Master's Comp
Marriage & Family Therapy Program Comprehensive Exam: Personal Philosophy of Therapy Statement
Completed, December 2011
My beliefs concerning therapeutic direction are fundamentally founded in systemic and second-order cybernetic concepts and are the essential starting points to which all other aspects of my work derive from. While I won’t be exhaustive in the explanation of all concepts, I will touch on some fundamentals. At the core of my work is the notion that individuals do not exist separate from their relationship to their environment; they are a part of a system of systems. Clients are best conceptualized in the broader context of their relationship to their systems rather than isolated beings. While I may have clients that present as individuals, my work with them is not ultimately restricted because I pull from this concept. Reciprocal causality as defined by Becvar and Becvar (2009) states, “A and B exist in the context of a relationship in which each influences the other and both are equally cause and effect of each other’s behavior" (p.10). Individuals interact within their systems in complex reciprocal influence and mutual interactions that occur simultaneously, reinforcing the notion that an individual cannot exist outside the context of their system. Additionally, the concept of wholeness states that systems (i.e. families) are greater than the sum of their parts (Becvar & Becvar, 2009). That is, the sum of two individuals does not equate to two because one must consider the interaction between them as an integral part of that system. We can conclude then, the broader context is not limited to who comprises the system (i.e. individuals), but also the reciprocal interactions that occur between them. Lastly, these concepts are not limited to a system, but rather are applicable to two or more interacting systems.
In an attempt to further contextually conceptualize individuals' and systems' interactions, my therapeutic direction pulls from postmodernism. The main postmodern concept is the notion of subjectivity. This principle indicates that objective and absolute truths cannot be known and therefore, our perception and understanding of our realities are subjective and thus, meaning is unique to the individual and to the system (Becvar & Becvar, 2009; Gehart, 2010). Our subjective realities are created through our experiences. Becvar and Becvar (2009) state that, “In the process of perceiving and describing an experience, whether to ourselves or to others, we construct not only our personal knowledge base about reality but also our reality itself" (p.90). Essentially, we are continually changing the meaning and understanding of our reality and therefore continually changing. That being said, considering the countless experiences we encounter throughout our lives, constantly building on one another, one can begin to appreciate the ever-changing complexity of our unique perceived realities, and thus, the complexity of our interactions with others and the world. The meaning and definition of interactions are created by those individuals involved in the system and by systems of systems (i.e. society). Each individual brings to the definition their own subjective reality, and each system brings to the definition their own co-constructed subjective reality. When one accepts this belief, it becomes apparent that each individual’s subjective reality and each system’s co-constructed subjective reality must be acknowledged as true to that individual or system and be respected as valuable and valid.
When one combines the notion of reciprocal causality with the notion of subjectivity, one can further state that two or more individual subjective realities can create together a mutually perceived co-constructed reciprocal reality that is again, neither objective nor deterministic.
Again, it should be noted that co-constructed realities are not limited to family systems, but that larger systems (i.e. school, religion, society) interact in the same reciprocal mutually influencing interactions and thus, co-create larger subjective realities often referred to as dominant social discourses (Becvar & Becvar, 2009; Freedman & Combs, 2008; Madsen, 2007). Postmodernism also emphasizes that the vehicle in which our subjective realities and the meaning and descriptions of our perceptions lie in our language. It is the kinds of valued language we learned from infancy to present and is often specific to a co-constructed existence with our families and community from which we learn to understand our world and in knowing simultaneously construct it (Becvar & Becvar, 2009; Freedman & Combs, 2008; Madsen, 2007). These unique co-constructed existences shaped by our language are often referred to as our culture. An emphasis on language within the context of our culture opens the opportunity for deconstructing the use of the valued language and unique meanings in the creation and maintenance of our subjective realities. Furthermore, it creates a conversational framework from which my work ultimately builds on.
As supported by the above addressed systemic, second-order cybernetic and postmodern concepts, problems are a co-constructed negatively subjective reality of reciprocal patterns of interaction between two or more individuals (a system) or between two or more systems. Further adding to the creation and maintenance of the perceived problem is the language the system uses to describe and understand the problem. Furthermore, due to the emphasis on subjectivity, it is understood that a problem that exists for one system may not be a problem for another, and certainly a perceived problem by one individual may not be perceived as problematic by another individual. One can also conclude then that one individual may perceive a solution that is different from another individual. Therefore, taking a both/and instead of an either/or position provides clients with opportunities to appreciate and value differing perspectives and reinforces the notion that truth is subjective and context dependent. Since clients are experts on their realities, we can assume they are experts on knowing what success will look like when a problem is no longer perceived as problematic (Berg, 1994; De Jong & Berg, 2008; Lipchik, 2002). Therefore, not only is the problem unique, but so are the solutions.
