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Keywords:

  • Epistemology;
  • Integrative;
  • Poststructural;
  • Social Constructionism;
  • Structural;
  • Systems

Abstract

  1. Top of page
  2. RESUMEN
  3. AN ORGANIZATIONAL MAP
  4. QUESTIONS
  5. EXAMPLES OF INTEGRATIVE APPROACHES
  6. CONCLUSION AND IMPLICATIONS
  7. REFERENCES

Integrative approaches seem to be paramount in the current climate of family therapy and other psychotherapies. However, integration between and among theories and practices can only occur within a specific epistemology. This article makes a distinction between three different epistemologies: individualizing, systems, and poststructural. It then makes the argument that one can integrate theories within epistemologies and one can adopt practices and some theoretical concepts across theories and across epistemologies, but that it is impossible to integrate theories across epistemologies. It further states that although social constructionism has influenced much of contemporary psychological thinking, because of the divergence between a structural and a poststructural approach, constructionism looks different depending upon one's epistemological stance. Examples of integration within epistemologies and of what looks like integration across epistemologies (but is not) further illustrate these important distinctions. The conclusions reached here are crucial to our philosophical considerations, our pedagogical assumptions, and implications for both research and a reflexive clinical practice.

RESUMEN

Los enfoques integradores parecen ser primordiales en el ambiente actual de terapia familiar y otras psicoterapias. Sin embargo, la integración entre teorías y prácticas solo puede ocurrir dentro de una epistemología específica. En este artículo se hace una distinción entre tres epistemologías diferentes: individualizadora, sistémica y postestructural. Luego se argumenta que uno puede integrar teorías dentro de epistemologías y adoptar prácticas y algunos conceptos teóricos a través de teorías y a través de epistemologías, pero que es imposible integrar teorías a través de epistemologías. Además se establece que aunque el construccionismo social ha influenciado gran parte del pensamiento psicológico contemporáneo, a raíz de la divergencia entre un enfoque estructural y uno postestructural, el construccionismo cambia según la postura epistemológica de cada uno. Se proporcionan ejemplos de integración dentro de epistemologías y de lo que parece integración a través de epistemologías (pero no lo es) para poner de manifiesto estas distinciones importantes. Las conclusiones a las que se llega son decisivas para nuestras consideraciones filosóficas, nuestros supuestos pedagógicos y las implicancias para la investigación y la práctica clínica reflexiva.

Palabras clave: epistemología, integrador, postestructural, construccionismo social, sistemas

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There is a common refrain in much of my teaching experience, often posed as a question, in which I invite students to “think about their thinking.” When they tell me how they are relating to a particular client, I ask them what thinking informs their work. When they ask a question, either of a client, or in a classroom or workshop situation, I usually want to know what led them to that question, how is the question important to them, how are they thinking about it. In other words, I ask them to be epistemologists. Epistemology is often defined as the theory of knowledge, also stated as “knowing what we know” or “thinking about how we think”; this indicates a reflexivity that is of signal importance in our work as therapists. It is an invitation to position ourselves in a way of thinking so that the practices we employ and the theories we follow are consistent and congruent. It is counter to a “seat of the pants” approach or to a performance of “whatever works.” It is thoughtful and intentional.

I position myself within a poststructural epistemology; this is in contrast to a structural one, in which I include both an individualizing and a systems perspective. Structuralism is an intellectual movement with beginnings in the early to mid-20th century; it posits that every system has a structure that is “real” and that lies beneath the surface of meaning. As a model that has been applied to sociology, anthropology, psychology, literary theory, and architecture, it emphasizes logical and scientific results. By the 1980s structuralism came under fire from such philosophers and literary theorists as Michel Foucault (1972, 1980) and Jacques Derrida (1978, 1981), who argued that the study of structures is culturally conditioned and therefore subject to historical changes. Their point of view came to be known as poststructuralism, which is not only a critique of structuralism, but also a positioning that seeks to understand how knowledge is produced. The poststructuralist will argue that historical conditions change how one interprets meaning, and that it this interpretive frame that is important to one's current understanding. Further, poststructuralism highlights how sociohistorical forces, and the discursive practices located within particular sociocultural contexts, constrain and govern behavior (Foucault, 1972).

One of the ways that a poststructural philosophy influences the field of psychology, and by extension family therapy, is to understand meaning as “a variety of local and partisan truths that may be told about everyday life” (Miller, 2006, p. 270). Thus, instead of generalizing from individual experience to some larger meaning that underlies it—a structural approach—the therapist co-researches (Epston, 1999) with the client what meaning an experience has for that specific person in this particular time.

