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Keywords:

  • relational competence;
  • joint action;
  • therapist-family interaction

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Two levels of interactional process
  5. Therapists’ strategizing
  6. Clients’ strategizing
  7. The dance between therapists and clients
  8. The therapist's relational competence
  9. References

In this article, I argue for a both – and position in regard to manuals. I suggest that manuals are appropriate when describing therapeutic strategizing and technical competence. However, I also argue that they are an inappropriate tool for understanding the contribution of the client's family in family therapy. This argument fuels a further view that manuals cannot capture the dance that occurs between therapist and family. For this type of knowledge, a relational type of competence needs to be developed.

We encourage you to listen to the JFT Editor, Mark Rivett, as he interviews the author on Manuals in the Practice and Research of Family Therapy. Available at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1467-6427/homepage/jft_podcast_series.htm.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Two levels of interactional process
  5. Therapists’ strategizing
  6. Clients’ strategizing
  7. The dance between therapists and clients
  8. The therapist's relational competence
  9. References

My position on the role of manuals in the practice and research of family therapy is critical but not radically critical. In fact, I think and argue that manuals can both help and limit therapeutic action. The issue is about being able to make the distinction. In my view, being able to make this distinction means having theories and methodologies that enable us to distinguish when manuals can strengthen the competence of the therapist and when, instead, they weaken it. I try to show how the ‘both – and’ position that I take is not just an ideological position but a methodological guideline.

Let me start from Bateson. Who better than Bateson can teach us about complementary vision or the connection of opposites?

I want to emphasize that whenever we pride ourselves upon finding a newer, stricter way of thought or exposition; whenever we start insisting too hard upon ‘operationalism’ or symbolic logic or any other of these very essential systems of tram lines, we lose something of the ability to think new thoughts. And equally, of course, whenever we rebel against the sterile rigidity of formal thought and exposition and let our ideas run wild, we likewise lose. As I see it the advances in scientific thought come from a combination of loose and strict thinking, and this combination is the most precious tool of science. (Bateson, 1972, p. 75)

In another work, Bateson introduced the notion of ‘double or multiple comparison’ that clarifies what he means by the phrase ‘a combination of loose and strict thinking’:

This chapter has defined a manner of search that might be called the method of double or multiple comparison consisting in the combination of information of different sorts or from different sources. Such combination results in something more than addition.… Consider the case of binocular vision. I compared what could be seen with one eye with what could be seen with two eyes and noted that in this comparison the two-eyed method of seeing disclosed an extra dimension called depth. But the two-eyed way of seeing is in itself an act of comparison. (Bateson, 1979, pp. 91–92)

Drawing from these ideas I will describe what I call ‘the double description’ of the therapeutic process and then use this to reflect more specifically on the role of manuals in the practice and research of family therapy.

Two levels of interactional process

  1. Top of page
  2. Abstract
  3. Introduction
  4. Two levels of interactional process
  5. Therapists’ strategizing
  6. Clients’ strategizing
  7. The dance between therapists and clients
  8. The therapist's relational competence
  9. References

Any interpersonal or social interaction can be analysed from the point of view of the individuals or from the point of view of the relationships among them (Fruggeri, 2002). When we choose to describe an interactional process from the individual point of view we focus on how people take part in interactive processes. From this perspective it is possible to point out the ways in which people make sense of their world(s), including themselves, others and the situations they cope with, and how they act accordingly. When we describe how individuals take part in interactional processes we can stress feelings, meanings, goals and behaviour. We may also indicate how forms of behaviour are connected to feelings that are connected to meanings that, in turn, are connected to forms of behaviour that are then connected to goals.

But while the participants in the interaction are engaged in these complex symbolic, behavioural, strategic processes, they also initiate a dance through which they negotiate and co-construct meanings, identities, relationships, roles and social realities (Pearce, 1994). When we choose to describe this joint process, we point out the relational construction implied in any human interaction. From this perspective we do not underline how people take part in an interaction but we focus instead on what they do together.

