The Narratives Which Connect…

Summaries of GT findings and Conclusions

I am more preoccupied with what people think and feel than with which enzyme affects which other enzyme (1, 45). Elisabeth (1)
The GT categories 3, 4 and 5 format the centre of the findings and concerns how the therapist’ personal and private values influence their therapeutic practice. In category 1, some of the participant’s personal experiences from life also enlightening some personal values that the therapists underline as abilities to “see” people’s situations, interests for people and intermediary skills. Rethinking the expert role and always let everybody be heard format foundations for therapists. The influence from category 2, being in therapy for themselves, in this way support the centre of the GT findings. Explicit value systems and strong beliefs naturally point to dilemmas (category 6) that challenge the therapists in their clinical practice.

In this research project, looking for the influence of personal and private lives on family therapy practice has been a major task. This research project documents several categories that have emerged through the GT analytic work, which might be used to explain and give meaning to aspects of the practice of the participating therapists. In some areas, the influence of the therapist’s own values and life experiences seems to form the context for some family therapy sessions.

For example both Karen’s (4) experience of being heard when she attended her own therapy and Elisabeth’s interventions in the family that was hiding the fact that the father had two children from a former marriage stand out as very important histories. I view this as an extremely important finding that give evidence of the need for us to revisit such topics repeatedly, both as a part of clinical practice, and as a part of family therapy education and supervision.

Personal and private values as context for clinical practice

Feather (Furnham, 1997, p. 262) has claimed that value systems “are systematically linked to culture of origin, religion, chosen university discipline, political persuasion, generations within a family, age, sex, personality and educational background”. These value systems are organized in such a way that they also may guide both beliefs and behaviour in many situations, also at work. The participant’s personal and private values seem to influence aspects of their therapeutic work. Categories 3 (Participants’ explicit personal values that influence family therapy practice), 4 (Dynamics that show how personal and moral values influence their therapeutic work) and 5 (Therapists’ acceptance and avoidance that personal and moral values influence their therapeutic work) deal in one way or another with how the therapist’s personal and private values influence her or his clinical practice.

When the relation between values and behaviour is assessed it is important to distinguish values that are espoused from those that are in use. Values are often socially and professionally desirable and that makes them important to express for many professionals. However, that does not necessarily mean that they are in use or show up in practice.

“Therefore, when an individual’s values are different from those that are prevalent in his or her environment (e.g., unit, organization), the values of the social environment may influence what the individual says, but they may not predict how he or she will actually behave” (Meglino and Ravlin, 1998, p 356).
From time to time there is a lack of consistency between what is said and what is done. Erik (2) is very clear when he points out the difference between his own personal and private life and his clinical practice. Erik (2) says that he has never used his own background and moral values directly in therapy (see category 5a, p. 112). He claims: “…obviously, I don’t have any particular ideas about how one should live one’s life” (4, 22). He points out that there has been a ”discrepancy” between his childhood and his life history as an adult (see category 4e, p. 109).

How therapists develop

Research on the development of therapists and how therapists with different gender, ethnicity, age and experience develop is extensive (Protinsky and Coward, 2001; Rønnestad and Skovholt, 2001; Rønnestad and Skovholt, 2003; Beutler et al., 2004; Skovholt and Jennings, 2004; Orlinsky and Rønnestad, 2005). However, the interest in therapists’ characteristics has decreased over the past twenty years due to the focus on manual-driven treatment and randomized clinical trials. Psychotherapeutic treatments are often evaluated as entities independent of the therapists who deliver them. Eventual effects of the therapist as a person are often viewed merely as a “…source of error” (Beutler et al., 2004, p. 227).

It is interesting however to investigate how professionals have found their way to becoming family therapists. It is even more interesting to try to understand what has made them stay therapists for many years. Jennings et al (2003) claim that there is evidence that expert therapists share some characteristics:

“These features include: experience, highly developed characteristics of master therapists, openness to change, cultural competence, and comfort with ambiguity. We believe that these factors characterize expert counseling and therapy practitioners and make an important difference in the quality of the counseling and therapy experience” (Jennings et al., 2003, p. 62).
Of the characteristics mentioned here, topics such as openness to change and comfort with ambiguity are confirmed and commented upon by therapists in my material.