My direction of therapy has led me to conceptualize and recognize my work as following similarly to solution-based therapies. The major distinction of solution-based therapies from other therapeutic models is the focus on moving clients away from a problem-saturated reality towards a more desired reality by noticing and amplifying client strengths, resources, abilities, and exceptions to the problem, which ultimately moves clients toward enacting solutions (Berg, 1994; De Jong & Berg, 2008; Lipchik, 2002; Hoyt, 2008). Furthermore, my work is influenced by collaborative and narrative models of therapy; those that emphasize collaboratively changing the problem-saturated reality towards a more desired reality through a change in how we story our lives by emphasizing a change in our cultured language. O’Hanlon and Weiner-Davis (1989) eloquently stated the following:
We must change the ‘doing’ of the situation that is perceived as problematic; change the ‘viewing’ of the situation that is perceived as problematic; and evoke resources, solutions and strengths to bring to the situation that is perceived as problematic. (p.126)
Here, the authors distinctly outline three major overarching goals for the therapist to attend to while working with clients. It is my understanding and belief that goal setting is a co- constructed fluid process that occurs throughout therapy, spanning from intake to termination. A solution-based therapy concept, goaling is described as an ongoing goal clarification process (Hoyt, 2008; Lipchik, 2002). There are a number of aspects of goaling that I believe contribute to the overall success of therapy. First, following with the foundation of my therapeutic direction, including clients in the co-creation process of goals is not only fundamentally necessary, but significantly empowers clients as it instills a sense of agency to which motivates them towards creating their preferred future, not someone else's. Furthermore, collaborative conversations that emphasize clients’ subjective perception enable therapists to more concretely co-identify goals that are not only unique, but that fit appropriately to what the client desires. This further instills a sense of agency and motivation. Secondly, the fluidity of goaling further supports the notion that subjective realties are continually changing. This allows for the client and therapist to not only acknowledge and appreciate the ever-changing complexity of the clients perceived interactions, but allows for adjustments to goals without feeling as though previous ones were failures (Berg, 1994; De Jong & Berg, 2008; Lipchik, 2002; Madsen, 2007).
If a system co-creates a perceived problem, then a system co-creates solutions. Clients provide direction by describing their subjective reality of what the problem is and what would constitute success when the problem is no longer perceived as problematic. The therapist follows the client's direction and guides for further clarification of the client’s perspective. The therapist is interested in learning about their unique thoughts, feelings, behaviors, and experiences (De Jong & Berg, 2008). As such, the therapist responds by asking questions and making statements that emphasize a change in language; one that further promotes subjectivity, agency, highlights client strengths and abilities, emphasizes problems in the past tense, and rephrases definitive words like always with non-definitive words like sometimes. Questions and statements like these supports the belief that “nothing is all negative” (Lipchik, 2002, p.16), a solution-focused assumption that significantly influences my work. Ultimately, these small changes in language transition the conversation away from a hopeless problem-saturated conversation towards one that focuses on finding and building on solutions to create a more positive future full of desired outcomes (Berg, 1994; Gehart, 2010; Lipchik, 2002). Additionally, multiple goal-building questions such as the miracle question, relational questions, scaling questions, questions that explore exceptions, pre-suppositional questions, and questions that emphasize specificity, descriptive details, and interactions, and what the future will look like when therapy has been successful, ultimately sets the groundwork for more opportunities for the client to view various and differing perspectives allowing for the creation of useful workable goals while simultaneously instilling hope and motivation (Berg, 1994; De Jong & Berg, 2008; Gehart, 2010; Hoyt, 2008; O'Hanlon & Weiner-Davis, 1989).
The solution-based therapies assumption that clients inherently have the strengths, abilities, and resources to overcome challenges is a staple in my work (Lipchik, 2002). It is often unacknowledged strengths and resources that are most helpful in allowing clients to formulate new goals. Not only are strengths and resources directly observable by a trained therapist, but as previously noted, specific questions can elicit the recognition of individual and family strengths, abilities, and resources. Furthermore, finding and amplifying previously successful patterns of interaction often reinforce these strengths. When identifying workable goals, it is ideal to emphasize small rather than large goals (Berg, 1994; de Shazer, 1991; Gehart, 2010; Hoyt, 2008; Madsen, 2007). Previously successful behaviors of interaction that are small are often less difficult to find. Small goals are often more attainable and appear less intimating to clients as well. Also, when clients discover that these small goals have already occurred, it encourages clients to look for other small changes. Therefore, repeating small successful behaviors of interaction become less difficult and certainly are often easier than emphasizing diminishing maladaptive behaviors which are often large (Berg, 1994; O'Hanlon & Weiner-Davis, 1989).
In essence, goaling is a collaborative fluid process in which focuses on the unique perspective of individuals and families, highlighting their strengths and abilities, de-emphasizing problem-saturated language, and instilling personal agency, hope and motivation towards envisioning a preferred future, and ultimately towards enacting solutions.
In my experience, it is often difficult for clients to think of their current situation without the problem and will frequently get stuck on problem-saturated language. Guiding clients towards envisioning a preferred future can often jump-start a change in language. In my work, utilizing the miracle question has been quite successful in doing just that.
