Copyrighted material CONTENTS. 1 Introduction 1 PART I 7

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1 CONTENTS List of figures and appendices Acknowledgements x xii 1 Introduction 1 PART I 7 2 The encounter 9 The first family therapy session: a protocol 9 The first meeting with the family 11 Introducing myself 13 Inviting the family members to introduce themselves 15 Hesitations and good reasons 19 Closing the session 27 A protocol for the first family therapy session 28 The person of the therapist 28 The voices of all family members 29 Hesitations 30 The dialectics of yes and no 30 Family therapy as a dialogue 31 3 Family therapy as a dialogue 35 Therapeutic alliance or treatment? Both! 36 The alliance as a process of attunement 38 Dialogue and attunement 39 Tensionality 40 Tensionality and attunement 41 Attunement and reflexivity in individual psychotherapy 42 But what about family therapy? 45 vii

2 CONTENTS Family therapeutic process 46 Complexity in family therapy 47 The complexity of the therapeutic alliance 48 Our conceptualisation of family therapy 49 Family therapy as a dialogue 51 Respect 53 4 Focus on worries 58 The first family therapy session: a protocol 60 The first meeting with the family 61 Introducing oneself 61 Again, the dialectics of yes and no 64 Worries and dialogue 67 5 Feedback orientation 72 Client feedback in family therapy 73 The Dialogical Feedback Tool 76 The Dialogical Feedback Scale 84 The use of feedback instruments as conversational tools 92 Enactment of the family dynamics 93 Making room for feedback 93 Feedback-oriented therapy as a responsibility 94 PART II The family s storytelling and their hesitations 103 A dialogic perspective on storytelling 105 The other 107 What is said and what is not said 107 Hesitations 109 Hesitations and their non-verbal expression 110 Good reasons to hesitate 112 Children and hesitations 112 Exploring the good reasons 115 Hesitations at the start of therapy 117 Hesitations at the start of a family therapy 119 Listening to what is not said 121 viii

3 CONTENTS 7 Listening 126 Listening is not obvious 126 To listen with the ears 128 To listen with the eyes 130 To listen with the heart 131 The complexity of listening Enactments in the here and now of the session 139 Enactments in the session 139 Hesitations (again) 141 Inviting enactments 142 Empowering through enactment 144 Focus on the here and now Children s drawings in family therapy 154 A dialogical approach 156 Room for making drawings 158 Dialogue with the child about the drawing (vertical reflection) 160 Inviting parents and siblings (horizontal reflection) Connecting with the context 174 Social context as a therapeutic factor 174 The therapeutic rich family tradition 175 The importance of the social context in family therapy 176 PART III In the attic, in the dark (case story of Liam and his family) 187 The Worries Questionnaires 188 Mother s 195 Some concluding remarks 198 Appendices 202 Endnotes 215 References 216 Index 226 ix

4 1 INTRODUCTION This book is about what most experienced therapists know: that therapy is a living process between people. It is about the family and their request for therapy; and about the way we as therapists try to respond to their request in an attempt to be useful for them. The perspective taken in this book is quite unusual in these times of medicalised psychotherapy practice, where the problem for which people consult is central; and where no distinction is made between the concepts of request for help and the problem. A medicalised view of psychotherapy is based on the problem-diagnosis-treatment model, and the problem is supposed to be something that exists out there in the world, like a tumour or an infection, weighing on the life of the person most affected by the problem, and also on the other family members. The information about the problem is gathered by the therapist in order for him/her to diagnose. This means that the problem is classified and named, based on its observable characteristics. This diagnosis then is not only supposed to be the causal factor explaining certain kinds of behaviour, but it is also the starting point of a treatment plan and ultimately of the treatment itself. THE MEDICAL MODEL AND PSYCHOTHERAPY The medical model is very successful. Curation and prevention of illnesses have never been as effective as in these times. The question can be posed, however, is the medical model the best model for the conceptualisation of psychotherapy? According to Wampold (2001; Wampold & Imel, 2015) the medical model is composed of five components: 1. Illness: The start of a medical intervention is the diagnosis of an illness. 2. Biological explanation: There is a biological cause for the illness. 1

