The family, the therapist, and the process in context Our search for the thing in the bushes over the past 40 years Peter Rober UPC KU Leuven, Belgium.

The family, the therapist, and the process

in contextOur search for the thing in the bushes

over the past 40 years

Peter Rober UPC KU Leuven, Belgium

AFT’s 40th Anniversary ConferenceDurham

Thursday 16th April 2015

History of Family Therapy

Family Therapy: a practice in search of a theory

First came the practice… Only then theory as a language (not as a model that allows predictions)…

How can we talk about what we do?

In the beginning borrowing concepts from the existing psychotherapy approaches (psychoanalysis, humanistic approaches, …)

Gradually a need grew to have our own concepts that capture something of the complexity with what we are confronted with in practice

Complexity of working with families

• Interactions between family members• Verbal vs non-verbal communication• What is said vs what is not-said• The history of the family• The context of the family• The future perspective (hope, fear, …)• …

Geel (Belgium)

• Clip documentary “Geel”

The thing in the bushes

Lynn Hoffman Foundations of Family Therapy (1981)

• Written when the second order cybernetics just started to come up.

• Start of family therapy: the advent of the one-way screen (analogous to the discovery of the telescope)… seeing differently…thinking differently…

Seeing differently…

Gregory Bateson Mind and Nature (1979)Binocular vision - Double descriptionWhat we see is a complex synthesis of information from the left eye and the right eye… the difference creates an extra dimension: depth sight

The importance of difference

Gregory Bateson Mind and Nature (1979)Interaction is triggered by difference or changes (=difference over time)

Material world - Pleroma … world of stones and billiard balls… Not interaction but impact/effect is importantdifference does not make a difference… (for example: to a stone it does not make a difference if it rains or shines)

Pleroma (the non-living world)

• Clip billiards

Pleroma: A B causality

• Simple• Predictable • Controllable (no surprises)

• Goal oriented (each step brings you closer to your goal)

• …This kind of causality is useful

in the world of stones and billiard balls,But what about the living world of animals, humans, class rooms,

football teams, traffic, cultures, …

Creatura (the living world)

It is not about impact or effect …

It is about interaction…

What do we call the complex thing in the bushes?

The living world according to Bateson(clip from the film “Ecology of Mind”)

The thing in the bushes

What language should be use?How can we talk about interaction? What language can help us see and notice?

Family therapy history

as a paradigmatic history

Paradigm…

Thomas Kuhn The Structure of Scientific Revolutions (1962)

Scientific progress… alternating phases of …

- Normal science - Accumulation of knowledge

- Scientific revolutions – A new language and a new way of seeing

Four main paradigms

1. The cybernetic paradigm

2. The narrative paradigm

3. The no-nonsense paradigm

4. The paradigm-to-come…

This is a crude simplification, of course

1. The Cybernetic Paradigm

Homeostasis through feedback

• Clip “Man on Wire”

The family as a self-regulating system.

Homeostasis and negative feedback (closed system)

Paradoxical interventions (Selvini et. al.)

Grow and positive feedback (open system)

Joining, enactment (Minuchin)

Crisis as possibility to grow (Whitaker, Andolfi, …)

Therapeutic relationship

Therapist was outside the system (neutrality)

- Observing (to find out what is the structure of the system, or how the different subsystems interact)

- Intervening (to find bring change in the system, if possible second order change)

Again, this is a crude simplification, of course

But what about responsibility?

If the family is a system, governed by circular interaction,• How can we talk about abuse, rape, violence,

without blaming the victim?• How can we talk about ethics and

responsibility?• …

2. The Narrative Paradigm

Central metaphors

Harlene Anderson & Harold Goolishian Human Systems as Linguistic Systems (Family Process, 1988)

Michael White & David Epston Narrative Means to Therapeutic Ends (1990)

– Story (Michael White)

– Conversation (Anderson & Goolishian)– …

New concepts

– Problem saturated story, externalizing, unique outcomes, … (Michael White)

– Not-yet-said, not-knowing, … (Anderson & Goolishian)…

Inspired by social constructionist and post-structuralist ideas, not truth, but ethics became central in decision making.