AN ORGANIZATIONAL MAP

  1. Top of page
  2. RESUMEN
  3. AN ORGANIZATIONAL MAP
  4. QUESTIONS
  5. EXAMPLES OF INTEGRATIVE APPROACHES
  6. CONCLUSION AND IMPLICATIONS
  7. REFERENCES

In my teaching I attempt to help students understand different theories in terms of how each approach considers “persons,”“problems,” and “change (Zimmerman & Dickerson, 1996; i.e., personality theory, pathology, and therapeutic approach). When I first taught an undergraduate psychology course in theories and methods of counseling I used an exercise I had developed (Dickerson & Zimmerman, 1995) that allowed participants to consider how we name a problem from three different epistemologies: an individualizing one, a systems approach, and a social constructionist/poststructural way of thinking, and how this can influence both the client and the therapist in terms of client identity and therapeutic process. With my students, we considered each of these different epistemologies from the person/problem/change understanding and developed an organizational map to parse out the different theories.

This map delineates these three separate epistemologies and then understands several different theories as situated within those epistemologies. The “practices” of each theory flow from the thinking and are purportedly consistent with the theoretical formulation. I prefer the word “practices” to “interventions” or “techniques” because it seems to fit a coresearch approach, whereas the latter two terms appear somewhat directive. (See Table 1 for a graphic representation of this map.) Unfortunately all maps/tables/graphs tend to be structural in form; even a computer-generated 3D graphic is flat and 2D. Our multiple points of understanding of epistemologies, theories, and practices cluster in certain ways with edges that are blurred. They create multidimensions, which we understand differently, depending on our point of view—like understanding constellations in a night sky and forgetting they might be in entirely different galaxies. This table is merely a starting point.

Table 1.  Organizational Map
EpistemologyIndividualizingSystemsPoststructural/Social Constructionist
TheoryFreud, Jung, Adler, Existential, Gestalt, Reality, Behavior, REBT, CT, CBTBowen, Strategic, Structural, Milan Systemic, Integrative ModelsFeminist, Collaborative Language Systems, Solution Focused, Narrative, Just Therapy, Integrative Approaches
Person (Theory of personality)Fixed structure, innate (essentialist)Whole is greater than the sum of its parts, relationship between …Identity “constituted” (constructionist)
Problem (Pathology)Deficit, inability, distortions (within person)Dysfunctional system (within system, between persons)Effects of societal expectations (outside person)
Change (Therapy)Expert approach therapist knowledge privilegedExpert approach therapist in the systemCollaborative, co-construction of alternative possibilities
Analysis of PowerTop downTop downBottom up

An Individualizing Epistemology

Individualizing theories include the historical and traditional listing: Freud, Jung, Adler, Existential, Gestalt, Person-Centered, Behavioral, Rational-Emotive, Cognitive Behavioral, and Reality. Almost any textbook on theories and methods names this group. The term “individualizing” refers to the conceptualization that each of these approaches employs, that is, that persons, problems, and change are individual concerns. Historically, when these theories originated, modernism and essentialism were the prevailing philosophies (e.g., Gergen, 1985, 1991; Winslade, Crocket, & Smith, 1999). There were real things, real objects, real goals, and real understandings about how things are. These individualizing theories fit within a structural frame.

From this perspective the “person” is an essential self with a fixed structure and innate capabilities; actualization is a goal, perhaps unattainable, but certainly something one should strive to attain. Problems are considered inabilities or deficits or distortions, existing inside the person, often caused by early childhood trauma, perhaps biochemically determined, or a reflection of inadequate parenting.

Change, seen from an individualizing epistemology, generally seems to weigh heavily on the therapist's judgment about what should occur as a solution to what the client's problem is. A good example of how this perspective thinks about both problem and change can be found in the Diagnostic Statistical Manual (e.g., Caplan, 1995). Problems are categorized and listed according to specific client states or behaviors. The therapist determines what those are in order to provide a framework for treatment. In a commentary on the current work of revision, the DSM is described as “the guidebook that largely determines where society draws the line between normal and not normal, between eccentricity and illness, between self-indulgence and self-destruction—and, by extension, when and how patients should be treated” (Carey, 2010, p. 1).

