In Therapy Together

Family Therapy as a Dialogue

Peter Rober

• Publisher: Bloomsbury Academic
• Year: 2017
• Print ISBN:
  9781137607645
• Edition: 1
• eBook ISBN:
  9781350305755
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Families come in all shapes and sizes, and all have love at their roots; however, by the time a family requests help from a psychotherapist, resentment, fear and disappointment have often become the dominant forces ruling everyday life.

Moving away from the medically-focused 'problem-diagnosis-treatment' model of psychotherapy, Peter Rober's thought-provoking new text conceptualises family therapy as a dialogue between living, breathing people; it emphasises the mutuality and relational context that serves as the backdrop of a therapeutic encounter, whereby family members will interact, emotions will be displayed and suppressed, and practitioners will need to navigate carefully, endeavouring not just to listen but to understand the stories being told.

Astute and engaging throughout, each chapter provides close analysis of a rich variety of case studies, combined with an examination of key theories and concepts from different schools of thought in family therapy; with a particular focus on dialogical thinking, the book explores the ways in which these theoretical concepts can be applied in everyday practice situations.

Written by a leading expert in the field, this insightful new addition to Palgrave's Basic Texts in Counselling and Psychotherapy series provides an accessible exploration of a complex area of practice. It will prove invaluable reading for those studying family therapy specifically, as well as students taking more general counselling and psychotherapy courses and practitioners looking for a fresh source of guidance.

1

INTRODUCTION

This book is about what most experienced therapists know: that therapy is a living process between people. It is about the family and their request for therapy; and about the way we as therapists try to respond to their request in an attempt to be useful for them.

The perspective taken in this book is quite unusual in these times of medicalised psychotherapy practice, where the problem for which people consult is central; and where no distinction is made between the concepts of ‘request for help’ and ‘the problem’. A medicalised view of psychotherapy is based on the problem-diagnosis-treatment model, and the problem is supposed to be something that exists out there in the world, like a tumour or an infection, weighing on the life of the person most affected by the problem, and also on the other family members. The information about the problem is gathered by the therapist in order for him/her to diagnose. This means that the problem is classified and named, based on its observable characteristics. This diagnosis then is not only supposed to be the causal factor explaining certain kinds of behaviour, but it is also the starting point of a treatment plan and ultimately of the treatment itself.

THE MEDICAL MODEL AND PSYCHOTHERAPY

The medical model is very successful. Curation and prevention of illnesses have never been as effective as in these times. The question can be posed, however, is the medical model the best model for the conceptualisation of psychotherapy?

According to Wampold (2001; Wampold & Imel, 2015) the medical model is composed of five components:

1.Illness: The start of a medical intervention is the diagnosis of an illness.

2.Biological explanation: There is a biological cause for the illness.

3.Mechanism of change: The treatment is established at the level of the biological system causing the illness.

4.Therapeutic procedure: Diagnosis and explanation lead to the design of the treatment involving the administration of a substance (e.g. medication) or the implementation of a procedure (e.g. surgery).

5.Specificity: The treatment can be shown to be more effective than a placebo, and it can be shown to operate through its intended mechanism.

 

Nowadays, psychotherapy is presented as a treatment for mental illness, and in that way psychotherapists are forced to practise within the limits of the medical model, which only partly fits their actual practices. Yes, it is possible to translate the client’s suffering into symptoms that refer to an underlying illness, and it is possible to make diagnoses that can orient treatment. But psychotherapy essentially is a response to mental suffering (e.g. anxiety, grief, depression …) that doesn’t always have a biological cause. Furthermore, psychotherapy involves a variety of interventions that can’t all be compared to medication or surgery, and, while psychotherapy is more effective than placebo (e.g. Lambert, 2013), there is a lot of controversy about its mechanisms of change (e.g. Norcross, Beutler & Levant, 2006).

‘Medicine, of course, is the predominant force and psychotherapy is subordinate’ (Wampold & Imel, 2015, p. 9), and, whenever psychotherapy does not seem to fit, it has to adapt to the dominant model and cannot expect the medical model to accommodate.

This book is different, as it rests on assumptions about the nature of human relationships that are in tension with the traditional view of the problem-diagnosis-treatment model.

One of my central assumptions is that all families have been sparked by love. In the beginning of each family there were two persons who loved each other and who decided to form a family. Of course, this assumption is tainted by our Western ideal of what a family should be. We have to be careful not to present our own views on families as the universal norm. Families come in many shades and colours in different cultures. On the other hand, in all cultures, as in most higher species in the animal world, the family – at least the mother and child, with or without the father, with or without the support of the broader family – is the place in which children grow up with the support of the parents, and in which love (in whatever form) is supposed to help the different family members through life, despite the pressures, obstacles and challenges they may be facing. Furthermore, we also know that, while love may be at the roots of a family, often, when families consult us, resentment, fear and disappointment rule the family instead. Still, using this assumption as a lens to look at families helps us to connect with family members through our best intentions. Furthermore, it helps us to support the resources in the family, their sense of belonging together, and their hope for a better future.

THE FAMILY

Some time ago I was asked by organisers of an international conference to make one PowerPoint slide in which I would summarise what I thought to be the most important thing in my work as a family therapist. At first, I felt a lot of hesitation because the assignment seemed impossible to accomplish.

Then I came up with this slide (see Figure 1.1):

Figure 1.1  An elephant family

For me, this slide summarises an important assumption in my work as a family therapist: the assumption that love is at the basis of a family. For me, to love someone is to feel that you belong to another like this other belongs to you. It is – and now I paraphrase Shotter (2016) – to notice and be responsive to the possibilities for further development inherent in his/her being – to be the voice inviting him/ her to develop into what he/she can become; as he/she is that voice for you.