5 IN THERAPY TOGETHER 3. Mechanism of change: The treatment is established at the level of the biological system causing the illness. 4. Therapeutic procedure: Diagnosis and explanation lead to the design of the treatment involving the administration of a substance (e.g. medication) or the implementation of a procedure (e.g. surgery). 5. Specificity: The treatment can be shown to be more effective than a placebo, and it can be shown to operate through its intended mechanism. Nowadays, psychotherapy is presented as a treatment for mental illness, and in that way psychotherapists are forced to practise within the limits of the medical model, which only partly fits their actual practices. Yes, it is possible to translate the client s suffering into symptoms that refer to an underlying illness, and it is possible to make diagnoses that can orient treatment. But psychotherapy essentially is a response to mental suffering (e.g. anxiety, grief, depression ) that doesn t always have a biological cause. Furthermore, psychotherapy involves a variety of interventions that can t all be compared to medication or surgery, and, while psychotherapy is more effective than placebo (e.g. Lambert, 2013), there is a lot of controversy about its mechanisms of change (e.g. Norcross, Beutler & Levant, 2006). Medicine, of course, is the predominant force and psychotherapy is subordinate (Wampold & Imel, 2015, p. 9), and, whenever psychotherapy does not seem to fit, it has to adapt to the dominant model and cannot expect the medical model to accommodate. This book is different, as it rests on assumptions about the nature of human relationships that are in tension with the traditional view of the problemdiagnosis-treatment model. One of my central assumptions is that all families have been sparked by love. In the beginning of each family there were two persons who loved each other and who decided to form a family. Of course, this assumption is tainted by our Western ideal of what a family should be. We have to be careful not to present our own views on families as the universal norm. Families come in many shades and colours in different cultures. On the other hand, in all cultures, as in most higher species in the animal world, the family at least the mother and child, with or without the father, with or without the support of the broader family is the place in which children grow up with the support of the parents, and in which love (in whatever form) is supposed to help the different family members through life, despite the pressures, obstacles and challenges they may be facing. Furthermore, we also know that, while love may be at the roots of a family, often, when families consult us, resentment, fear and disappointment rule the family instead. Still, using this assumption as a lens to look at families helps us to connect with family members through 2

6 INTRODUCTION our best intentions. Furthermore, it helps us to support the resources in the family, their sense of belonging together, and their hope for a better future. THE FAMILY Some time ago I was asked by organisers of an international conference to make one PowerPoint slide in which I would summarise what I thought to be the most important thing in my work as a family therapist. At first, I felt a lot of hesitation because the assignment seemed impossible to accomplish. Then I came up with this slide (see Figure 1.1): Figure 1.1 An elephant family For me, this slide summarises an important assumption in my work as a family therapist: the assumption that love is at the basis of a family. For me, to love someone is to feel that you belong to another like this other belongs to you. It is and now I paraphrase Shotter (2016) to notice and be responsive to the possibilities for further development inherent in his/her being to be the voice inviting him/ her to develop into what he/she can become; as he/she is that voice for you. Furthermore, rather than starting from the assumption that there is an objectively existing problem out there that affects the family, we start from the 3

7 IN THERAPY TOGETHER request of the family: a family member phones us and asks for an appointment. As will become clear in this book, the choice of the starting point has a lot of consequences. For one thing, the existence of an objectively existing problem in a lot of families is a matter of discussion. Usually when families come consulting they don t agree on what is the problem, or even on the question if there is a problem at all. This book is also different in another respect. Most books and publications in the field of family therapy (in fact, in the field of psychotherapy) assume that the therapist s actions originate in knowledge and that this knowledge guides his/her actions. Our assumption, to the contrary, is that the therapist s actions are relational responses that are intuitive and bodily in the first place. First there is the other, and immediately our body has a response. And then, as if they were epiphenomena, there are our thinking, our reflections, our hypotheses These cognitive activities are in constant dialogical tension with our bodily responses; reinforcing them, correcting them, inhibiting them The interaction between the bodily immediate responsiveness and the cognitive postponed reflections can be seen as a dual process: Process 1: Without much explicit reflection, as it were from a default position (Reimers, 2006), the therapist acts in the flow of the dialogue, immersed in a shared we with the family, intuitively searching for some kind of attunement. Process 2: The therapist is goal oriented and observes what happens, processes information, evaluates the evolution, and so on. Cognitive dual process theories can capture the complexity of this process: the theory of Daniel Kahneman (2011), for instance, or the theory of Donald Schön (1983). Process 1 is captured by Schön s concept of knowing in action, and process 2 by the concept of reflection in action. It is optimal if the therapist can flexibly move from intuitive responsiveness to cognitive reflection and back again, and if, attuned to the family s rhythm, a balance is found between the intuitive actions of the therapist immersed in the flow of conversation, and his/her perceptions of what is happening in the session enriched with his/her self-awareness of his/her inner dialogue. THE WORLD WE ARE LIVING IN We think that our world is made up of discrete entities ( things ) that impact on each other. One thing moves and touches a second thing, and upon impact this second thing starts to move. That s causation, and such causation is easy to 4