Systems

My initial personal foray into the world of psychology was less toward an individualizing approach and more toward a systemic one, since my early learning as a therapist occurred in the 1970s when family therapy was exploding into a psychological field that was previously dominated by individualizing thinking. This paradigm shift created a major reaction, with many believing that a family therapy approach was a practice in search of a theory (Manus, 1966). Now when I teach a graduate course in family therapy, I am often befuddled about how and what to teach. Is this a survey course, a history course, a comparative literature course? What do family therapists actually “do” these days? I ask my students to ask their supervisors (if they even do family therapy—see Fraenkel, 2005) what their theoretical approach is, and I further ask them to find out what it is that these therapists pay attention to in the room. In response I get everything from: “Bowen,” and “Structural with a little bit of Narrative,” to the common response “eclectic.” Sometimes they say: “I do whatever works.” What they pay attention to varies from how people sit in the room, to communication pattern, to the family's attempted solution. I tell my students that family therapy these days is more of an integrative approach, that therapists tend to use a variety of theoretical conceptualizations and interventions across the field of systems thinking (Fraenkel, 2009; Lebow, 2003; Patterson, William, Edwards, Chamow, & Grauf-Grounds, 2009). I often refer to Lynn Hoffman's (1981) question:

Finally, one cannot help but wonder what lies ahead. Will there be a mingling of these tributaries into a mighty river? Will one approach subsume the others? Or will each accentuate its borders and harden into a sect? (p. 337)

Almost 30 years later we know that there has been a mingling, although vestiges of the initial ideas abound. The early approaches continue to influence teachers and students: Bowen's (1978) intergenerational theory, the Mental Research Institute strategic model (Weakland, Fisch, Watzlawick, & Bodin, 1974), the Milan systems work (Selvini-Palazzoli, Boscolo, Cecchin, & Prata, 1980), and structural family therapy, originating at the Philadelphia Child Guidance Center (Minuchin, 1974), are among the most commonly cited. Perhaps one of the first to integrate theories in the family field was Jay Haley (1976, 1984) combining what he learned from those at MRI with Minuchin's approach, developing his own structural–strategic brand of therapy.

Walsh (2010) describes how the field of family therapy has evolved from the paradigm shift of the 1950s into a broad biopsychosocial systemic perspective, not only including biological influences, but also attending to broader sociocultural issues of race, class, gender, and sexual orientation. As well, considerations of the growing diversity of families and the contexts in which they live have become salient. Although problems might continue to be considered as deficits located within a dysfunctional family, there is likewise a focus on family strengths, resilience, and resources.

There are numerous new models: Cognitive Behavioral Family Therapy (Dattilio, 2005), Functional Family Therapy (Alexander & Sexton, 2002; Sexton & Alexander, 1999), Internal Family Systems (Schwartz, 1995, 1999), Emotionally Focused Therapy (Greenberg & Johnson, 1988; Johnson, 2004), and attention to larger systems (Imber-Black, 1988). Integrative approaches include, but are not limited to, Scheinkman's (2008) multilevel road map with couples, Fraenkel's (2009) therapeutic palette, Madsen's (2007, 2009) collaborative therapy, and Weingarten's (2000, 2003, 2004, 2010) work in witnessing and hope.

What happened to influence the evolution Walsh mentions? A possible response is that family therapy benefitted from what became known as the postmodern turn, even though postmodernism had been a philosophical point of view in art, architecture, and literature for some time. Ken Gergen (1985) was the Paul Revere for family therapy, giving the clarion call for a new way of thinking. The Milan group had already been sniffing the scent of something other than the prescriptive ways they were working, as noted in the closing sentence of their seminal article Hypothesizing, Circularity, and Neutrality: Three Guidelines for the Director of the Session:“Can family therapy produce change solely through the negentropic effect of our present method of conducting the interview without the necessity of making a final intervention?” (Selvini-Palazzoli et al., 1980, p. 12). These words ended up being prophetic, for as we now know, social constructionism and poststructuralism changed the way many thought about how the therapy process might work.

What about person, problem, and change (personality theory, pathology, and therapeutic process) from a systems approach? For the systems thinker, the person is in relationship and identity is formed in the relationship process. Instead of focusing on an “internal” structure, the family therapist focuses on an “external” structure. For example, Levy (2006) notes that “… family therapy include(s) the systemic interest in thinking about family interactions as a system (using concepts like boundaries, hierarchy, and role structure) …‘and he notes that this holistic approach’… characterizes individuals as responding to external conditions” (p. 60).

From this perspective, a problem is an effect of something that is not working well within the system, beginning with the earliest double-bind theory of schizophrenia to a multigenerational transmission of chronic anxiety to coalitions and triangulation and on to vicious cycles (reciprocal invitational patterns gone awry). The newer integrative approaches often combine several of these conceptualizations; for example, Scheinkman's multilevel approach considers the problem as (1) embedded in a dance (pattern), (2) stress triggered by social context and/or transitions, (3) intrapsychic vulnerability (from an individualizing model), and (4) intergenerational unfinished business.