The two levels together describe the embrication (Varela, 1979) of the individual and relational processes implied in any social and interpersonal interaction. An individual enters into a social-relational-interactional situation starting from premises (such as the definition of self, goals, representations of others, prejudices, culture and education) developed in previous social-relational-interactional experiences. Participation in the present interactional situation confirms or changes old meanings and realities and and creates new ones, which will constitute the premises through which they will participate in further and future interactional situations through which they will confirm, transform and generate old and new meanings and realities. The interactional process is fed by the contributions of all the participants, and constructs realities that are generated in joint actions. The distinction between the individual and the relational levels of interaction is helpful when analysing the processes of psychotherapy (Fruggeri, 2002).

Therapists’ strategizing

  1. Top of page
  2. Abstract
  3. Introduction
  4. Two levels of interactional process
  5. Therapists’ strategizing
  6. Clients’ strategizing
  7. The dance between therapists and clients
  8. The therapist's relational competence
  9. References

The individual level of the therapeutic process shows its lineal and strategic dimensions. I am aware that after the critiques of the strategic approach, the word ‘strategy’ evokes an attitude by therapists towards clients that is both unilateral and disrespectful and might sound wrong to many ears. But it is my intention to use the term strategy in its literal meaning: that is, as ‘a plan of action designed to achieve a long-term or overall aim’. According the Oxford Dictionary ‘strategic’ means ‘designed or planned to serve a particular purpose’.

In fact, if we focus on the therapeutic process from the point of view of therapists, we focus our attention on their thoughts, intentions, decisions and language. We could talk of goals, descriptions, ideas and theoretical models or even of prejudices, values, ideology and actions. At the individual level of analysis, we attend to the way in which all these elements connect with each other in a pattern that could be defined as the way in which the professional participates in the interaction with the client. At this level of analysis we underline the strategic dimension of the therapeutic intervention that is the process of generating plans of action, evaluating them and deciding on which course to follow. As Karl Tomm puts it, therapists

are continually making decisions on a moment-to-moment basis as the interview unfolds. In effect, they are posing questions to themselves and are answering them, either consciously or non-consciously. Some of these questions might be: ‘Which hypothesis should I explore now?’; ‘Is the family ready to talk openly about that subject?’; ‘What would it mean not to explore that area just yet?’; ‘Which question should I ask?’; ‘What effect do I want?’ … and so on’. (Tomm, 1987, p. 6)

According to Tomm the answers to these questions arise from ‘the therapist's history of socialization as a human being in general and of his or her specific development as a therapist’ (p. 6). We could also add that the answers to the above questions arise from the position occupied by therapists in the institution to which they belong.

Figure 1 shows how therapists, according to their theoretical model (but also to their institutional objective, to the prejudices they share as members of a social community and to their beliefs, culture and education), make sense of the situation and make decisions to do this or that in order to help their client. The therapists’ strategizing implies different types of professional competences: namely a reflexive competence, an institutional competence and a technical competence.

figure

Figure 1. The strategic level of the therapeutic process from therapists’ point of view

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Reflexive competence refers to the ability to reflect on one's own prejudices, beliefs or cultural premises. In fact, therapists are responsible for becoming aware of points of view that could limit their understanding of the situation and their potential to help. As Cecchin has often underlined, prejudices are not necessarily negative, nor is acknowledging a prejudice sufficient to be able to overcome it (see Cecchin et al.,1992). Nevertheless, reflexive competence helps therapists to develop an awareness of the limits of their knowledge. Reflexive competence emerges through participation in team discussions and in conversations with colleagues but also through the acquisition of others’ reflections on this issue.

Institutional competence refers to knowledge of the organization, task, rules and procedures of the setting within which a professional operates. Therapies take place in social and institutional contexts determined by rules, procedures and objectives. Reflection about the difference between private and public settings, or between enforced or free access agencies has made a pivotal contribution to the development of systemic family therapy (Campbell and Draper, 1985; Fruggeri et al.,1991).

