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The Dialogical Therapist

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Several good books exist about systemic understanding in therapy and a few about dialogic understanding. However, none try to bridge the gap between these two world views, which have some similarities, but also a whole array of differences. This book is an attempt to find a bridge.According to systemic theory, we exist only in and because of the network of relationships we are embedded in. In dialogic theory, we inhabit different worlds, and we need dialogue (we need engaging in that hard struggle that is proper dialogue) in order to make them communicate with each other. Putting these different views together poses problems but provides a good dialogic exercise too. The author found it increasingly necessary as he felt more and more uncomfortable with the more conventional versions of Batesonian systemic wisdom he had adopted in previous years. At the same time he did not feel convinced by some of the new ideas about dialogue, where one was compelled to get rid of everything one thought valuable in systemic understanding.

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10 Chapters

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1. Understanding and influencing

ePub

Aclient arrives in my office. A family, maybe, or an individual, or a couple: this is not so important. Let us assume, for the sake of clarity, that it is a couple, a heterosexual couple, with both partners in their mid-thirties. A dialogue—neces-sarily—takes place: I listen, I ask questions, I get answers, I make statements; I am asked questions, too. This is the stuff therapy is made of, and it never seems to change: it could have been the same twenty years ago, except for the clothes, perhaps, or some mannerisms in speech. But therapy does, in fact, change; and it has changed a great deal in recent years. Sometimes we are very aware of the fact, extremely conscious of such changes; at other times the changes are not so conspicuous for us to notice. For me, the last few years have been among the most challenging, in terms of the mutation in my (our) everyday practice.

I will leave my couple to rest for some time. I will not introduce their problems, nor my own problems in dealing with them. Before going into the centre of action, we need to set the stage: it is necessary to enter a historical perspective.

 

2. Text and context

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The first possible dialogue, for the contemporary therapist, concerns the relationship between the modern and the postmodern: because “postmodern”, if we take a closer look at it, is a positional word. The postmodern exists only in relationship to the modern (as the modern exists in relationship to “ancient” or “classic” tradition): the relationship between the modern and the postmodern is necessarily dialogic (Mecacci, 1999). In therapy, this means that a postmodern therapist (a therapist living in a postmodern world) should probably centre her attention on the (dialogic) relationship between two of the seminal metaphors in two different phases of its evolution: the context and the text.

Prescriptions for the postmodern therapist

First of all, I want to make one point clear: We—all of us—cannot but be postmodern. Our thinking is, by force of circumstances, “weaker” than that of our predecessors, in the sense that we cannot have any more certainty of an all-encompassing model to explain the world—not even this small chunk of the world that is therapy. Minuchin's “voices” (1987), Cecchin, Lane, and Ray's irreverence (1992), Boscolo and Bertrando's epigenetic model (1996), are all examples of the stable settlement of postmodern ideas in therapy.1The therapist's hypothetical knowledge that I outlined in chapter 1 is another example of the same kind. I cannot have any grasp of an objective truth: all I can do is make hypotheses about what I will never be able to know outside my own—necessarily—limited position.

 

3. Practices and theories

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From the preceding pages we can get some flavour of the evolution, over the last five decades, of systemic therapy— inscribed, at least in part, within the mainframe of family therapy, which is, in turn, inscribed within the wider context of psychotherapy. And, especially from chapter 2, we can start developing an understanding of the basic theoretical assumptions of systemic therapy. For me, at least, in my way of working, the therapy's basic theoretical assumptions stem directly from the dialectic—the dialogue—between modern and postmodern thinking. If I had to summarize them, the list would be something like this.

The first assumption concerns relationships. Of course, most family therapy models, other than the systemic one, accord great relevance to interpersonal relationships,1 and in the last decades the same interest has emerged also within other therapeutic fields, such as psychoanalysis and cognitive therapy.2 Still, there is a seminal difference between these approaches and systemic therapy: in the latter, relationships are constitutive, in the sense that they come—from a logical standpoint—before individuals. As I observed elsewhere (see Bertrando, 1997), within the systemic metaphor as established by Bateson, “relationships are more important than individuals”. The individual, in other words, does not come first, in isolation, and then interact with other individuals, creating relationships: relationships come first, and then, from them, we can isolate individuals.