8 INTRODUCTION observe, for instance on the billiards green. This is what Bateson inspired by Jung calls pleroma. It is the physical world where forces and impacts provide sufficient basis of explanation (Bateson, 1979, p. 16). This world is also a world that we can observe without being affected by it, or without affecting it. We can observe, describe, measure and count whatever happens in this world. There is another world: the world of living things, which Bateson calls creatura. In this world, things can t be explained in terms of forces and impacts. Even the concept of causation is problematic in this world of living things; as living processes are complex and even an absence can have effects. For instance, a letter that I did not write to someone can evoke an angry reply (Bateson, 1972). In this world of living things, the concepts that make sense in pleroma do not fit. Specific concepts are needed if we want to reflect on and talk about what happens there. It is not a world of things that can be objectively described as observers we influence what happens, as we are influenced by it; rather, it is a world of meaning and relationship. It s not a world of stable states; rather, a world of living processes; a world of relational becomings (Shotter, 2016). Observation, description, measurement and counting are problematic in this world, for diverse reasons (for instance, because we are continuously in interaction with the living world, whenever we want to observe it). Psychotherapists navigate in creatura. They should be careful not to use words like cause, impact, effect, and so on when they talk about the life of their clients (Bateson & Bateson, 1988). They are working with living creatures (persons) and, in working with them, they are part of the system they are working with. The assumption of the primacy of the relationship with others, instead of the individual minds, has deep ethical-philosophical roots in the work of thinkers like Martin Buber, Emmanuel Levinas, Jacques Derrida and Mikhail Bakhtin. Otherness is central, as I become myself through the other. In this book, family therapy will be conceptualised as a dialogue between living persons. Such a conceptualisation offers a perspective that makes it possible to capture something of the mutuality and shared activity of a therapeutic encounter in practice. It could be argued, of course, that the expression a dialogue of living persons is a tautology, since all persons in dialogue are living; how else could they interact or communicate? Emphasising these persons vitality, however, directs our attention, not to the content of these persons stories, but to the fact that these persons are all breathing, their hearts are beating, and they have worries, dreams, disappointments, memories and fears. These persons are alive, and they are also relational beings as they are involved with their surroundings, continuously tuned in to each other and interacting with each other. A description of family therapy as a dialogue of living persons makes it possible to highlight that 5

9 IN THERAPY TOGETHER the relational context these living persons create together is essential for the therapeutic process. This mutually created relational context serves as the background against which family members will share some of their stories and leave other stories untold. The central thesis of this book, then, is that this concept of dialogue as a meeting of living persons can help us address the mutuality of human relationships, as well as the complexity of listening and understanding. 6

10 INDEX Accountability, ethics of Alliance, therapeutic 35, 36, 38, 48, 72, 73, 198 Atttunement 4, 38, 39, 41, 42, 44 47, 50, 53, 92 93, 95, 97,105 Children 29, 49, 74, , 119, Common factors 37, 199 Complexity 47, 48, 134 Context, social 37, Conversational tool 67, 92 Deference, the client s 43 Dialectics of yes and no 26, 30, 64 Dialogical Feedback Scale (DFS) 74, 84 88, 90, 92, Dialogical Feedback Tool (DFT) 74, 76 83, 84, 92, , 204 Dialogical understanding 164 Dialogue 5, 39, 40, 67, 105, 107, 156, 160, 199 Dialogue, family therapy as a 31, 35, 51 52, 67 Drawings, children s , 191 Empowering 144 Enactment 93, Feedback 44, Good reasons 19, 112, 115 Hesitations 19 27, 30, 64, , 117, 119, 135, 141, 189 I-Thou (Buber) 40, 53, 96, 126, 201 Listening 121, Listening with the ears 128 Listening with the eyes 130 Listening with the heart 134 Love 2 Medical model 1, 198 Nonviolent resistance 175 Other 107 Outsider witnesses 175 Problem-diagnosis-treatment model 1, Problem-saturated stories Process 46 Protocol 9, 28, 60 Reflexivity Reflexivity, horizontal 44 46, 128, 162 Reflexivity, vertical 43 46, 128, 160 Research, psychotherapy 35, 38, 49, 51, 174, 198 Respect 53 Responsibility, ethics of Responsiveness/responsivity 4, 41,

11 INDEX Storytelling Tensionality 40, 41 Therapist 28 Worries Worries Questionnaire (WQ) 58 67, 75, 84 85, 88, 90, 165, 188,