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The Space Between

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The papers in this book focus on many different aspects of the therapeutic relationship, including the self of the therapist, working cross-culturally and with language difference, impasse, risk taking, the place of research, and the influence of theory. Clinical examples illustrate successful as well as less succssful outcomes in therapy, and these clinical explorations make the book accessible to both systemic and non-systemic practitioners alike.Part of the Systemic Thinking and Practice Series.Contributors:Rhonda Brown; John Burnham; John Byng-Hall; Alan Carr; Carmel Flaskas; Jo Howard; Alfred Hurst; Ellie Kavner; Sebastian Kraemer; Inga-Britt Krause; Rabia Malik; Maeve Malley; Michael Maltby; Barry Mason; Sue McNab; Amaryll Perlesz; David Pocock; Hitesh Raval; Justin Schlicht; and Lennox K. Thomas.

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1. Relational reflexivity: a tool for socially constructing therapeutic relationships

ePub

John Burnham

Introduction

When clients come for therapy, the relationship that develops between therapist and clients is seen as a significant factor in whether there is a therapeutic outcome (Hubble, Duncan, & Miller, 1999). Naming one person in the relationship as “therapist” doesn’t automatically make it a “therapeutic relationship”. It takes hard work as well as imagination to coordinate the resources of client and therapist to create and maintain a relationship that is experienced as therapeutic for the client. One of the questions I regularly ask myself (in the spirit of self-reflexivity) is “How can I practise so as to increase the chances of this relationship becoming therapeutic for the people I work with?” This chapter is an account of some of the ways in which I have enjoined the people I work with in working with me (in the spirit of relational-reflexivity) towards answering that question. I will begin with a practice example, relating to theory, and offer definitions as I go, since this more accurately reflects how the praxis of relational reflexivity developed in my work. The initial development was mainly in my work as a therapist but I have since easily transferred these questions and practices to my work as a supervisor and trainer.

 

2. From system to psyche

ePub

Justin Schlicht and Sebastian Kraemer

I I 1 heory underpins therapeutic practice, but, like the underpinning of a building, it comes to be taken for granted. We could T not be free to eat, sleep, fight, argue, or love if we constantly feared falling into the cellar. There are times, though, when we need to tread carefully. As family therapists and psychiatrists we want to limit the constraints of theory, but that liberty comes only from the security provided by the ideas underpinning our work: systems theory, psychoanalysis, structural descriptions of families, inter-generational influences, and medical models of mental and physical illness. These are ideas that inform, but do not dominate, practice. Our goal is an informed spontaneity in which respect for our own experience is as important as respect for the patient’s. Therapists know what they know, and patients, too, know what they know. When both are free to acknowledge this they may learn something new, the difference that makes a difference (Bateson, 1969).

 

3. “Alice and Alice not through the looking glass”: therapeutic transparency and the therapeutic and supervisory relationship

ePub

Maeve Malley and Alfred Hurst

Introduction

This chapter addresses the issues raised by working in a particular context, a London-based voluntary sector counselling and therapy agency for lesbians and gay men, and in a particular way—”in-the-room” supervision with all discussion in front of the clients. The experience of working in this way, in this context, made us aware of the effect that it had on us as therapist and supervisor and of how it seemed to be received by the clients seen during the two-year period that we worked together in this way. Some of the issues that it raised, though initially context-specific, were in fact general issues about power, knowledge and disclosure within therapy and about the nature of the therapeutic and the supervisory relationship. We discuss these issues from the angle of vision of the therapist, the supervisor, and what we surmise and were told about the experience of clients.

In-the-room supervision

While “in-the-room” supervision is not a new phenomenon within systemic practice (Gorell Barnes & Campbell, 1982), it is not a common way of working and is distinct from behind the screen supervision and reflecting team practice. This experience was distinct from the latter in that reflecting teams generally focus on the experience of the family, rather than the experience of the therapist, or the therapist with the family, and do not conduct their entire team discussion in front of clients, or confine supervisory input to this context. When we first embarked on this particular way of working we were not sure how it would be for the therapist or the supervisor, or indeed the clients, to confine our discussions about the work to this context. So, initially, it may have been a kind of experiment to see if we could talk about the things that seemed important to talk about, such as the therapist’s approach, or the ways that the clients engaged with therapy and with the therapist, and the supervisory relationship—all in front of the clients.