 

4. Hypotheses and dialogues

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Let us start from the beginning. Adopting a hypothetical position may be considered the first—perhaps the key— principle for the systemic therapist as we conceive her.1 This, though, leaves most issues open. For example, what does it mean to adopt a hypothetical position? Actually, it may simply mean seeing (therapeutic) reality as hypothetical, or it may mean working by creating particular (systemic) hypotheses within the therapeutic dialogue, too. In therapy, we act according to the second meaning, but this leads to another question: what does it actually mean, to create a hypothesis? Is it the therapist, the person, who creates the hypothesis? Or, if it is not, where does it come from? And, after all, what, precisely, is a systemic hypothesis?

The issues, we can see, are complex and manifold, their complexity presumably being due to the shifting from a hypothetical position regarding clinical knowledge (I cannot have access to actual realities, I just can make hypotheses about them) to a clinical activity where hypotheses are supposed to guide my practice (what specific hypotheses are possible for me in this unique situation?) Probably, however, we can centre most issues around a couple of pivotal points: First, what happens in the process of hypothesizing? Second, what is the role of the persons—therapists and clients—involved within that process? The points are intertwined, of course, but the attempt at separating them favours clarity. To be even clearer, we will start seeing the whole process from just one vantage point: that of the therapist. And we will consider a clinical situation.

 

5. Therapists and clients

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How can we see our clients—both in the proper, perceptual meaning of the word, and in its figurative one? Another apparently innocuous question, which can, however, have interesting answers. For we can only see things and persons from our own point of view. Our view is always situated. This is also, probably, what Maturana means when he states that “everything that is said, is said by an observer” (Maturana &Varela, 1980): anything I can say, I say from my own point of view.

Of course, science had to transcend the individual point of view in order to grow and to establish another kind of point of view—that of the disembodied, all-knowing Maxwell's demon—a point of view that can encompass virtually everything and that, as such, is neither situated nor even human.1 But in my ordinary life I can still say that the scientific view is but one point of view—one that is more relevant that many others, but one point of view all the same.

The theory of the observer, made popular by constructivist theorists (see Maturana &Varela, 1980; von Foerster, 1982), tends to emphasize too strongly the uniqueness of my point of view and to overlook another side of this situatedness, one that is considered by Bakhtin (1923). According to him, my point of view is necessarily limited. In order to transcend, to trespass such a limitedness, I need another perspective: the perspective of another—of the Other. This is one of the reasons why psychotherapy is relevant for peo-ple—at least for some of them—and supervision for the therapist: because in therapy I am constantly faced with another perspective, another position, and at the same time this other person is striving to give me—or us—some sense, in my exclusive interest.

 

6. Frames and relationships

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The third of my principles is the most slippery one. It is not easy to define what it means to pay attention to the therapeutic relationship in the course of therapy. And, if we take a closer look, it is not easy to define the therapeutic relationship itself. This is why I will start precisely from such a—crucial—point.

What is a therapeutic relationship?

How can I describe psychotherapy in formal terms? The issue is complex. Any manual for would-be therapist deals with it, with more or less convincing results—which tend, of course, to differ from each other. I will try to add my own definition: it is, of course, provisional, and I will have to rework it several times, but I have to draw it all the same. First of all, psychotherapy can be defined as a series of interactions framed by the message “This is psychotherapy”. In other words, when two—or more—persons agree that what they are doing is psychotherapy, that is psychotherapy. The message “This is therapy” is constitutive of therapy: psychothera-124 peutic placebos are notoriously difficult to create, and those that have been tried tend to come too close to proper psychotherapy (see Snyder, Michael, &Cheavens, 1999). In a first approximation, the statement “This is therapy” generates therapy, just as the stool used as a pedestal in Marcel Duchamp's “ready-made” objects could transform a bicycle wheel into a work of art.

 

7. Dialogues and systems

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Therapy—necessarily—entails dialogue. Outside dialogue, therapy simply cannot exist. What we can discuss, however, is the specific kind of dialogue our therapies are made of. From this—rather different—standpoint, peculiarities start to emerge. I think such peculiarities and differences are linked to the role played by the therapist within the therapeutic dialogue, and to the counter-role(s) consequently played by client(s). In order to flesh out my reflections, I will start from a clinical vignette.