Openness to change

The link between therapy and change is probably one of the most common ideas in the field of psychotherapy. Arguably, most psychotherapists will agree that change is one major goal in clinical psychotherapeutic work with clients. In the field of family therapy a discussion of how change occurs, what is needed to make change occur and how we may understand the phenomenon of change, came to be an important discussion after the publishing of “Change” by Watzlawick, Weakland and Fisch in 1974. These ideas suggest connections with the discussion of how to understand change and balance, and the differences between concepts like steady state, homeostasis and homeodynamics (Watzlawick et al., 1967; Rogers 1970).

Karen (4) claims that her experiences with change from private life have played an important role in understanding what is going on in therapy (see category 3a, p. 100). She draws a direct line from personal and private life to her clinical practice when she comments “…that’s the way I work in any case as a therapist and it’s also true of my life as well” (8, 27).

Erik (2) takes an even more radical stand when he says (see category 3a, p. 100): “…I think that if you’re to survive, then you have to change as well (4, 146). This view of change, as a part of life and of living, influences therapeutic work in a way that raises the question simultaneously of stability or preservation. Erik (2) claims that it may also be necessary to not move too quickly. However, change is something ” you can’t avoid…” (4, 146).

When change is used as a concept both to describe what is going on in life in general and to understand how we move psychologically it is essential to understand that we operate on different levels. At one level we may perceive that all living creatures are part of an ongoing process of change. However, as human beings we are not capable of being conscious of all constantly ongoing changing processes. In our minds, a certain kind of stability or equilibrium is maintained during periods of our lives. Some phenomena, persons and structures seem the same over a period of time. Both first order change and second order change might be included in this kind of equilibrium for periods of time. However, because the process of change is ongoing, this equilibrium will be challenged and this will end in crisis and change from time to time. Thus changes might be viewed in terms of both first and second order change. This point of view also gives meaning to the understanding of therapeutic processes.

Comfort with ambiguity

The research on the importance of the therapist’s experience is very much spread out (Hubble, Duncan, Miller, (eds) 1999; Wampold, 2001; Skovholt and Jennings, 2004; Orlinsky and Rønnestad, 2005). However, according to Christensen and Jacobson ”the evidence for the value of accruing professional experience is weak at best. Interest has also waned in the areas of therapist race/ethnicity, age, and sex” (Beutler et al., 2004, p. 239). This may partly be understood in the context of evidence-based practice. When one believes it is the psychotherapeutic techniques that work, variables such as experience, age, ethnicity and sex do not seems to be very important in the understanding of what works in psychotherapy. The understanding of the therapist’s expertise has in the same way been out of focus in psychotherapy research. Although therapists often claim that they are much more professional as seasoned practitioners than they were as novices this is seldom supported by research: “…empirical research supporting this idea has been slow to accumulate though there has been more work in recent years” (Skovholt et al., 2004, 24).

Therapists and counsellors need to go through many of the same types of processes to develop their practical and clinical skills. According to Skovholt and Jennings there are four signposts on the novice to master counsellor path (Skovholt and Jennings, 2005, p. 1). These are that:

1. 
   It takes Time;
   
2. 
   The essentials include extensive experience in the Domain, will to grow, an open work environment and reflection;
   
3. 
   That novices (a beginner) stay with the big picture (uncertainty) while doing the small picture (certainty); and
   
4. 
   That professional life stages are like personal life stages.
   

These four points emphasize that it takes time to be a good clinician and that clients are the therapist’s primary teacher. It is also clear here that the novice needs structure and that “faced with the heat of the ambiguous complexity of human life, needs help in doing counselling” (Skovholt and Jennings, 2005, p. 1). Finally, these authors compare the stages of professional life with the stages of personal life. In terms of comfort with uncertainty and ambiguity, Jennings claims that

“Tolerance for the elusive—ambiguity, anxiety, disorder, conflict, ambivalence, and paradox seems essential for expertise in the helping professions” (Jennings et al., 2003, p. 68).