 

4. Working with men who use violence and control

ePub

Jo Howard

Introduction

The Southern Collective Against Violence and Abuse (SCAVA)1 is an autonomous reference group that guides the development and delivery of two community health programmes for men who use violence and control in their intimate partnerships with women. Our decision to work as narrative and systemic family therapists with men in the Men’s Responsibility Group (MRG) originated in wanting to develop a useful and meaningful response to women who had experienced family violence and who wanted to retain their relationships while hoping for the violence to end. Most of the men are mandated to attend the groups—either through the criminal justice or child protective systems or through their partners threatening to end the relationship unless the men address their abuse and violence.

This chapter describes ways our SCAVA collective, over the last decade, has attempted to develop and sustain effective therapeutic relationships with the men while privileging the accounts of the women and children. We use the voices of the facilitators and the stories of two men in the programme to explore the significance of relationship, gender, and feelings in building connections between violent men and their partners, and between group facilitators and the men in their endeavours to establish non-violent, respectful practices.

 

5. Not getting lost in translation: establishing a working alliance with co-workers and interpreters

ePub

Hitesh Raval and Michael Maltby

Introduction

A

n interpreter is booked with one day’s notice by a practitioner in order to carry out a mental health assessment with a client from an ethnic minority referred by her GP. The interpreter arrives prior to the client’s first appointment and the practitioner meets them both for the first time in the waiting room where they are talking animatedly. As the interview progresses it becomes evident that the client is becoming increasingly uneasy. The interpreter does not seem to be asking the practitioner’s questions verbatim and at times appears to be having additional exchanges with the client. The interpreter and the client both become more agitated and the practitioner is confused and uncertain about what is happening. There is no time at the end of the session for the practitioner to explore his concerns as both he and the interpreter have other appointments to keep.1

How do we begin to understand something of the process of what has happened? Would it have been possible to do this piece of work differently? What steps could have been taken to make this first contact more productive and to develop a more effective working relationship between all the parties involved?

 

6. Intercultural: where the systemic meets the psychoanalytic in the therapeutic relationship

ePub

Lennox K. Thomas

The therapeutic relationship is a creation of the therapist and the client or patient. It is the constant factor in all therapies. T Just as the wheels of a railway carriage must fit the rails in order to pass along them, so the way in which the therapeutic relationship is constructed can facilitate the progress of the therapy. The therapeutic relationship can also be a place where race, class, and other prejudices can be subtly played out or, alternatively, where the meeting of difference can be fruitful and enlightening.

Different schools of therapy have a variety of ways of seeing and using the relationship, sometimes considering the personality of the therapist as determining the nature of the relationship. Some therapists combine more than one, or even two, schools of therapeutic thought. Social workers in the 1950s and 1960s, whose contact with clients extended beyond the strictly therapeutic, found a way to use psychoanalytic theory to understand emotional states and repeated patterns in their clients’ behaviour while being clear about how they managed the real relationship (Ferard & Hunnybun, 1962; Irvine, 1956a,b). The work of Bowlby and Winnicott provided an opportunity for therapists and social workers to pay attention to the effect of the environment on the individual and the relational experiences during development. Recent writers in integrative psychotherapy (Clarkson, 1995) have taken a more contemporary and realistic view of the therapeutic relationship in which the traditional transferential relationship is only a part.