Technical competence refers to knowledge of theories, techniques and methodologies, and the ability to apply them. It develops from participation in a training course and grows through the continuous education that professionals acquire through supervision, seminars, workshops, conferences and reading. It is in the development of technical competence that manuals have a great role. Technical expertise must have a foundation in scientific studies that document the validity of models through research protocols, standardized procedures and treatments. Sophisticated systemically oriented manuals are able to take into account the context, in both its physical and symbolic dimensions, as a constitutive element of psychotherapy. In other words, some manuals can point out how different techniques should be used in different ways in different institutional and cultural contexts.

It is important both for the inexperienced and for the experienced therapist to be able to describe the principles of their chosen approach. In teaching a model, operational methods such as manuals can be essential. They also allow therapists to demonstrate that they do put into practice what they say they do. This is an appropriate role for manuals. All this pertains to the technical responsibility of therapists, as well as to their reflexive and institutional ones. But as I will argue, these skills are not the only ones that are evident in the process of therapy.

Clients’ strategizing

  1. Top of page
  2. Abstract
  3. Introduction
  4. Two levels of interactional process
  5. Therapists’ strategizing
  6. Clients’ strategizing
  7. The dance between therapists and clients
  8. The therapist's relational competence
  9. References

It has been pointed out that the emphasis upon the application of a technique and the consequent privileging of technical expertise has led family therapists to avoid exploring how families think and feel in family therapy (Teacher, 1992). Yet, in the therapeutic process, families also form a significant part of the interaction. Professionals are not the only ones who individually construct and act in the therapeutic context. Clients are engaged in the same kind of process. They respond to the interventions of professionals according to the sense they make of what the professionals do, that is according to their own way of constructing the situation and in order to achieve their own goals, whatever these may be. Paraphrasing what Tomm wrote about the strategizing of therapists, we could say that clients also make decisions on a moment-to-moment basis as the interview unfolds. Clients, as well as therapists, pose questions to themselves and answer them, either consciously or non-consciously. They might, in fact, wonder about the therapist's questions or wonder what could be more helpful for the therapist to know. Families act in order to protect their integrity and express their feelings; they have expectations about what a therapist should do in order for them to feel helped and they evaluate to what extent the therapist is doing just this and so on.

Figure 2 shows that clients do not have formal theoretical models to refer to but they have naive or implicit theories, previous experiences, prejudices, cultural views and personal goals according to which they also make sense of what is happening. Let us describe the strategic level of the therapeutic process from the point of view of a client in a client's words; no technical or scientific language could do it better.

figure

Figure 2. The strategic level of the therapeutic process from clients’ point of view

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John Perceval is a gentleman who writes a diary of his treatment in a psychiatric hospital of the nineteenth century. In that diary he gives an explanation of the aggressive behaviour that he used in the presence of his doctors. He wanted them to have evidence of his madness and the reason he wanted them to think he was mad is described in the following excerpt:

I knew that, of all the torments to which the mind is subject, there is none so shocking, so horrid to be endured as that of remorse for having injured or neglected those who deserved our esteem and consideration. I felt for my sisters, my brothers, and my mother: I knew they could not endure to look upon what they had done towards me, to whom they were once so attached, if they rightly understood it; that they could know no relief from the agony of that repentance which comes too late, gnawing the very vitals, but in believing me partly unworthy of their affection; and therefore I often gave the reins to my pen, that they might hereafter be able to justify themselves, saying he has forfeited our respect, he has thrown aside the regard due to his parentage and to his kindred – he has deserved our contempt, and merited our abandonment of him. (John Perceval's narrative of the treatment experienced by a gentleman, 1840 reported in Bateson 1978, p. 49)

This excerpt from John Percival's diary is a vivid example of how clients continually intervene in the interaction with therapist, contributing to the outcome of the intervention itself. This acknowledgment of the point of view of the client is exactly what challenges the idea of ‘doing therapy by the book’, so let me further elaborate on this issue through a clinical example.

Marta and Ivan Panni (pseudonyms) have seen a family therapist (Dr Rose) for some sessions because of the behaviour of their 15-year old son (Fabio) who had become aggressive and refused to go to school. The following extract is taken from a conversation among them and a second family therapist (Laura) to whom they had been referred after an unsuccessful previous experience:

Marta

Every time I say something he says the opposite.