I had a case in which a 12 year old grandson was referred by his guardian, maternal grandmother. The grandmother reported concern for the grandson’s lack of respect at home. She proceeded to provide a laundry list of negative behaviors that supported her perspective; talking back, yelling, not listening or following directions and rules. While listening to the grandmother's perspective, the grandson appeared to become increasingly withdrawn and sullen. When by the end of the second session I found even myself feeling hopeless, I turned to utilizing the miracle question. Where direct questions aimed at the grandson further withdrew him from participation, asking him the miracle question elicited an excitement I had not seen in him before. It was apparent my effort in being curious and valuing his unique perspective elicited a change in motivation. The grandson's very first response to the question was that he would wake up the next morning feeling happy. Emphasizing clarification and specificity, the grandson noted that if he were happy, he would notice that he would have more energy to take on his morning routine. When we explored this further, both he and grandmom were able to identify occasions in which he had more energy in the morning when he went to bed earlier the night before. This provided a small previously successful behavior that acknowledged their abilities, further instilling hope and motivation to repeat the behavior, and thus provided the family with their first small workable goal. Additional inquiry into this preferred future focused on relational questions; what would he notice about grandmom that told him the problem was no longer problematic? His response was that grandmom would appear happier too. He would notice this because she would greet him with a hug in the morning. This provided the family a different perspective that emphasized a co- creative effort in creating a solution. Not only was the grandmom able to recognize her role, she was also able to recognize that it had been a while since she was affectionate towards him. This amplified a family strength; the family desired a relationship that reflected closeness. Lastly, by also asking the grandmother the miracle question it emphasized not just the value of their individual perspectives, but reinforced reciprocal interactions and that not only are problems co- created, but so are the solutions. Upon the forth visit, both grandson and grandmom not only appeared less tense, but expressed that things were beginning to get better at home. Having had established a groundwork of reality that existed without the problem, our subsequent sessions allowed for additional opportunities in exploring other workable goals and solutions.
Here, we were able to create a small change in the ‘doing’ of the situation that was perceived as problematic, a small change in the ‘viewing’ of the situation that was perceived as problematic and were able to pull on family strengths. These efforts ultimately further empowered the clients, and instilled hope and motivation toward further enacting a preferred future.
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The role and function of the therapist is an incredibly crucial part of influencing therapeutic success. It is more than just something we fit ourselves into as therapists, but rather is reflective of whom we are as individuals and our relationship with our clients. First and foremost, given my therapeutic direction, one can assume how I conceptualize my position in the context of the client system; I bring to the therapeutic system my own experiences and subjective reality, and I interact with clients in the same patterns of reciprocal mutual influence; I am a part of the system. As Gregory Bateson (1970) states, "Any complex person or agency that influences a complex interactive system thereby becomes a part of that system, and no part can ever control the whole" (p.362). While I come to the therapeutic environment as an individual, I also come as someone who has specific knowledge on certain theoretical assumptions that provide a guideline for the kind of relationship I have with clients, all in the name of benefiting them (Lipchik, 2002). So while I fit similarly in how I interact with the system, I am a change in that I bring to the system a different unique therapeutic perspective. I consider the essential definition of my role as collaborative and of taking a “not knowing” stance. I believe that when the role of the therapist does not emphasize an expert hierarchical position, a collaborative relationship can exist that promotes an environment of trust, respect, understanding, and ultimately promotes a space where clients feel a sense of agency, hope, and motivation towards creating a more positive future. While the words role and function are synonymous, I view them as playing different, but reciprocally interactive parts in my work as a therapist. My function follows, undoubtedly, my therapeutic direction and is supported by my collaborative non-expert role. My essential function is to interact with individuals and their system(s) in a way that interrupts patterns that create, maintain, and reinforce a subjective reality that emphasizes negatively perceived reciprocal patterns of interaction (i.e. "the problem"). I do this by guiding and facilitating a collaborative conversation. I actively maneuver through these conversations by guiding the client(s) towards clarification and deconstruction of their perspective in a different language that de-emphasizes problem saturation language and emphasizes a sense of agency towards enacting solutions. As previously stated, this is done through goal-building, relational, pre-suppositional, and exception- finding questions, and statements that promote the value of subjective perspectives, promotes a "nothing is all negative" assumption, and highlights client strengths, resources, and abilities (Becvar & Becvar, 2009; De Jong & Berg, 2008; Hoyt, 2008; Lipchik, 2002, p.16; O'Hanlon & Weiner-Davis, 1989).
In the process of conceptualizing client perceptions of the problem, one can begin to view clients as having differing degrees of motivation and readiness for change. How I respond to these differing degrees affects the client-therapist relationship and overall success of therapy. Another solution-based therapies concept I pull from is the belief that there are three different distinguishable types of client-therapist relationships.