 

7. Before and beyond words: embodiment and intercultural therapeutic relationships in family therapy

ePub

Rabia Malik and Inga-Britt Krause

Social constructionism has provided a valuable framework for ^^^ a social perspective on science. Its followers have questioned, and even been irreverent of, scientific theory and results. Nevertheless, approaches that are commonly referred to as social constructionist constitute a broad genre (Williams, 2002) rather than a clearly unified body of theory and they may also implicate different theoretical, ethical, and political points of view and possibilities. To some extent this depends on the question of what it is that we consider to be socially constructed. Are we talking about language, texts, meaning, culture, the self, the person, relationships, knowledge, or emotions? And by “social construction” do we mean that any of these entities need not be the way they are, that they are not inevitable in their particular form, or that they are not determined by the nature of things (Hacking, 1999, p. 6)? Alternatively, do we mean that the forms that these entities take are the results of particular shared conventions for making sense and understanding the world? In the one case, we seem to be raising the issue of whether or not “anything goes”. In the other, we seem to suggest that, once up and running, conventions themselves exercise restraint, so that all making-sense must move in a hermeneutic circle (Taylor, 1981) because there is no means of understanding anyone with whom you do not share the same conventions.

 

8. Sticky situations, therapy mess: on impasse and the therapist s position

ePub

Carmel Flaskas

Foreword

Let me begin this discussion of impasse with two descriptions of practice already published within the family therapy literature.

Peter Rober (1999)1 writes about a first session with a family with a rebellious teenage son, a mother, and father. The mother begins to cry before she even opens her mouth, and the father is bristly and abrupt in his first interactions with the therapist. The therapist continues to try to engage the father, becoming more irritated with him as the session goes on, as the father becomes more rigid and blaming of the son, and more adversarial towars the therapist. Later, when talking with one of his colleagues, Peter explodes in an angry outburst against the father, and when he hears himself doing this, he is struck by the proportions of his rage towards the father.

I have written before about my work with a couple, whom I had already seen with their children as part of a piece of work focusing on one of the mother’s daughters (Flaskas, 2002).2 It is a blended family, and following the successful conclusion of the family therapy, we embark on couple work focusing on some of the parental differences that had been raised in the family sessions. In the privacy of the couple work, the therapeutic net widens, and the wife’s unhappiness and disappointment with her husband, and his anger about this, very quickly come to be placed on the table.

 

9. Systems of the heart: evoking the feeling self in family therapy

ePub

David Pocock

“TW “T” ear the end of the first year of a psychoanalytic individual I ^k I therapy, a male patient, ill for most of his adult life with N depression, anxiety, and bodily pains, explains that he really doesn’t mind the forthcoming holiday break. Instead, it is in his words “a perfect arrangement”, since he can spend more time with his children. A few moments later he draws his knees up to his chest to cope with intense pains in his abdomen. He feels that the most comfortable position for easing the pain would be to curl up on the couch on his left side, which would mean turning his back to me. This feels impossible to carry out since he fears I would feel so rejected that I would never forgive him and our relationship would be permanently damaged. A year later, he is still unaware of any difficult feelings when this break comes round but is less physically affected. Instead, I find myself feeling tetchy and needled. Exactly two years further on, the patient—by then mostly free for several months from physical pain—is so enraged at the prospect of me leaving him that merely the sound of my breathing triggers his intense irritation.

 

10. Shame and the therapeutic relationship

ePub

Ellie Kavner and Sue McNab

S tories about emotion were not privileged in the development ^^^ of systemic therapy with the interest being focused instead on communication patterns, life cycle issues, transgenerational patterns and belief systems. The move from the metaphor of systems to language has re-activated attention to emotions and the ways they are expressed within relationships. For ourselves, we have reflected upon our interest in working with communication at an emotional level. We have connected to the idea of Greenberg and Paivio (1997) that meaning is emotion based and that emotions both move and inform us. The expression of emotions may provide a signal to the therapist about what may be significant to the client and a “directional compass” (Greenberg & Johnson, 1994) about where and how to intervene.

Helmeke and Sprenkle (2000) have researched those moments in therapy that both clients and therapists feel were particularly significant and change related. They concluded that focusing and refocusing on subject material that is emotionally important to a client seems to be a key factor related to the occurrence of such pivotal moments. In a similar way, Maher (1988) produced a “good moment” list of therapeutic moments, of which six out of the twelve categories were emotion based, including expressing a high level of emotion towards the therapist.