Therapeutic relationship

The therapeutic relationship as an ethical, egalitarian relationship…

- Co-authoring (Michael White)

- Collaboration – The client as expert (Anderson & Goolishian)

Stories were everything

• Clip “Searching for the wrong-eyed Jesus”

Integration

John Byng-Hall Rewriting Family Scripts (1995)

• Narrative perspective• Cybernetic perspective• Attachment research• Intergenerational family therapy• …

3. The No-nonses Paradigm

Evidence Based Practice

• Partly based on the scientist-practitioner model, that is promoted by academics complaining about the gap between research and therapeutic practice...

• Picked up by policy makers and administrators as a way to legitimize changes in the organization of the mental health system …

e.g. mandatory outcome management

Managed Care Systems

• Policy makers and administrators re-organized the mental health system

• First concern: money (cuts)

• Legitimation of the changes: evidence based practice, concept of “accountability”, …

The ethics of accountability

The ethics of accountability

Important ethical principle when it is used as part of an ethics of responsibility

But often abused within Foulcauldian power practices, involving… – registration and control by administrators– selective blaming– …

The difference between

accountability and responsibility

accountvs response

Each individual?

Control & registration

Trying to have control through registration… auditing… manualizing… monitoring…

As if the living world (Creatura) can be reduced to Pleroma: • translating complexity to simple cause-and-effect relationships …• translating quality into what is countable or measurable …• making the average into the norm …

Cfr. effect studies of therapy, …

Commodification of mental health care (Bloom & Farragher, 2011)

Evidence-based protocols are for sale…Sales men/women travel the world to convince policy maker to buy licenses to their product…

This affects the trustworthiness of the scientific enterprise of outcome research (allegiance effect) and of the development of systems of categorization of pathology.

Managed care was a good idea…

At least on paper it promised to be…

• Costumer friendly: demand oriented• Efficient• Transparant• Offering better quality• …

…but it did no live up to its promises(Bloom & Farragher, 2011; Tonkens, 2008; 2015)

• Too expensive… (bureaucracy, high manager salaries, expensive licenses for evidence based protocols, …)

• Quality deteriorates… (long waiting lists, pathologization, …)

• No transparency… (except the illusion of transparency for the policy makers)

• Profound demoralization of the workers (psychiatrists, therapists, administrators, …)

• …

Mental health system is “system under siege”

4. The Paradigm-to-come

4. The paradigm-to-come

The paradigm-to-come is an unknown

We don’t know what the future will bring,But we have the responsibility to contribute to building a better future… and there is hope…

Some promising elements that may announce this new paradigm…a. Responsive interactionb. Feedback oriented therapyc. Responsibility and trust as basic context for systems and

organizations

4. Paradigm-to-come

a. Responsive interaction

4. a. Responsive interactionAttachment as responsive interaction

Clip Ed Tronick

4. a. Responsive interactionStarling murmuration as responsive interaction

Clip Starling Murmuration

4. a. Responsive interactionAnimal-human relationship as responsive interaction

Clip Whale rescue

Responsive interaction refers to a special kind of causality

Not: A B;

But: a kind of spiral causality that is a process through time and creates something new.

• Complexity • Implicit, bodily knowing (instead of explicit knowing)• Orientation towards each other (instead of intentionality)• Always to some level unpredictable• Impossible to control • Trust as a pre-condition• Impossible to prove (often disbelieve from critical outsiders)• For insiders, meaningful (although you can’t be sure what the meaning is)

4. a. Responsive interactionResponsive interaction and spiral causality

4. a. Responsive interactionSpiral Causality

time

4. a. Responsive interaction Human relationship as responsive interaction

Clip Comfort Girls

4. a. Responsive interactionThe helping relationship as responsive interaction

Clip Short Term 12

4. a. Responsive interactionResponsive interaction as dialogical in practice

John Shotter – Conversational Realities (1993) and

Getting It – Withness-thinking and the Dialogical in Practice (2011)

About the joint nature of human activity.

About the living world (Creatura).

About responsiveness

4. Paradigm-to-come

b. Feedback oriented therapy

b. Feedback oriented therapyAccountability as norm in society

• “Prove that what you do works”

• Registration and control

• Evidence based practice

b. Feedback oriented therapyWhat works in therapy?

