked in other clinics (Andy at the Department of Child and Family Psychiatry at the Royal United Hospital, Bath; Sigurd at the Trowbridge Child and Family Guidance Clinic), it was difficult to collaborate regularly.

In October 1986, Carolyn White joined Andy, in Bath, in order to undertake nine months’ work experience (as part of her degree in social studies). Carolyn was also very interested in users’ views and was keen to undertake a project in Wiltshire. It was this project that really made the writing of this book possible. Carolyn was able to gain the co-operation of both teams (at the Chippenham and Trowbridge Clinics), but the two teams were themselves then prompted to carry out further studies which meant that the research eventually became more action-orientated as the teams became interested in applying the lessons they learnt from the users who participated in the surveys.

The results of the Wiltshire project are reported in Chapters 6 and 7 of this book, but it is important now to introduce you, the reader, to the overall structure of the book, which reflects the slightly differing paths that we have taken to develop our notions of user-friendliness. Andy has tended to develop his ideas largely because of his unhappiness with systemic models of family therapy that have tended to recapitulate many of the more problematic factors of the medical model. Sigurd, on the other hand, as a social work team leader charged with contributing to the running of a service, had been more preoccupied with the necessity of developing a service that was more in tune with users’ needs. These different paths to developing ideas of user-friendliness have resulted in a division of labour as far as the book is concerned. Some chapters have been written conjointly but others could only have been written by us singly because our involvement with the issues concerned has been quite different.

The next section of this chapter is a reader’s guide, which we hope will help you make some decisions about how to read our book. Like many other books, it is not necessarily best read from cover to cover. You may find that after reading this chapter and the next, you want to branch out and perhaps read the research survey chapters before returning to the more theoretical chapters (Chapters 3, 4 and 5).

READER’S GUIDE

Chapter 2 of our book paints a kaleidoscopic picture of contemporary family therapy. We argue that the overall picture is far from rosy and that there are many facets of family therapy that require urgent attention if the reputation of the movement is not to suffer.

This theme is discussed in sharper detail in Chapter 3. Andy reviews Jeffrey Masson’s swingeing criticism of psychotherapy and concludes that he is essentially correct in including family therapy in his criticisms. We personally believe that family therapists (ourselves included) have persistently neglected to focus attention on the importance of ethical issues and have, in particular, been extremely complacent about the extent of abusive behaviour by therapists towards their users.

Chapters 4 and 5 are linked chapters which attempt to provide some explanations as to why users have been rendered invisible as far as family therapy theorists are concerned. In these chapters Andy uses a personal account of his own development as a therapist to explore how systems theory frameworks can seduce a well-intentioned therapist into neglecting the humanistic aspects of therapy. The pursuit of efficacy, the desire to be professionally powerful and the fascination of technically sophisticated interventions can combine to create a heady mixture which can intoxicate the therapist and seriously distort therapy as far as the user is concerned.

Chapter 6 by Sigurd and Carolyn is a pivotal chapter in the book since it reports the results of the initial survey we have already discussed. In this chapter we begin to move away from our own professional preoccupations to listen more carefully to what users think and feel about being in therapy.

In Chapter 7, Sigurd discusses how the results of the initial survey were translated into a form of action research which encouraged the therapy teams to begin to modify their practice on the basis of the feedback provided by users.

Chapters 8 and 9 (by Andy) review the remarkably small number of studies that have directly addressed users’ experiences of marital and family therapy. The studies reviewed are very variegated and are difficult to summarize but nevertheless there are a number of important themes that emerge. For example, the importance and significance of the role of the therapeutic alliance, a cornerstone of user-friendliness, clearly emerges from this review.

Chapter 10 (by Sigurd) takes a wider-angle approach to user-friendliness by examining how changes in social policy have influenced family life and structure. User-friendliness necessarily insists that therapists must be sensitive to the wider, societal pressures which impinge on families. The current moral panic about single-parent families is but one example of how societal attitudes towards particular minorities can be manipulated for political gains. Needless to say, the felt experience of such families (who are picked out for attack) is very complex, with families feeling distraught and victimized because of the basic de-humanization and unfairness of the attack to which they have been subjected.

Chapter 11 (by Sigurd and Andy) returns once again to the more narrow concerns of family therapy as a developing body of knowledge and practice. The chapter reviews the very different contributions that second-order thinking and feminism have made to modifying the original systemic formulations that formed the bedrock of many of the major models of family therapy. We conclude that both approaches have made contributions that can, with some modification, be absorbed by a user-friendly approach.

Chapter 12 (by Andy) is concerned with spelling out the major parameters of user-friendliness. Andy discusse...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of illustrations
• Foreword Lynn Hoffman
• Acknowledgements
• 1 Introducing user-friendly family therapy
• 2 Family therapy – a cause for concern?
• 3 Coming to terms with Jeffrey Masson
• 4 Steps towards a user-friendly approach
• 5 Further steps towards a user-friendly approach
• 6 Learning from users
• 7 Research and practice, practice and research
• 8 Reviewing consumer studies of therapy: social work and marriage guidance research
• 9 Reviewing consumer studies of therapy: family therapy research
• 10 Social policy, the family and family therapy: is there a meeting point?
• 11 User-friendliness and theories of family therapy – the contribution of second-order thinking and feminism
• 12 Guidelines for user-friendly practice
• 13 Bringing it back home: putting a user-friendly perspective into practice
• Appendices
• Bibliography
• Index