Change is a “perturbation” of the system, or as Hoffman (1985) would say, “give it a bump and watch it jump” (p. 388). In the early systemic approaches, the therapist was coach, director, master manipulator, final prescriber, or some combination or permutation of the above. More recent versions often combine these roles, indicating the lean toward both social constructionism and integration. Fraenkel (2009) bases his approach to change on a combination of time frame, degree of directiveness, and change entry point; this positions him as therapist to utilize a variety of practices, moving from inquiry to psychoeducation to positive connotation, as an example. Many systems therapists currently see their stance as a collaborative one (e.g., Fraenkel, 2009; Scheinkman, 2008), encouraging clients to be participants in actively shaping the process of change. It is difficult, however, to totally eschew the “expert” role, somehow assigning more credence to the therapist's knowledge and coming across as knowing what is best for the client (e.g., Guilfoyle, 2003; Madsen, 2007, 2009; Winslade, 2005, 2009).

Even with the evolution in the field of family therapy, I think of a systems approach as a structural one. This is based on an understanding of the family having a structure with established properties and existing within and being affected by external social structures.

Poststructuralism

Although I have described this term previously, it is a particularly slippery one. It is often used interchangeably with a similar expression, postmodernism, and sometimes conflated with the phrase social constructionism; however, the three actually describe quite different processes. Considering these expressions as similar can lead to confusion about how one is thinking (e.g., Hoffman, 1992).

Postmodernism is most appropriately thought of as a philosophical movement, one that sprung up in the late 20th century primarily in the writings of the French philosophers and literary theorists (e.g., Derrida, 1978, 1981; Foucault, 1972, 1980). It was a contrast to modernism and a critique of that philosophy; and it influenced the arts, architecture, literature, cinema, journalism, and design, among others, long before it infiltrated the field of psychology. What postmodernism introduced was a focus on multiplicity: multiple views, multiple possibilities, and multiple lives. Along with the influence of social constructionism, what previously was held as “true” and “real” became suspect; there were many truths available and what once before had been construed as reality was now considered a negotiated experience.

Vivien Burr (2003) calls postmodernism “The cultural and intellectual backcloth against which social constructionism has taken shape, and which to some extent gives it its particular flavour …” (p. 10). Burr defers to Gergen (1973, 1985) for a definition of social constructionism; Gergen (1985) states that “… it begins with radical doubt in the taken-for-granted world” (p. 267) and argues that all knowledge is historically and culturally specific. From this perspective, all meaning is socially negotiated, thus countering essentialism and realism; Burr notes that “… the proper focus of our enquiry (is) the social practices engaged in by people, and their interactions with each other” (p. 9). Social constructionism impacted psychology and therapy by challenging empiricism (Gergen, 1985) and the notion of the “scientist-therapist” (McNamee & Gergen, 1992). What clients say about their experience is no longer what the “expert” therapist interprets and thus knows but now becomes open to a collaborative process of questioning, listening, and a mutually constructed meaning.

Poststructuralism is more specific, although it is embedded within the postmodern, social constructionist philosophy. It is a distinct response to and a critique of structuralism; it “… challenges any framework that posits some kind of structure internal to the entity in question, whether we are talking about a text, a family, or a play” (Hoffman, 1992, p.7). Most trace a poststructural viewpoint to Foucault's (1980) writings with his emphasis on knowledge and power, strikingly his argument that people have power in direct proportion to their ability to participate in the discourses that shape society. Or as Stephen Madigan would say: “Who has the story telling rights to the story being told?” (Madigan, 2010).

Joshua Levy (2006) offers a helpful metaperspective on understanding structuralism and poststructuralism as he distinguishes between a family systems structural family therapy and narrative family therapy. This article is in the wake of an earlier discussion among Minuchin (1998), Combs and Freedman (1998), Tomm (1998), and Sluzki (1998). Levy's meta-analysis from a social theory perspective situates a narrative metaphor clearly in an interpretive approach (e.g., Geertz, 1973, 1986), distinguishing it from structural theory by using macro and micro perspectives. From a philosophical frame, he notices the hermeneutic tradition of emphasizing meaning in a collaborative manner, with client and therapist tentatively negotiating what might be the client's experience. He further indicates that it is poststructuralist literary theory (and he refers to Derrida, 1978) that greatly informs an interpretive approach.