The visitor relationship occurs when a client is referred involuntarily by some other individual or system. The referring source often comes with specific ideas about what the problem is and thus, specific and often differing goals than the client (Berg, 1994; Gehart, 2010; Lipchik, 2002). Consequently, the client generally does not recognize a problem exists and can appear non-compliant. Further adding to the difficulty of the situation, visitor relationships can create for the client a feeling that the therapist is in collusion with the referring source. The therapist must ensure that the client experiences their relationship as different; one that promotes collaboration and trust. In order to do this, the therapist attends to the most basic of joining by focusing on active listening, compassion, and sympathy for the client’s situation (Berg, 1994; De Jong & Berg, 2008; Lipchik, 2002). Not only does inquiring about the client's unique perspective support these efforts as well, but opens opportunities for the client to first recognize that a problem exists. When a problem is perceived, the client is able to be engaged on a different level and thus, in a different client-therapist relationship (Berg, 1994; De Jong & Berg, 2008).
The complainant relationship is often seen when the client recognizes a problem, but views him or herself as being affected by the problem and not yet conceptualizing their role in influencing the problem or role in the execution of a solution. Furthermore, complainant relationships are often marked by clients who focus on providing detailed accounts of the problem, speculates causes, and even provides solutions to the problems that others should carry out (Berg, 1994; De Jong & Berg, 2008; Gehart, 2010). Here, the therapist functions by recognizing and being sympathetic to the client's involvement in the situation, and to thank the client for their information and commitment to helping the perceived troubled individual (Berg, 1994). By acknowledging the client’s involvement from their perspective, I am creating a space that promotes trust, respect, and understanding. As previously addressed, providing a supportive environment allows for clients to form a sense of agency and motivation towards creating change. When this occurs, the complainant relationship morphs into the customer relationship. The customer relationship may not have a fully conceptualized idea of their role in finding solutions, nor have established clear goals, but possess a notable desire and motivation toward creating a change in their situation (Berg, 1994; Gehart, 2010).
In my internship experience, the majority of my clients were referred by someone else, mainly due to the fact that my clients were primarily children and adolescence. I found that most client-therapist relationships that followed the visitor description were younger children. Pre- adolescent and adolescent clients more often followed the complainant client-therapist relationship. I had a case in which a 16 year old daughter was referred by her parents for constant fighting at home. Not only were the parents able to identify how they were negatively affected by their daughter’s behaviors, but the daughter was also able to identify how she was negatively affected by her parents' behaviors. Both saw the other as having and being the problem. Furthermore, each individual gave detailed explanation for how the problem would be solved by a change in the others’ behavior. Ultimately, the parents were uninterested in participating in therapy, insisting the problem and resolution to the problem existed in their daughter. While I was initially unsuccessful in influencing the parent’s perception, my work was not ultimately ineffective. As I’ve established, working with an individual does not limit my work because a change in one part of the system can create change in other parts of the system. For a number of sessions, I focused my work on clarifying and deconstructing the client's unique perspective while portraying compassion for her situation, respect and acceptance for who she was and her subjective reality, and encouraged her by noting and supporting her efforts and abilities for coping with the situation. Our conversations began to shift away from a focus on problems with her parents and towards a positive focus on herself. This opened the door to opportunities for further conversations that reflected a preferred future that was driven by her and her desires.
I believe that had I not been so clearly aware of our complainant client-therapist relationship, any attempt to directly identify her role in creating a change would have resulted in a distancing from her and ultimately a poor rapport. It is clear the value of paying close attention to where clients are and meeting them there, particularly in regards to their motivation and readiness for change. I believe that when the collaborative relationship created an environment that promoted trust, respect, and understanding, the client was able to have a sense of agency, hope, and motivation toward actively participating in her preferred future and ultimately towards enacting solutions.
My therapeutic relationship to change emerges from the notion that change in one part of a system creates change in another part of a system and the belief that change is constant and inevitable (Gehart, 2010; Lipchik, 2002). Given my position within the system, my very presence creates change. I have come to recognized that I facilitate change in three distinct areas; I create change through a difference in space, in conversation, and in my unique perspective.
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The diagnosis of a mental health disorder in western American society is generally followed by the assumed belief that the disorder exists within the context of the individual and thereby the symptoms are diminished through a change in the individual’s behaviors. Furthermore, while the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) provides mental health professionals with useful guidelines as to how symptoms present, it does not emphasize subjective perspectives, the notion that every client is unique, and the reciprocal influence within and of their systems. Additionally, the current emphasis on drug treatments for mental health disorders further highlights individual responsibility. In contrast, I view symptoms of a mental health disorder as negatively perceived reciprocal interactions that occur within the boarder context of the individual's environment, the systems of which they are a part. This includes not just the individual's family system, but their school system, their friend system, and any other community systems in which they interact. Furthermore, the word pathology implies a deficit. As I have established, I believe clients possess within them the strengths and resources necessary to overcome challenges. Therefore, I do not view my clients through the lens of a deficit but rather through a strength-based lens. I find no benefit in contextually conceptualizing the interactions as pathological, wrong, or bad. I consider my work with my clients as non- pathologizing.