Both Erik (2) and Karen (4) comment on these topics (see category 3b, p. 102). Karen (4) even claims that she has never been able to cope with a setting or an organization that demands clarity. Erik (2) takes something of the same stand when saying: “And I think it is important to discover the humane elements in what is inhumane” (4, 136). Erik (2) connects this the ability to see two different views at the same time to ambivalence (see p. 103). Karen (4) makes this point even more strongly by claiming that she likes to work with ambivalent clients (see p. 103).

The ability to handle ambiguity is a central part of these kinds of developments. “The counselor's job is to understand one of hundreds of strains of this complex ambiguity as expressed in the life of one person at one time and then to offer assistance to that person. It takes lots of time to get good at this” (Skovholt and Jennings, 2005, 1). Ambiguity is often presented as a special challenge. To meet ambiguity and live with ambiguity as a part of your daily work can for some therapists be tiring and draining. This could, for example, be the case when clients and the therapist come from different contexts. Jennings remarks:

“Related to working effectively with clients who are culturally different is an inherent comfort with ambiguity. The complex ambiguity of the helping professions can sometimes appear to be so daunting as to make the process of acquiring competence an impossible task. This does not have to be the case. Instead, complex ambiguity can be an asset” (Jennings et al., 2003, p. 67).
As we have seen, ambiguity is an asset for some therapists. Karen and Erik comment on ambiguity and how to handle equivocal situations in different ways. These involve processes that are characterized by unclear understanding and ambivalent feelings.

Living with ambiguity as a therapist is often described as an important characteristic and a special ability that is essential to becoming a psychotherapist (Skovholt et al., 2004). The systemic understanding that analogue communication is equivocal is basic to the understanding of human communication. This means that a “translation” from analogue communication to a digital message never will be able to replace or capture the full meaning of the analogue “messages”. According to Bateson, this understanding of communication as equivocal and paradoxical promotes the development of communication; “…without these paradoxes the evolution of communication would be at an end. Life would then be an endless interchange of stylized messages, a game with rigid rules, unrelieved change or humor” (Bateson 1972, p. 193). We will never fully understand, but we are in the process of understanding.

Inexperienced therapists often try to solve their own frustration in therapy sessions by looking for simplistic solutions and frames of reference through which to view clients in such a way that enables them to avoid being overwhelmed emotionally. This might lead to “premature closure” in therapy sessions. Premature closure is defined as the “tendency to offer only a single solution to any problem that, because of insufficient or ambiguous information, logically permits more than one solution” (Skovholt et al., 2004, 20). With their attitude to ambiguity, Erik and Karen are unlikely to get into situations where premature closure emerges as a problem or a limitation in the therapeutic process.

The influences on a family therapist’s own personal and private life of practicing psychotherapy are also many. It was however easier for most participants to tell general stories (as under GT category 7) of how being a therapist has been a part of forming their personalities as open, listening and tolerant. One special situation where connections between private and personal life occur is when the therapist’s own personal crises and problems in life are of the same kind as the client and may even occur at the same time. I have called this GT category parallel connections. I have chosen to depict and discuss this issue in the following chapter called “paradigm cases”. In an effort to develop these findings further and make it possible to widen the reflections both on systemic family therapy practice and family therapy training, I will in chapter 8. develop a middle range theory that include these findings and that offers some new concepts that might be useful.

The researcher’s personal reflections:

I am overwhelmed! In addition, I am worried. When I started this project I was prepared to accept that very little would come forward in this project. Just by examining my own history as a clinician, I knew that I was not able to tell many stories about direct links between my own personal and private experiences and my clinical practice. It thought it would be more indirect, like links between personal values and practice. The amount of stories from the therapists’ personal and private lives and their therapeutic practices both surprised me and worried me. How could I and we as educators of family therapists’ in Norway avoid all these topics in our education programmes? What should we do next? I was in the middle of writing a proposal for the first Masters degree in Family Therapy and Systemic Practice in Norway. I decided to write in 100 PPD sessions to the proposal although I did not know what it should contain.