We might then wonder if there are specific theories/therapies that the postmodern/social constructionist/poststructural philosophy engendered? Most theorists would say “yes,” and they would name Anderson and Goolishian's (1988) Collaborative Language Systems, de Shazer and Berg's (1992; de Shazer, 1985) Solution-Focused Therapy along with O'Hanlon's (O'Hanlon & Weiner-Davis, 1989) Solution-Oriented Therapy, Narrative Therapy as initiated by Michael White and David Epston (1990; White, 2007), and Just Therapy (Waldegrave, 1985, 2009) out of Wellington, New Zealand. These therapies situate themselves in a poststructural, social constructionist epistemology because they all think of the “person” as “constituted,” rather than as essential, as dependent on context, and as having access to multiple identities. They consider “problem” as constructed in response to, or as supported by dominant discourse, as not fitting what is considered “normal,” and as therefore somehow aberrant. And they think of “change” as a collaborative endeavor with therapist and client in conversation about possibilities and preferences. From a “person,”“problem,”“change” understanding, these theories/therapies are quite different from either the individualizing or the systems approach.

One can also situate many feminist approaches in a poststructural epistemology. Certainly later versions as exemplified by Goldner (1998, 1999) are more clearly socially constructed and poststructural in their approach. Also, many narrative therapy ideas have a history in feminist thinking (see Denborough, 2009; Gremillion, 2003).

Practices

What are the ways of practicing from these three differing epistemologies? They are multiple, although a close attention to the various theories shows an interesting cross-fertilization. It is not a surprise that the psychoanalytic, Jungian, and Adlerian approaches share practices (interpretation, dream analysis) or that Existential and Gestalt practices look somewhat similar; the behavioral therapies, especially Rational Emotive Behavior Therapy, Cognitive Therapy, and Cognitive Behavior Therapy, use disputation as a key way of working; and Reality Therapy utilizes some Adlerian techniques.

Once a systems approach became an alternative way of thinking, it made sense that the early practitioners used what they knew. Some of the early, more psychodynamic family therapists did a fair amount of interpretation, shifting what they understood from individuals to families. The MRI, PCGC, Haley, and Milan followers interpreted, too, ensconcing their thinking in complex formulations about problem formation and family structure and functionality. Paradoxical interventions, symptom prescription, reframing, enactment, and positive connotation were elegant interpretive practices, whether it was that the “solution is the problem,”“the structure is the problem,” or the “problem serves a function.” Recent integrative approaches within a systems epistemology utilize a variety of methods from different approaches (see examples above and further on from Scheinkman and Fraenkel).

When social constructionism/poststructuralism came along, it was no surprise that some of the practices looked amazingly familiar. In particular, a solution-focused session might be full of “strategic” practices with many ways of working in a “brief ” manner. The “miracle question” is not a far departure from “the question” in an Adlerian approach. However, the collaborative language systems approach focused on “not knowing,” letting the client tell the story and being curious about that. Even so, it is difficult to totally free oneself from a position of power (e.g., Guilfoyle, 2003). Narrative therapy's practices often seem like a radical departure, situating the work in “deconstruction,” including externalizing, asking effects questions, looking for unique outcomes, or what White (2000) began to call what is “absent but implicit,” all of which are tied to the particular way of thinking that a narrative approach embraces.

QUESTIONS

  1. Top of page
  2. RESUMEN
  3. AN ORGANIZATIONAL MAP
  4. QUESTIONS
  5. EXAMPLES OF INTEGRATIVE APPROACHES
  6. CONCLUSION AND IMPLICATIONS
  7. REFERENCES

Social Constructionism, Structuralism, and Poststructuralism

Is our contemporary psychotherapy world influenced by social constructionism? It seems so. My current students in a family therapy class are in a program that is CBT oriented, and they work in an on-campus clinic where the predominant thinking is from an individualizing perspective. In their conversations in the classroom and the papers I receive, I understand that they are interested in the client's meaning, wanting not to impose their own, even though they often inadvertently end up “pushing their agenda.” I suspect their concern about meaning as local and socially negotiated is a sign of the influence of constructionism. There is, however, a difference between a way of working that is “informed” by social constructionism, and one that comes from a social constructionist “perspective.”

For example, in some of the integrative approaches it seems that the work involves collaboration and co-constructing meaning with clients. Vivien Burr (2003) interrogates a social constructionist practice by making a distinction between a structural and a poststructural positioning. She indicates that a structuralist (individualizing or systemic) therapist might coconstruct meaning with a client, but that this perspective may fail to note the changed meanings words have over time and also might have in different contexts. An excellent example of this is the evolution of the term “heterosexuality,” which cannot be found in the 1901 edition of the Oxford English Dictionary. In the same year, however, in Dorland's Medical Dictionary, it was considered an abnormal and perverted appetite toward the opposite sex. Not until 1934 in Webster's Second Edition Unabridged did “heterosexuality” acquire a definition that is still the dominant mode of “normal sexuality” (Katz, 2007).