 

11. Relational risk-taking and the therapeutic relationship

ePub

Barry Mason

Introduction

This chapter comprises three interlinked, mutually influencing elements.

1. I am writing from a view that there are problems in the field about risk-taking and the therapeutic relationship that come out of some of the more recent developments around the construction of collaborative practices. In particular, I wish to raise some of the associated issues related to the systemic therapist’s ownership of expertise and some of the disingenuous-ness that I think is still around in relation to this matter.

2. In particular, I wish to explore some of the thinking around the not-knowing position (Anderson & Goolishian, 1992b) and the preferred meanings that have been attached to this concept. While there has been an encouraging trend more recently (Anderson, 1997) to clarify the original thinking around the not-knowing position, I still believe that the concept can be misunderstood, not least in the very nature of the terminology itself. In this respect I suggest in this chapter another, additional way of looking at the nature of the therapeutic relationship (and this complements the work of Silver, 1991; Larner, 2000, and Flaskas, 2002). The not-knowing position will remain with us and I am not seeking here to expunge it from the literature. I wish to offer an alternative way of looking at how the therapist owns their own position and how this influences the nature of the therapeutic relationship. For some people this may not seem a risk at all, but for many I do think it involves the risk of thinking and practising in some different ways.

 

12. Adopting a research lens in family therapy: a means to therapeutic collaboration

ePub

Amaryll Perlesz and Rhonda Brown

Introduction

Collaborative approaches have become widely popular, in theory and practice, within the family systemic and narrative therapies. In this paper we revisit the ideal of collaboration and explore how it fits best with different research and therapy conceptual frameworks. We propose that the participatory, cooperative research inquiry paradigm may be more synchronous with the idea of collaboration than other frameworks, such as the social constructionist therapies that are founded on a basic assumption that the co-creation of meanings in therapy is an automatically collaborative process. We explore the process of collaboration, or lack thereof, in different knowledge generation and therapeutic interview contexts: a grounded theory, research family interview; an anthropological, ethnographic research project; and a family therapy interview.

In examining the implications of adopting a “cooperative/ participatory researcher lens” in family therapy, we discuss the concept of “co-research” created by David Epston and explore the relationship of “co-research” to the collaborative, participatory paradigm. Knowledge generation is examined at the different levels of local and archival knowledge and experience, with implications for the therapeutic/research relationship.

 

13. Research on the therapeutic alliance in family therapy

ePub

Alan Carr

Introduction

The chapter opens with a brief description of therapeutic alliance assessment scales that may routinely be used in clinical practice and then discusses research that highlights the strong relationship between the therapeutic alliance and outcome in marital and family therapy. The remainder of the chapter is a selective review of process research which points to specific practices that therapists may incorporate into their own styles to improve the quality of therapeutic relationships.

In the integrative approach to practice that informs my clinical work (Carr, 2000) I assume that the formulations which emerge from talking with families about their problems and exceptions to these are social constructions. The primary frame of reference for this aspect of the work is observing systems. Since it is possible to co-construct multiple formulations to explain any problem or exception to it, it is important to have a criterion by which to judge the merit of any particular one. In my approach it is the usefulness of formulations in suggesting a variety of feasible solutions that are acceptable to families which is the sole criterion for judging the merit of one formulation over another. In deciding about the usefulness of formulations and interventions, I take account of the results of empirical research, such as those reviewed in this chapter, on the process and outcome of couples and family therapy. The primary frame of reference for such research is observed systems. Thus, the integrative approach I have developed attempts to bridge the frames of reference, often referred to within the field of family therapy, as observed and observing systems. A fine harvest may be reaped from both of these fields. This chapter is largely concerned with fruits from the field of observed systems. I have tried within the space constraints of the chapter to draw together empirical findings that may be useful to practitioners and which may have important implications for practice.

 

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