Given my perspective on mental health disorders it is important to pay close attention to how society influences individuals’ and families' perceptions of diagnoses. Because of the western American societal dominant discourse that the individual possesses the disorder, families in these situations often present the individual as the problem, not the diagnosis. To counter that belief, I actively maneuver through our conversations by directing the client(s) with a focus on clarification and deconstruction of their perception of the diagnosis with a change in language that emphasizes not just systemic, second-order cybernetic and postmodern concepts but by emphasizing externalizing the diagnosis or problem. Externalizing language can be applied to any aspect of an individual or family's perceptions, interactions, or problems, but can be particularly useful with a diagnosis. It should be noted that externalizing should take into account the boarder social context of the situation as it can impact what and how we externalize (Morgan, 2000). Externalizing language, in the form of statements, questions, and metaphors, emphasize problems as existing separate and outside of the individual or family rather than as an internal part of their identity or as a personal deficit. Externalizing supports the idea that clients have within them the strengths and abilities to challenge and overcome the influence of the diagnosis or problem, to which promotes a sense of agency, hope and motivation towards creating a change. Furthermore, externalizing language promotes a relational stance, emphasizing that clients interact with a diagnosis or problem rather than having or possessing it (Becvar & Becvar, 2009; Gehart, 2010; Madsen, 2007; Morgan, 2000; White & Epston, 1990). This change in language creates a different perspective that allows clients to move away from viewing the diagnosis as internal and towards a different reality in which the diagnosis is a separate part of the system in which they all interact with and have influence over. Each part of the system interacts, responds, and attempts to manage the symptoms of a mental health disorder or problem in their own unique way, supported by their own subjective perspectives. Therefore, inquiry into how each member interacts, feels, responds, and manages the diagnosis or problem is essential.
The following is a case in which a 13 year old daughter was referred for struggling with interpersonal issues with her mother. While her mother was not formally diagnosed, her patterns of interaction were symptomatic of Alcoholism. Additionally, the mother was uninvolved in participating in therapy. The family members concerned were the daughter's father and step- mother, both of whom appeared to exhibit a complainant client-therapist relationship that contributed to not only the vilification of the mother, but significantly supported their perception of their involvement as outside the problem, but having been affected. Essentially, they saw the mother as "the problem". Despite the family's acknowledgement of the alcoholism, they struggled to identify and recognize the alcoholic symptoms as occurring separate from the individual. First, my work with the family was to explore how each part of the system interacted, felt, responded, and attempted to manage the symptoms. I did this in a manner that expressed curiosity, promoting respect, and acknowledging and showing sympathy for their involvement, owning to the client-therapist relationship and emphasizing a systemic perspective. Secondly, my work with the family was to influence their perspective in viewing the mother and her behaviors differently. I did this by emphasizing a change in language through our conversations that demonstrated externalizing the alcoholism.
When the family expressed particular frustration for not understanding why the mother was behaving the way she was despite acknowledging the role of the alcoholism and despite the emphasis on externalizing language, I took it upon myself to draw a diagram. In my experience with the family, it was apparent that one of their strengths was being able to view things differently with use of visual cues. In this diagram I drew two circles, one within the other. In the center circle I wrote the mothers name and around that were both positive and negative behaviors the family had previously identified as being exhibited by the mother. The identification of the positive behaviors and characteristics was essential, as it reinforced the mother’s strengths and abilities, and promoted the "nothing is all negative" (Lipchik, 2002, p.16) assumption. Outside both circles was the phrase the alcoholism. I proceeded to draw arrows from the alcoholism to the negative behaviors that were symptomatic to alcoholism (e.g. lying, unreliable, hiding things, having poor judgment, incongruent communication, and “choosing” the alcoholism over family) and proceeded to explain just how the alcoholism had had influence on the mother. I then proceeded to underscore the positive behaviors, noting how she was separate and still possessed strengths and abilities.
Furthermore, work with the daughter focused on highlighting her strengths in managing the effects of the alcoholism herself. These conversations allowed for opportunities for finding and expanding on exceptions. As a result of our work, the family, and predominantly the daughter, was able to not begin only conceptualizing the alcoholism as a separate part, but were also able to identify their abilities in managing the effects of the alcoholism, further supporting a sense of agency over the situation. This was particularly empowering for the daughter as she could now conceptualize that not only was she not responsible for her mother's behaviors towards her, but that her mother’s behaviors were the result of the strong influence of the alcoholism.
At my internship site, there is little emphasis on diagnosing mental health disorders. Not only do we not have a psychiatrist or psychologist on staff, but the service is free, negating any utilization of managed care in which often requires a diagnosis. As a result, my experience diagnosing has thus far been limited. Further adding to my limited experience diagnosing, I have not yet had a case in which formally diagnosing or referring a client to be evaluated has been necessary. However, there are a number of possible situations in which I acknowledge the benefit of requesting a psychiatric evaluation. First, any case in which there is suspicion of possible psychosis should be referred. Second, any case in which the client’s safety is at risk where either the inclusion of medication or hospitalization is necessary. Lastly, I imagine a case in which a family presents symptoms within an individual as the problem without the knowledge of such symptoms being indicative of a mental health disorder. In this case, having a diagnosis can help individuals, and the family, conceptualize the symptoms differently. Of course, informing clients of a diagnosis is a delicate process and an emphasis on non-pathologizing is essential. Once a diagnosis has been established, or the acknowledgement of one, as previously stated, utilizing my role and function to create a change in language that emphasizes externalizing the symptoms for both the individual and the family is necessary.