Assay & Lambert, 1999

b. Feedback oriented therapySpecific non-specific factors in MFT

(Sprenkle & Blow, 2004)

• Relational conceptualizing

• Working with the broader system

• Therapeutic alliance with all persons involved

The family in the first session…

b. Feedback oriented therapyEvidence based practice

• RCT research is important because ift show that psychotherapy in general works– but this kind of research has limitations (e.g. focus on the average patient in stead of on the unique patient, doesn’t teach us what exactly works, bad external validity, …)

• Feedback oriented therapy – the client’s feedback as a guide… is efficient, has beneficial effects, and connects better with the essence of psychotherapy as it focuses on the unique patient

b. Feedback oriented therapyThe creation of a feedback culture

Ongoing project at our university with Karine Van Tricht (B), Rolf Sundet (No), and others

• Not only a question of using scales or feedback instruments!

• How can we make space in the therapy for the feedback of the clients? Especially for the critical voice of the client?

• The biggest challenge: the child’s voice

a specific approach is needed in which a feedback culture is created with the family

b. Feedback oriented therapyInstruments

Specific instruments that fit the specificity of the family therapy setting…

• Worries Questionnaire – Adults• Dialogical Feedback Scale- Adults• Dialogical Feedback Tool- Children• …

b. Feedback oriented therapyDialogical Feedback Tool

The Peeters Family

10 8 4

IP Behavioral problems

Rage, anger

Son PeetersFirst session

Nothing has changed There will be less conflicts in our home

My brother got all the attention

It was fun drawing

Daughter PeetersFirst session

The time went by so fast

It was a funny session and we moved up one step but we are not upstairs yet.

Son PeetersThird session

Traditional model outcome management

Therapeutictreatment Evaluation

Outcome

Therapist + Client Administration (manager, director, …)

Therapist Client

process of attunement

Our model

ResponsiveInteraction

EvaluationOutcome

Therapist

ClientProcess

Administration (manager, director, …)

Therapy

b. Feedback oriented therapyWhat we learned this far…

• The specificity of the setting is the real challengeE.g. giving voice to children

• Positive effect of the use of feedback instruments on the therapeutic alliance

• We stopped using traditional outcome instruments (OQ-45, …)• The ongoing focus on outcome isn’t helpful; a focus on the alliance

is.• Measurements can create unwanted expectations and can invite

patients to become passive.• Some patients are concerned about measurements because they

limit their time to talk about their concerns

4. Paradigm-to-come

c. Responsibility and trust

- Accountability vs responsibility Accountability risk of blame and social control Responsibility assumes freedom and trust

- Response-ability fits a paradigm of therapy as responsive interaction (cfr. Shotter: Knowing how to go on)

- Both ethics are important, but for practicing therapists the ethics of responsibility towards our patients has priority, and (in cases of conflict) overrules the ethics of accountability.

c. The ethics of responsibility

Responsibility and trust

- We should not only focus on the importance of inclusivity, diversity and respect for the other…

- But also: - make room for an ethic of responsibility, we need to

engage in a new kind of political action within our field.- prioritize our responsibility towards our patients,

instead of our accountability towards administrators and policy makers

- find ways to explain to lay persons what our job really is…

c. The ethics of responsibility

Political responsibility

ThCause

Mental model of Therapy-as-problem solving view

Client

Cause

Problem

Normal developmentSolution

TherapyTherapist

as a problem solver

ThCause

Mental model of Therapy-as-treatment view

Client

Cause

Disorder

HealthCure

TherapyTherapist

as a medical doctor

Therapy-as-problem solving view

Problem SolutionIllness Cure

Patient is passive recipient of a service provided by the therapist.What is central is the effect of the treatment on the patient…

Cfr. Causality in pleroma - the world of the stones and the billiard balls (Bateson)

Mental model of Therapy as responsive interaction

Client

Therapist as

dialogical partner

Responsiveinteraction

Society as constitutive

through privileging and

suppressing

Society as constitutive

through privileging and

suppressing

Inner dialogueO

uter dialogue

reflection reflection

Therapy

reflection reflection

Therapy as responsive interaction

Worries/concerns Responsive interaction & reflections

Patient is active agent in the therapy, and the therapist is responsive and uses the patient’s feedback to orient in therapy.

What is central is the joint responsibility of the therapist and the patient…

Cfr. causality in Creature - the world of living beings (Bateson)

The paradigm-to-come as a responsibility

• The paradigm-to-come is a responsibility… the future does not just happen… we make it…

• Re-connecting with our rich past? • My hope is that– We will be proud of what we do – not giving in to

pressure to compromise what we do in favor of our accountability towards society

– We focus on the families we work with and try to be useful for their efforts to live the best life they can…