The major departure of poststructuralism from a structuralist view of language is that meaning is never fixed, always contestable, and “up for grabs” (Burr, 2003, p. 53), as the above example demonstrates. Although most would consider the term “heterosexuality” to have a firm definition, the fact of its dominant position in “sexuality” obscures the shifting meanings and also obfuscates one's understanding of “sexuality” in general. A respectful inquiry about the meaning of a word could enhance everyone's appreciation, moving perhaps from problem to possibility.

From the above distinction, we could draw the conclusion that one can be a structuralist and be informed by social constructionism, whereas a poststructuralist holds a social constructionist perspective, which imbues all understandings.

Theoretical Integration

Can one borrow concepts from different theories? We know that Jung built on as well as departed from Freudian concepts, Adler leaned on both, Perl's Gestalt therapy took from the existentialists, and so on. So it seems that one can mix theories within epistemologies. An integrative view would say “yes.” Many of the individualizing theories borrow from each other: the psychodynamic approaches follow a similar theoretical conceptualization and the cognitive-behavioral approaches seem to have several different combinations and permutations within the same theoretical base. As indicated above, most family therapy these days is a mix of some of the earlier formulations, and greatly influenced by biological and sociocultural issues.

Similarly, one might ask if it is possible to transmute practices across theories as well as across epistemologies? It seems so—see, in particular, the above section on Practices. Many in early family therapy (I, for one) used Adlerian techniques. And the solution-focused miracle question is clearly from Adler. Sometimes structural therapists use externalizing. Narrative and solution-focused therapists might employ CBT techniques (e.g., scaling).

However, simply using a “technique” from a specific therapeutic approach does not by itself define the epistemological underpinning. If someone uses externalizing and is thinking from structural family therapy theory, that particular therapist's epistemological positioning is a systemic (structural) perspective—not a poststructural one (e.g., Levy, 2006). And when a student of mine uses CBT techniques but is thinking poststructurally, she/he is no longer a CBT (individualizing) therapist/theorist, but perhaps more narrative or solution focused in her/his approach.

A larger question is: can one mix theories across epistemologies, thus mixing and matching these disparate points of view? I believe this is both illogical and existentially impossible. As stated above, one can be a social constructionist, but how can one be structural and poststructural at the same time? In the following examples I demonstrate the implausibility of an epistemological integration or eclecticism. I also show how what might appear to be a crossing of epistemologies is actually a clear positioning within one point of view while using theoretical concepts and/or practices from another. This is a different matter entirely.

It may be quite possible, however, to sequentially position oneself. In any given therapy session, a therapist might utilize a poststructural practice (e.g., deconstruction) coming from a poststructural position, and later find him/herself to be quite directive, giving specific advice, which comes from a structural epistemology. Likewise, a practitioner might want to use “externalizing,” a poststructural way of working, and yet be thinking about how to leverage the conversation toward a specific outcome; this is more of a structural positioning. Are these examples of sequential positioning? I believe that the response to this question lies in the therapist's intentionality. In describing positioning theory, Davies and Harré (1990) write: “There can be interactive positioning in which what one person says positions another. And there can be reflexive positioning in which one positions oneself. However, it would be a mistake to assume that … positioning is necessarily intentional” (p. 48; my italics).

I prefer to intentionally position myself within a poststructural epistemology, and yet I might find myself occasionally using a structural concept or practice (example below). Does this move me into a different epistemology? Temporarily, perhaps. However, if I strive to make my positioning intentional, then the practices flow from the epistemology, even if they seem to shift to a different one. Thus one can position oneself structurally or poststructurally—not eschewing a sequential positioning—from either one of which a therapist can use structural and/or poststructural practices.

EXAMPLES OF INTEGRATIVE APPROACHES

  1. Top of page
  2. RESUMEN
  3. AN ORGANIZATIONAL MAP
  4. QUESTIONS
  5. EXAMPLES OF INTEGRATIVE APPROACHES
  6. CONCLUSION AND IMPLICATIONS
  7. REFERENCES

In the following examples, I describe and critique four different integrative approaches: Scheinkman's (2008) multilevel road map, Fraenkel's (2009; Fraenkel & Pinsof, 2001) therapeutic palette, Madsen's (2007, 2009) collaborative therapy, and Weingarten's work on witnessing (2000, 2003, 2004) and on reasonable hope (2010). Although lines are always blurred, depending upon where one stands, I would place these four examples on a continuum from structural to poststructural. They illustrate a variety of theories and therapies, perhaps showing multiple positioning. I wonder whether these approaches are primarily situated in structuralist systemic thinking, using theories and practices from other perspectives, or situated in a poststructuralist epistemology, using other practices but attending to the shifting meanings of discursive influence. The third possibility is to knowingly alternate between epistemologies.