Laura

Your wife complains a lot.…

Marta

Yes I do.… Dr Rose told you again and again but here we are at the same point!

Laura

So may be this means that complaining is useless.

Marta

Exactly!

Laura

Have you ever thought of a different way? It's … how many years?

Marta

Twenty-two.

Laura

‘You have been complaining for 22 years without any result. You have taken him [Ivan] to many therapists so they could tell him to behave differently … again without results.

Ivan

Every time it looked as if it were our fault, as if myself as father and she as mother weren't able to raise our children. It seemed that the cause of Fabio's problems was the fact that we [the parents] didn't go out together.

Unfortunately, Marta and Ivan Panni did not keep a diary of their therapy and we therefore have no documentation to show that Ivan Panni acted in therapy sessions in order to protect himself from feeling he was a bad father, but what he says allows us to hypothesize he did. From his previous therapeutic experience, he got the idea that family therapists blame parents. In the first extract he is interacting with the second family therapist (Laura) according to the premise generated in interaction with the first one (Dr Rose). Nothing has been said by Laura that would confirm Ivan's idea, yet Ivan acts according to the premise previously developed.

Most of the time, therapists describe their job only from their own point of view, they make sense of what is happening from their own understanding, and act according to the principles of their model, which is eventually described in manuals. But as we have argued, clients are very active in determining the direction of the therapeutic process. This is why it is important to acknowledge that a description of the therapeutic situation that ignores the contribution of the client can make the therapist blind to the interactional process that takes place with the contribution of everyone involved.

The dance between therapists and clients

  1. Top of page
  2. Abstract
  3. Introduction
  4. Two levels of interactional process
  5. Therapists’ strategizing
  6. Clients’ strategizing
  7. The dance between therapists and clients
  8. The therapist's relational competence
  9. References

While professional and client are engaged in their individual construction processes, they also participate in a cooperative dance, a joint action through which they negotiate and co-construct who they are, what they are doing together and what the situation is that they are involved in, as shown in Figure 3.

figure

Figure 3. The construction of psychotherapy

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The analysis of this level of the therapeutic process does not pertain to the professionals’ ideas or actions, goals or expectations, nor the clients’ ideas, actions, goals or expectations. At this level, the analysis implies a description of interactions, that is, of the joint action of therapist and client and of the meanings generated within it. It should be noted that the process of co-construction here described is not the same as the therapeutic alliance (Carpenter et al.,2008) or, generally speaking, the empathy and emotional connectedness conveying understanding and respect among therapist and client. The relational analysis of the therapeutic process as conceptualized here refers to the process of co-construction, that is, the joint action through which clients and therapists generate identities, relationships, social worlds.

The outcome of joint actions is not unilaterally determined. Joint actions have unintended consequences (Shotter, 1987). In the process of co-construction the outcome can, in fact, be the opposite of the effect that therapists would like to produce according to their approach or model. Roy-Chowdhury (2006) presents a very effective example of how a therapist, wanting to remain faithful to her model of a non-directive, non-expert, curious approach, ends up by not listening to the clients who were searching for advice while another therapist, by accepting an expert position, contributed to the construction of a context in which everybody felt respected and competent. Roy-Chowdhury (2006) claims that a therapist observing the interactional process taking place during the unfolding of the session, should raise the following types of questions:

How does this utterance position the speaker in relation to other interactants and how does it position me in relation to her? What is the purpose of constituting these positions at this moment in the conversation? What do the ways in which discourses are being evoked say about the individual and her history, and what does the individual's history say about the ways in which discourses are being evoked? (Roy-Chowdhury, 2006, pp. 170)

With this list of questions Roy-Chowdhury draws attention to the therapist – client conversation as a way of exploring what therapist and client are doing together. Indeed, several studies on family and family therapy discourses (Aronsson and Cederborg, 1994; Ervin-Tripp et al.,1984; Klein et al.,2007; Ochs and Taylor, 1992, 1996; Tannen, 2007) have clearly shown that family hierarchy, identities, roles and psychological states are continuously constructed and deconstructed through the use of particular conversational strategies. In fact, the reciprocal positions that individuals take in interaction are bound by the type of discourse that is taking place (Harré et al.,2009), which means that different types of conversational contexts allow for the emergence of different types of relationships and identities.