The unsympathetic therapists

The situation is a clinical suspension, in the form of a role-play with a supervision team, which takes place during a course in Brisbane. In this instance I happen to be the coordinator of the team. We are presented with a couple in their late fifties. “Joan” is a woman of principles, brought up in a religious, deeply Christian family. Her mother had suffered from some indefinite ailment all her life, and in her virtual absence Joan, the first-born, had “to raise five children, it was my duty!” Her father, a Christian minister in a small rural environment, apparently minded his flock much more than his daughter. “Richard”, on the other hand, comes from a more affluent family, apparently centred on self-realization. The last of three sons, to his parents—according to Joan—he has always been “the golden boy”. Quiet, self-contained, and very private, he has steadily opposed what he feels is a ceaseless attempt on Joan's part to get attention from him. Joan's life seems dominated by the theme of illness: she complains of several health problems—in fact, she has undergone an operation for breast cancer 12 years ago—and feels that her husband is cold and distant. Richard, in turn, has recently discovered that he suffers from Parkinson's disease, and his disease is rapidly progressing. At the same time, he resent any offers of help on Joan's part.

 

8. Statements and questions

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There are techniques, too, in therapeutic dialogue. Sometimes, just sticking to principles is enough, sometimes it is not. The problem with technique is that it is difficult for me to give guidelines. Every time I give a specific guideline—such as, “A therapist should not give advice”—immediately a counterexample comes to my mind, where I did give advice, it was well received, and it contributed to the success, if not of a therapy, at least of a session. And the same could be said of any other specific guideline: in therapy, rules are made to be broken, at least in some instances.

And there is more. My own way of working changes from client to client. With some clients or families I happen to discuss my hypotheses a great deal, to process dialogical hypotheses, as described in chapter 4. With others, on the other hand, I can wait for longer, then give back some well-formed hypothesis towards the end of the encounter. With some clients I ask many questions—sometimes circular questions—with others I listen, perhaps saying something towards the end of the encounter. This is partly a personal characteristic: there are therapists who love to tell stories and old clinical cases (Milton Erickson was a paramount example), which is perfect for them but is not part of my style. Partly, though, it is the dialogical relationship that dictates my style in any particular instance, which happens, I think, with most—expert—therapists. Any therapy is unique: the encounter of that singular therapist with that singular person in that singular moment.

 

9. Presence and absence

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Iwill deal, now, specifically with systemic individual therapy. Once again, starting from a very basic question: how can I distinguish my own therapies from therapies arising from a different orientation? I think I have made it clear that, for me, the simple fact of professing a certain theoretical creed does not guarantee ipso facto the quality of my undertaking. In order to answer this question—or, better, to try to do so—I will try to compare my own therapeutic model with another one, with regard to a single theme: the handling of interpersonal relationships. I have chosen to compare the use of the “third party” in individual systemic therapy to the psychoanalytic practice of transference analysis.

The third party in individual systemic therapy: presence in absence

When working with individuals, the systemic therapist seeks to create connections between both the inner and the outer world of a person, while keeping at the same time an interest in the patterns that provide, in the life of a human being, a link between actions, relations, emotions, and meanings. As a systemic individual therapist, not unlike any other colleague, I consider the time and place of the therapeutic encounter, as well as the relationship between client and therapist, to be the main relation to be taken into account, the true “venue” for therapeutic events. I am therefore aware—as I hope to have made clear in chapter 6—of the therapeutic relationship: for example, of the essential fact that, when discussing and relating their stories, the clients are telling them to their therapist and are sensible of the approbation of the latter, however conveyed it may be—that is, through the subtlest of nonverbal signals.

 

10. Selves and technologies

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The last of the—apparently—childlike questions in this book is, once again, deceptively simple, besides being a consequence of what I said in closing chapter 9: what happens when—if—a therapy is successful? To some extent, finding an answer to such a question is even more difficult than to the others. It is not surprising, then, that, in order to look for an answer, I have to start from a situation that was far from successful.

Gustavo, or the two pathways

“Gustavo”, a young man of 25, arrives in my office requesting individual therapy. He feels, he says, insecure, undecided, with a problematic relationship with women. He has never had a complete sexual intercourse in his whole life, only brief and insignificant affairs with young women who regularly made him feel “not understood” or “rejected”. He also says he is asking for therapy because of his difficulties with his father. The issue is made more complex by the fact that for years he has been contemplated entering a seminary and becoming a Catholic priest, although he has not yet come to a decision. As a—possible—future seminarian, though, he entertains a close relationship both with his confessor and his spiritual father.1 He has been advised to try systemic individual therapy by his sister, who is a psychologist. We agree on a time-limited therapy, with a maximum of 20 sessions.2

 

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