Further contributing to my non-pathologizing stance is how I conceptualize normative family function. Family function as viewed through the perspective of systemic and second-order cybernetic concepts, as previously established above, is uniquely subjective and contextually co- constructed. Since clients are experts on their lives, they are experts on knowing what for them is normal. No single way to live one's life is right nor exists a model of normalcy or health for therapists to pull from (Becvar & Becvar, 2009; Gehart, 2010; O'Hanlon & Weiner-Davis, 1989). Additionally, normal is a co-constructed meaning that is driven by the context of any given family's culture and influenced by broader dominant social discourses (Freedman & Combs, 2008). Therefore, I cannot state that I possess a predetermined definition of specific patterns of interaction that I impose as a normal for families. And ultimately, I cannot possess a preconceived notion of how a family should present when therapy has been determined successful. As a result, my work can be described as taking a non-normative approach.
Since individual and family realities are subjectively influenced by their experiences within the context of culture, it is imperative that my work with my clients explore what for them is normal and the impact of broader dominate social discourses. Just as I've established above, inquiry into their perspective and remaining curious and respectful is vital. Noting the influence of dominant social discourses is particularly important when it is in contrast to a family’s cultural perspective of normal. Allowing a conversation that provides a space for differing perspectives and noting the influence of those perspectives may be useful for a family who is dealing with the Department of Children and Families (DCF) involvement for hitting their children. While society has more recently established that physical abuse is not an acceptable behavior of normal, a family may believe that hitting their children is appropriate. My job here is to explore with the family their perspective through clarifying and deconstructing the impact of dominant social discourses on their situation. It is particularly important here to maintain a non-pathologizing stance. Both efforts support creating for my clients a sense of agency and encourages motivation towards identifying and enacting solutions to their situation. The inverse of this would be a case in which a family presents with a problem that from their perspective is not normal, is maladaptive, wrong, or bad while a broader social discourse implies normal developmental behavior. My job here is to respect their reality by inquiring about their perspective and to further clarify and deconstruct their reality by involving a discussion about the influence of social discourses, all while emphasizing a non-pathologizing stance.
Lastly, families often present their perception of their problems as pervasive, fixed difficulties resulting from a personal deficit (De Jong & Berg, 2008). Supporting my therapeutic direction and beliefs, the task of normalizing a problem can significantly alter this detrimental problem-saturated perception. Normalizing is essentially the recognition that some situations arise from common developmental obstacles that many people struggle with and overcome, and that what clients experience is often within the range of normal human behavior. It is another way of non-pathologizing their thoughts, feelings, and behaviors (Berg, 1994; O'Hanlon & Weiner-Davis, 1989). When this occurs, individuals and families are able to perceive their situation as temporary and manageable, promoting a sense of agency and hope.
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A fundamental aspect of my work is the notion that change is constant, fluid, and inevitable and therefore the evolution of progress can be perceived on a continuum (Berg, 1994; Gehart, 2010; Lipchik, 2002). Consequently, assessing my therapeutic endeavors spans the length of therapy, not just at the time of termination. Furthermore, supporting the collaborative nature of my work, assessing my therapeutic endeavors requires both the therapist and client to continuously monitor change and to allow new information to provide direction as to how we should make modifications (Berg, 1994; De Jong & Berg, 2008).
Moreover, since I take a non-normative approach in my work and maintain that clients are experts on their realities, assessing my therapeutic endeavors relies substantially on assessing client perception of success. Paying close attention to both the behavioral observations of my client’s actions and directly asking clients about what has been better is imperative. Inquiry into client perspective is essential to understanding where to go next. Asking, “What has been better?” not only opens the opportunity for exploring exceptions and implying client capabilities, but further de-emphasizes problem-focused language (Berg, 1994; De Jong & Berg, 2008).
A useful tool for conceptualizing client perspective, particularly in relation to change, is scaling questions. While scaling questions are often utilized at any point in therapy, for any number of reasons, the use of scaling questions to determine client perception of change in an effort to assess therapeutic endeavors is significantly useful (De Jong & Berg, 2008; Berg 1994; Lipchik, 2002). When the therapist and client(s) can both conceptualize where they are in the process of therapy, determining the next course of action becomes clearer. Not only is this particularly useful when “resistance” occurs, but also when determining how close clients are to recognizing therapy as successful, and thus how close clients are to terminating.