The following extract from the same family therapy session quoted above, shows how in the context of exploring the relationship between father and son, the father Ivan emerges as inadequate independent of his attempt to show how good a father he is; the therapist Laura loses her neutral position independent of the interventions aimed at reconstructing a balance in relation to the parental couple and the mother Marta appears as the person who boycotts the therapy even if she is the one who strongly seeks it and, overall, wants her husband to be in it. In other words, the context of exploring the relationship between father and son, that, per se, is a fundamental principle of family therapy, contributes, in this case, to the construction of the opposite of what is intended:

Laura

So when you and your son are together he tells you …

Ivan

Yes, many things.

Laura

Does he talk about himself?

Ivan

No, not about himself. He hides certain things. That's the way he is.

Laura

Does he talk about his wishes?

Ivan

Yes, his wish is to become a model, but I say

Marta

When does he talk to you? I have never heard this.

Ivan

Yes, he does … also the other day …

Laura

Signora, may be every once in a while your son and your husband talk to each other when you are not around.

Ivan

Exactly!

Marta

I am not sure!

Ivan

I tell Fabio that he has to behave well. At home we have rules that he needs to respect. He says, ‘I have to study, leave me alone’. He always has some excuse.

Laura

Does he have excuses for not spending time with you?

Ivan

I know, I know!!

Laura

And what explanation do you have?

Ivan

I think that …

Marta

We are not a perfect couple.

Ivan

But no, we are a couple like many others. When you work …

Marta

Don't bother me about work; everyone in the world works.

Laura [to father]

Let's go back to the question I asked you: what is your explanation for Fabio's problems?

Ivan

I am not very educated. I only have the 5th grade so I don't know

Marta

You know nothing!

Ivan

It could be but I decided to work and I like my work and I am happy with my choice. I always say this to Fabio.

Laura

What future do you imagine for your son?

Ivan

I don't know.

Laura

What would you like him to do?

Ivan

I'd like him to become a good worker!

Marta

What? You don't know what you are saying! A worker? He is studying for the University.

Laura

Your wife would like you to be more authoritarian …

Marta

Exactly!

Laura

They all ask you to do something: your wife asks you to be more authoritarian with your son, and your son with your wife. And you in front of these requests …

Marta

He lets things go!

Laura

You don't seem to want to be more authoritarian. Maybe they are asking you to do something that you don't want to do!

Marta

But overall he doesn't want to come here. He just doesn't understand that Fabio has problems!!

Ivan

No.

The therapist then consults with her colleagues and reflects that it is not a matter of asking the right question; it is rather a matter of changing the context of questioning. And the therapist is aware that in order to change the context of the conversation she has to change her position in it (Harré et al.,2009; Jones, 2003). Following this, the therapist decides to abandon the exploration of relationships and chooses to explore individual issues as a way to position herself differently, and in so doing to move away from a context that has been shown to allow for only negative identities for everyone involved. This is revealed in the following extract:

Laura

Signora, when you called asking for therapy you said that Fabio was afraid that he will be called finocchio [faggot].

Marta

Yes.

Laura

Who thinks he is?

Marta

At the beginning I thought he was.

Laura

Since when?

Marta

When I saw that he didn't go out, he was a bit feminine, he was so attached to me; also Dr Rose said he needed to get closer to his father. At that time I was afraid he was …

Laura

And now?

Marta

No.

Laura [to Father]

And you?

Ivan

No!

Marta

He never was … he never thought he was!

Laura

And Fabio, does he have doubts about being gay?

Marta

Yes, he has said so to Dr Brown [a psychologist that he had seen before the first family therapist]. Dr Brown told me that Fabio had told him. But he told me that it was not true, Fabio was not gay, and that if I had doubts I had to tell Fabio. So during a session, Dr Brown said it and Fabio looked at me: ‘Mother I can't believe it! You are just like all the others’ and since then he lost his trust in me [Mother cries].