Furthermore, rather than starting from the assumption that there is an objectively existing problem out there that affects the family, we start from the request of the family: a family member phones us and asks for an appointment. As will become clear in this book, the choice of the starting point has a lot of consequences. For one thing, the existence of an objectively existing problem in a lot of families is a matter of discussion. Usually when families come consulting they don’t agree on what is the problem, or even on the question if there is a problem at all.

This book is also different in another respect.

Most books and publications in the field of family therapy (in fact, in the field of psychotherapy) assume that the therapist’s actions originate in knowledge and that this knowledge guides his/her actions. Our assumption, to the contrary, is that the therapist’s actions are relational responses that are intuitive and bodily in the first place. First there is the other, and immediately our body has a response. And then, as if they were epiphenomena, there are our thinking, our reflections, our hypotheses … These cognitive activities are in constant dialogical tension with our bodily responses; reinforcing them, correcting them, inhibiting them … The interaction between the bodily immediate responsiveness and the cognitive postponed reflections can be seen as a dual process:

•Process 1: Without much explicit reflection, as it were from a default position (Reimers, 2006), the therapist acts in the flow of the dialogue, immersed in a shared we with the family, intuitively searching for some kind of attunement.

•Process 2: The therapist is goal oriented and observes what happens, processes information, evaluates the evolution, and so on.

 

Cognitive dual process theories can capture the complexity of this process: the theory of Daniel Kahneman (2011), for instance, or the theory of Donald Schön (1983). Process 1 is captured by Schön’s concept of ‘knowing in action’, and process 2 by the concept of ‘reflection in action’. It is optimal if the therapist can flexibly move from intuitive responsiveness to cognitive reflection and back again, and if, attuned to the family’s rhythm, a balance is found between the intuitive actions of the therapist immersed in the flow of conversation, and his/her perceptions of what is happening in the session enriched with his/her self-awareness of his/her inner dialogue.

THE WORLD WE ARE LIVING IN …

We think that our world is made up of discrete entities (‘things’) that impact on each other. One thing moves and touches a second thing, and upon impact this second thing starts to move. That’s causation, and such causation is easy to observe, for instance on the billiards green. This is what Bateson – inspired by Jung – calls pleroma. It is the physical world ‘where forces and impacts provide sufficient basis of explanation’ (Bateson, 1979, p. 16). This world is also a world that we can observe without being affected by it, or without affecting it. We can observe, describe, measure and count whatever happens in this world.

There is another world: the world of living things, which Bateson calls creatura. In this world, things can’t be explained in terms of forces and impacts. Even the concept of causation is problematic in this world of living things; as living processes are complex and even an absence can have effects. For instance, a letter that I did not write to someone can evoke an angry reply (Bateson, 1972).

In this world of living things, the concepts that make sense in pleroma do not fit. Specific concepts are needed if we want to reflect on and talk about what happens there. It is not a world of things that can be objectively described – as observers we influence what happens, as we are influenced by it; rather, it is a world of meaning and relationship. It’s not a world of stable states; rather, a world of living processes; a world of relational becomings (Shotter, 2016). Observation, description, measurement and counting are problematic in this world, for diverse reasons (for instance, because we are continuously in interaction with the living world, whenever we want to observe it).

Psychotherapists navigate in creatura. They should be careful not to use words like cause, impact, effect, and so on when they talk about the life of their clients (Bateson & Bateson, 1988). They are working with living creatures (persons) and, in working with them, they are part of the system they are working with.

The assumption of the primacy of the relationship with others, instead of the individual minds, has deep ethical-philosophical roots in the work of thinkers like Martin Buber, Emmanuel Levinas, Jacques Derrida and Mikhail Bakhtin. Otherness is central, as I become myself through the other.

In this book, family therapy will be conceptualised as a dialogue between living persons. Such a conceptualisation offers a perspective that makes it possible to capture something of the mutuality and shared activity of a therapeutic encounter in practice. It could be argued, of course, that the expression a dialogue of living persons is a tautology, since all persons in dialogue are living; how else could they interact or communicate? Emphasising these persons’ vitality, however, directs our attention, not to the content of these persons’ stories, but to the fact that these persons are all breathing, their hearts are beating, and they have worries, dreams, disappointments, memories and fears. These persons are alive, and they are also relational beings as they are involved with their surroundings, continuously tuned in to each other and interacting with each other. A description of family therapy as a dialogue of living persons makes it possible to highlight that the relational context these living persons create together is essential for the therapeutic process. This mutually created relational context serves as the background against which family members will share some of their stories and leave other stories untold. The central thesis of this book, then, is that this concept of dialogue as a meeting of living persons can help us address the mutuality of human relationships, as well as the complexity of listening and understanding.

PART I

2

THE ENCOUNTER

When family therapists write about the first family therapy session, they often highlight the importance of motivating family members to accept therapy (e.g. Sexton & Alexander, 2005), of gathering information in order to assess the family’s functioning (e.g. Keitner, Heru & Glick, 2010), of forming a hypothesis (e.g. Nichols, 2011) or of building a therapeutic alliance (e.g. Nichols, 2011). While these may all be important goals of the first family therapy session, in this chapter I will describe the first session as an encounter with the family. I will furthermore point to some challenging issues for therapists meeting with families for the first time. I will describe, in the form of a step-by-step protocol, the way I usually deal with these challenges when I do a first family therapy session. The backbone of the chapter will be a detailed study of the first session with the Cox family.

The first family therapy session: a protocol

I developed this method over the past years of working with families in the context of an outpatient marital and family ...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Contents
• List of figures and appendices
• Acknowledgements
• 1 Introduction
• Part I
• Part II
• Part III
• Some concluding remarks
• Appendices
• Endnotes
• References
• Index