I had a case in which scaling the clients perception of progress led to a clarification of the direction of therapy that ultimately led to successful termination. The client was an 11 year old boy that was referred by his parents for being disrespectful and irresponsible at home. Through work with the family, we identified four larger overarching themes of which the family's goals derived from; respect, helpfulness, responsibility, and expression of thoughts and feelings. Each of the four themes had within them small concrete behavioral goals, and not just for the son. In support of my therapeutic direction, each parent also had for themselves a set of goals that were aimed toward supporting their son’s efforts. When the family members began to report significant improvements, we began to evaluate their perception of success thus far. I chose to first focus on the son’s goals by drawing out the scales during an individual session. For each of the four themes, we scaled from 1 to 10, with 1 indicating how things were when he first arrived to therapy, and 10 indicating how he would know when therapy was successful. None of the four themes yielded a perception number less than 8. We also wrote under each of the themes the associated smaller goals; what it was that he was doing that told him he was an 8 or higher. Upon presenting the written scales to his parents, further discussion around what the family found successful occurred. Both parents were able to agree with the son’s scales, reinforcing a changed perception in reality that emphasized strength-based positive behaviors. In reflection of the scales, the parents determined that the difference between an 8 and a 10 was insignificant. They had realized that their son’s efforts were already deemed successful and any further movement would be perfection. Accepting the idea that perfection was not only unrealistic, but unnecessary, the family and I collaboratively began conversing about terminating services.
Furthermore, determining client perception of change in an effort to assess therapeutic endeavors when the therapists become aware of possible “resistance” is particularly important. When clients' behaviors insinuate "resistance," for example, by not following through on tasks, it is necessary for the therapist to directly assess their own efforts. The word "resistance" has been written in quotations because it is my belief that clients do not resist, but rather their behavior informs us that some aspect of therapy isn't working (De Jong & Berg, 2008; Hoyt, 2008; Lipchik, 2002). I believe that when this becomes apparent, it is not a reflection of therapeutic failure, but rather is an opportunity that is indicative of requiring a change or modification to some aspect of therapy. Determining what isn’t working requires a collaborative conversation, but also requires the therapist to be aware of the kinds of aspects of therapy that can negatively impact success. As I’ve established, the characteristics of identified goals obviously impact motivation, and ultimately success. Therefore, the therapist should question whether the goals are too large, are not appropriate to the unique client, are no longer appropriate given other changes, or are no longer a focus in therapeutic efforts. Another significant aspect of success is the client-therapist relationship. Given the differences in degree of motivation and readiness for change, and the understanding that client-therapists relationships change throughout therapy, revaluating whether a client-therapist relationship is a visitor, complainant, or customer is imperative.
Furthermore, assessing my therapeutic endeavors involves paying close attention to the invaluable relationship I have with change. As previously addressed, I am a facilitator of change in that I provide a space, a conversation, and a perspective that is different. Therefore, it is imperative that I am continuously aware of actively creating a space that promotes trust, respect and understanding through interacting with my clients in a manner that supports my collaborative non-expert role. As I've established, this is necessary in promoting a sense of agency, hope, and motivation toward creating a preferred future, and ultimately, to successful therapy. For this, the therapist must rely mostly on paying attention to their actions and behaviors, rather than the clients. However, given the reciprocal nature of the client-therapist relationship, client behaviors can certainly indicate to a therapist that they are no longer providing this necessary environment.
Additionally, given the substantial importance of the role of language in the creation and maintenance of our subjective realities, and its fundamental function in creating change, it is imperative that I am continuously aware of not just the client’s use of language, but of my own as well throughout our collaborative conversations. Providing a difference in language that promotes subjectivity, agency, highlights client strengths and abilities, emphasizes problems in the past tense, as external, and “partial rather than global” (Gehart, 2010, p.368) statements, emphasizes a non-pathologizing and non-normative approach, ultimately moves the clients away from a stuck, problem-saturated language towards a language that emphasizes a more positive future full of desired possibilities, and ultimately toward enacting solutions. Being aware of the power of language, one cannot ignore its critical impact on therapeutic success.
Lastly, given that my individual therapeutic perspectives have been created and maintained by my experience in graduate school and internship, it is important that in order to continue in my therapeutic endeavors of providing a different perspective, I must continue post- graduate education. Efforts will be made to be involved in workshops, conferences, and other Marriage and Family Therapy (MFT) community related events. Furthermore, it is important to be aware of changes through research and new publications.
Through reflection of how I assess my therapeutic endeavors, it appears apparent that a fundamental aspect is to possess constant awareness. I must always remain vigilant to how I and what impacts my clients and their efforts towards success. By doing this, I am providing my clients with the best opportunity for creating their preferred future, and ultimately, successful therapy.
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How I demonstrate sensitivity to client diversity is supported by the above addressed systemic and postmodern concepts, by my collaborative non-expert role, and by my non- normative and non-pathologizing approach. At the core, recognizing and appreciating clients' uniqueness is fundamental. Work with clients that reflect promoting their own goals and motivations add to the applicability of my approach (Hoyt, 2008). I am, therefore, not limited in my effectiveness by the diversity of my clients.
Furthermore, as a participatory member of our society, I am aware of broader social discourses that can and often negatively impact client perspectives, interactions, and lives. Such discourses often involve issues of power around culture, race, gender, sexual preferences, and socio-economic statuses and tend to have a pathologizing deficit-based perspective (Becvar & Becvar, 2009; Freedman & Combs, 2008). Therefore, sensitivity to diversity requires that I pay close attention to the role of social discourses on my client’s lives and to inquire how those discourses impact their situation.