Laura

Signora, do you still have this doubt?

Marta

No, not now, at that time I was afraid, not that I knew, I was afraid.

Laura

And do you think that Fabio has doubts that you still have this doubt?

Marta

I don't know.

Ivan

Maybe, yes.

Laura

With whom would Fabio talk to if he decided to talk about this topic?

Ivan

I think with his mother. But I also think that he might have the courage to tell me, too. Even if with his mother it would be different.

Laura

You know, there is something that I can't explain to myself! I see you as very accepting and benevolent. So one would expect that a son would also feel safe to talk about this, but Fabio doesn't feel safe, he fears the word can't be said! If he were gay and would like to talk …

Marta

I would accept him as he is.

Ivan

Anything.… he will always be my son.

The decision made by the team in this case refers to a type of competence that is different from the technical one. It is a second-order competence that implies the ability to understand what therapist and client are doing together while the therapist is acting at the strategic level.

The therapist's relational competence

  1. Top of page
  2. Abstract
  3. Introduction
  4. Two levels of interactional process
  5. Therapists’ strategizing
  6. Clients’ strategizing
  7. The dance between therapists and clients
  8. The therapist's relational competence
  9. References

Family therapists are interested in family processes, patterns and dynamics. The therapeutic interview is at the same time a means for understanding and a way of constructing new stories, new connections and new meanings that can help clients overcome problems, troubles and pains. In this pursuit therapists are supported by their technical competence. But while they understand and try to help, they engage in an interactional process that produces effects that are not unilaterally determined; the effects are the outcome of joint actions. Not deriving from the intentions and unilateral actions of therapists, the interactional dance may produce unintended consequences. The second extract above is an example of this. Marta (the mother) wanted very much to involve her husband in family therapy, being convinced that this would solve their problems. Ivan (the father) wanted very much to show his competence as a father. Laura (the therapist) wanted very much to explore their relationships in order to offer the opportunity to see new connections and meanings. Together they constructed a context within which none of them emerged as what they wanted to be; instead each became an obstacle in the path of everybody else. Talking, instead, about individual issues of the designated problematic person (the last extract above) constituted a context within which healing feelings, emotions and words could be expressed.

In other therapies with other families with different stories, the context of exploring relationships can be helpful in constructing positive identities, new meanings and enlightening connections. For this family, such a context proved to be unhelpful if not dangerous for the relationships and identities of everyone involved, therapist included. On the other hand, the kind of conversation that emerged as helpful for Marta and Ivan Panni could become, for other families, an occasion for blaming each other.

The ability to make these distinctions implies a type of expertise that I define as relational, a type of competence that enables therapists to observe and understand what they are doing together with their clients. Relational competence refers to the ability to contribute to the construction of interactive contexts within which clients develop the answers to their needs and can show their competence. Relational competence implies a process – oriented approach that is implemented in the moment when one is part of the process analysed. From this point of view the expertise of the therapist is shown when she is able to take a directive position that opens space for the others; when she is able to address individual issues that generate the context within which relationships can be addressed; when she is able to give up her technical competence in order to construct the clients’ competence. The answer to the question of whether it is necessary to take a directive or a non-directive position or to explore relationships or individual issues is not found in manuals.

The development of such competence requires training in analysing the interaction of which one is a part. It requires the skill of making sense of the unexpected and the acknowledgment of the unknown. Manuals, in their inevitable fixity, assertiveness and predictability are useful tools for developing technical expertise but can they be an instrument for developing, enhancing or supporting relational competence?

In this article I have argued that the answer to this question is ‘No’. Rather, learning relational competence requires a different sort of research; one that is focused on conversations between the family and the therapist, with the aim of pointing out the coordinated dance of negotiation of identities, relationships, hierarchies, psychological states, social realities and so on. This could be a good starting point for training therapists to enrich their relational competence; that is, for training them to find guidelines for their practice in the development of the interactive process in which they are engaged with clients.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Two levels of interactional process
  5. Therapists’ strategizing
  6. Clients’ strategizing
  7. The dance between therapists and clients
  8. The therapist's relational competence
  9. References
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