My understanding of these examples relies on the specific words that the authors use in their descriptions of their respective approaches and the concomitant clinical work. However, from a poststructural/social constructionist perspective, I do not know exactly what they mean by the words they choose; ideally, I would engage in a conversation about meaning. Nonetheless, words often reflect how the writer positions him/herself, and I base my critique on that assumption.

The Multilevel Road Map

Michele Scheinkman's (2008) multilevel approach is a well thought through framework for working with couples. She utilizes the interactional model of MRI, White's narrative ideas, applications from Haley and Minuchin, formulations of intrapsychic/interpersonal processes, and attention to multigenerational patterns. She also incorporates multicultural and feminist perspectives. She states at the outset that her intention is to eschew the deficit approach and incorporate a more collaborative therapist/client relationship. It is a rich integration and takes the reader on a journey with a road map much like a modern GPS system, with starting and ending points and clear directions along the way.

It would be far beyond the scope of this article to do a complex analysis, so I will simply focus on a few major points. Her four levels migrate from a systems approach—pattern, social context, organization (levels 1 and 2)—to an individualizing approach—intrapsychic (level 3)—and back to systems—intergenerational (level 4). All levels are structural, although nowhere does she situate her thinking in either a structural or a poststructural position. Scheinkman indicates that she uses “deconstruction” and “externalizes,” both poststructural practices, while saying they are in the interest of arriving at “more effective ways” of the couple being able to communicate. The practice described seems more structural/systemic than it does poststructural/social constructionist.

For example, Michael White (1993)—self-defined as a poststructuralist—states, “deconstruction has to do with procedures that subvert taken-for-granted realities and practices … that are subjugating of persons' lives” (p. 34). In another version, Alice Morgan (2000) calls it “…‘taking apart’ (deconstructing) the beliefs, ideas and practices of the broader culture in which a person lives that are serving to assist the problem and the problem story” (p. 45). These definitions situate the problem in a cultural production of meaning, rather than in an individual or relational understanding, thus making the practice itself poststructural and one that reflects the epistemology. It appears that Scheinkman's practice is a means to an end rather than a coresearching of meaning; this is a structural positioning.

In other places Scheinkman speaks of the couple's arrangements as “equitable and fair” (p. 203), an unachievable mutuality according to Foucault's understanding of knowledge and power. (See also Knudson-Martin, 2010.) Also, in her closing statement, Scheinkman indicates her work strengthens the couple's “structural” foundation. Although this is a rich map of understanding and can likely result in genuine help for couples, this example describes how one can utilize poststructural practices and position oneself structurally.

The Therapeutic Palette

Another integrative approach is Peter Fraenkel's (Fraenkel, 2009; Fraenkel & Pinsof, 2001) therapeutic palette, which makes a case for multiple approaches both in teaching graduate students and in working with couples. In his introduction Fraenkel (2009) refers to the postmodern premise that all theories are partial constructions and then presents an approach that thoughtfully draws from several different schools of couple therapy. He seeks to be collaborative in his approach, drawing upon the couple's expressed needs and requests, although he does not comment on the implicit imbalance of power between therapist and client. Fraenkel assembles a complex system that consists of three organizing themes: Time Frame, Degree of Directiveness, and Change Entry Point, along with two overarching principles: Health/Resource Perspective and Balance Support of the Existing System with the Need to Introduce Novelty.

Within this frame Fraenkel employs several diverse theories and practices, utilizing “different theoretical perspectives simultaneously, like overlapping lenses that create a kind of ‘convergent validity’” (p. 238). The choices depend on the couple's needs as well as the therapist's skills, and in this case include multiple practices from cognitive-behavioral, feminist, narrative, solution-oriented, emotion-focused, family of origin, and structural-strategic approaches.

A close reading of the clinical example indicates an intricate and complex use of these practices from the theories named, but as argued above, a practice does not a theory or an epistemology make. The theories and practices Fraenkel employs cut across the three epistemologies, but is his positioning a structural or a poststructural one? If it is structuralist/systemic in its thinking then the poststructural practices utilized are from a structural positioning, that is, they point to a particular goal or outcome. If it is more poststructuralist, then the conversational space opens possibilities that could not be predetermined by either therapist or client.