As I have indicated through my work, discussing the impact of social discourses is imperative. However, such conversations are not utilized as a political way of conversing, it is a dialogue that reflects the client’s unique perspective through a lens that acknowledges the powerful impact social discourses have on our perceptions, and thus, on our lives. And while I may have my own beliefs and assumptions about social discourses, it is ultimately how the individual or family is uniquely affected that should be explored. Therefore, remaining genuinely curious about learning from the clients is essential (Hoyt, 2008). Guiding clients toward clarifying and deconstructing their perspective with a change in language that emphasizes externalizing, allows client to form a relational stance with social discourses. As established above, a relational stance helps clients to perceive their interaction with problems (i.e. social discourses) as reciprocal (Freedman & Combs, 2008; Madsen, 2007). With a relational stance, the therapist can inquire as to how the client(s) have been able to manage with the social discourses impact on their lives. When this occurs, clients are more likely to become aware of strengths, resources, and abilities not previously discovered. This not only empowers and motivates clients, but provides further opportunities for finding solutions to their problem.
The following is a case in which a 17 year old transfer high school student from another city was self-referred for interpersonal issues with her mother. The local high school participates in an outreach program that brings talented students from other cities with the intent that the students will attain a better education locally. While the student complained of numerous difficulties with her mother, looking at the broader social context, it appeared as though she was struggling with bridging the gap between two cultures. Upon inquiring in what ways the social discourses of the differences between the cultures affected her, she began discussing how issues of power around race and socio-economic status discourses were pervasively impacting her situation. Through clarifying and deconstructing her perception, and through externalizing the dominant social discourse, the student was able to recognize that the perceived negative behaviors her mother was exhibiting may have been indicative of feelings of frustration for not having the resources within her city and culture to provide her daughter with the same education as the other town and culture. The student also recognized that while the school’s efforts are often successful, the program implies a deficit exists in the city and culture and that perhaps the mother was internalizing this pathology. Through exploring how negative dominant social discourses impacted her relationship, my client was able to explore ways in which she had been managing the difficulties, and essentially led her to finding unacknowledged strengths and resources that not only she possessed, but her mother as well. Not only was this empowering, but when the student was able to perceive her situation as less internally maladaptive and more external, she reported having more of a sense of agency over the situation and hope for change.
Recognizing the benefit of viewing situations through a broader context leads me to recognizing the impact of my own personal experiences on my therapeutic endeavors. My experience in the graduate program has provided me with knowledge and tools to explore my own family-of-origin (FOO) in a way that allowed me to become differentiated. Furthermore, through my education I have formulated a worldview (i.e. therapeutic direction) that not only impacts my relationships with my clients, but impacts how I interact and relate to my family. I am now able to perceive my FOO system and our interactions through a similar strength-based lens that emphasizes the value of unique subjective realities. As a result, fewer FOO issues arise and those that do often resolve more quickly.
Given that I am an individual with my own personal life and I interact with the client system reciprocally, one can recognize the delicacy of the client-therapist relationship and therapeutic environment. While I enter the system as an individual, I also enter as a therapist. I maintain a professionalism that supports a separation of my personal life from my work. Additionally, my work highlights the value of client uniqueness and the act of respecting subjective realities. Ideally, this provides a therapeutic space that allows the client and the therapist to posses differing perspectives without jeopardizing the relationship or environment. However, given the nature of our interactions, it is foolish to assume that therapists do not react to their clients. Therapists should always remain aware and monitor their own internal responses, and in a manner that does not impact the effectiveness of therapy. When a reaction occurs in session, remaining calm is critical. Should a therapist express strong emotion in response to something a client said or did, they are compromising the necessary professionalism the therapist must maintain in order to provide an effective client-therapist relationship and therapeutic environment, both of which are vital to the success of therapy. Upon realization of an internal response, regardless of the degree, it is imperative to clarify and deconstruct the thoughts and feelings in supervision.
Last year, I received a frantic phone call from a mother who had recent concern that her daughter had been sexually mistreated by the daughter’s older brother. Upon contacting my supervisor, it became apparent the significance of my role in appropriately maneuvering through this highly delicate situation. I became significantly overwhelmed and cried. At first, I was unaware of why my reaction was so strong. However, through clarifying and deconstructing my feelings with my supervisor, it was apparent that because the case had become significantly more challenging, I was afraid of failure. And while my reaction was not directly related to issues with my FOO, it was directly related to issues of questioning my competency that began as early as grade school. When I was able to recognize this, and with the support of my supervisor, I was able to maneuver through the case in a professional manner, maintaining my personal concerns separate.
Therapists are human and we cannot not react to our clients. What is important is how we handle our reactions. It is critical to be aware of internal changes and when they occur, maintain professionalism and seek supervision.
References
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Running head: MARRIAGE & FAMILY THERAPY PROGRAM COMP EXAM !33
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