It is unclear where Fraenkel would position himself, although he hints at it from his final statement of wanting to “work collaboratively … to ‘paint’ with (the couple) as co-artists a preferred present that equipped them for a better future” (p. 246). It is difficult to discern if this example is an intentional shifting of epistemologies.

Collaborative Therapy with Multistressed Families

In William Madsen's (2007, 2009) writing on collaborative work with families he clearly situates himself in poststructuralism. In a recent article (2009), he states, “This framework is embedded in a post-modern or post-structuralist approach to helping efforts in which helpers move from a role of experts repairing dysfunction to appreciative allies helping families envision and develop desired lives …” (p. 104). He calls his work integrative and draws from both poststructural and structural practices, including motivational interviewing, solution-focused therapy, the signs of safety approach to protective work, and narrative therapy. A close reading of his work indicates that he utilizes the structural strategies from a poststructural positioning.

For example, when Madsen talks about collaborative work, he qualifies it by saying, “While this is a collaborative process, it is not an egalitarian partnership.” Further, he considers “expertise” to be in the realm of inquiry, while being accountable to clients for both the direction and the effects of the questioning process (p. 105). In work with clients, he looks for “threads of competence, connection, and hope” (p. 106). He indicates he is aware that therapists hold normative views, which he believes can be countered by developing with families their vision of what they desire. These words are echoed in Fraenkel's work, although Fraenkel does not explicitly position himself either structurally or poststructurally.

Madsen also refers to a distinction between problems as being culturally produced—which is a key component of a poststructural approach—and problems in persons as being affected by a sociocultural context. The latter (structural) places the problem in the person or in the relationship and possibly affected by culture, whereas the former (poststructural) understands the problem as produced by cultural conditions, such as gender, race, class, sexuality, and other relations of power (cf., Foucault), and current, local interpretations of meaning, thus creating constraints on behavior. (See p. 110 for an example.)

Madsen sees profound effects on clinicians who work with families when we position ourselves in a poststructural perspective: that it can revitalize, reinspire, and enrich our work and work lives.

Witnessing and Reasonable Hope

An example of thinking that integrates ideas within a poststructural frame is the work of Kaethe Weingarten. In particular, her complex appreciation of the act of witnessing, as expressed in her work Common Shock (2003) and companion articles (2000, 2004), shows a multifaceted approach within a social constructionist and poststructural epistemology. In her 2010 article on Reasonable Hope, Weingarten does not call her work integrative in the usual sense of that term. Instead she states: “The construct of reasonable hope can be integrated into any model of family therapy since it infuses an attitude, informs a stance, and opens areas of inquiry that might otherwise be dormant” (p. 10). Implicit in this statement is a poststructural positioning.

Weingarten enumerates four steps for clinical work; these include interviewing for resilience and using questions that activate reasonable hope. She also identifies nine supports for the clinician, including believing that the small is not trivial and cocreating conversational hope spaces. These “steps” and “supports” take us through a process of therapy that does not situate itself in any particular theoretical approach, but are all poststructural in their thinking. For example, she suggests four witnessing positions, a reprise from her earlier work, noting that the combination of awareness and empowerment will allow therapists to position themselves to “launch the kinds of conversations that cocreate reasonable hope” (p. 11). This statement is in the wake of an earlier comment that this activity derives from a different way of thinking, that no one “gives or provides hope to another, but rather one creates the conversational space for hope to arise from the forms of conversation one shares” (p. 11).

This “different way of thinking” is poststructural; rather than giving something to someone (a structural position), it notices possibilities. An elegant example is one in which Weingarten relates a conversation with a man who talked about having to be aggressive growing up (pp. 15–16). He says, “… at our dinner table there were six boys. After prayers, I learned to leap across the table and grab the drumstick. That was how I survived.” Weingarten, as the therapist, does not ask about survival; she is paying attention to other meanings, other possibilities; she asks him to tell her about the dinner table. “Did you have fixed seats?” The man's response confirms what Weingarten suspected. He tells about his younger brother who sat next to him, and how they worked it out to each get what they needed. He said, “We always shared.” What a different outcome from the suggestion of survival: sharing, not grabbing; collaborating, not being aggressive. The incident as told by the client became an opportunity for the therapist to notice something less visible—absent but implicit (Carey, Walter, & Russell, 2009)—which allowed this man to change his way of thinking about himself as well as how he related to his wife.

A further indication that Weingarten's work is poststructural is the link she makes between social justice and reasonable hope. A poststructural social justice approach situates the work in resistance, “… namely that we must resist what is unjust to realize what is just. Recognizing and resisting unfair conditions sustains a practice of reasonable hope” (p. 22). This echoes the following: “Poststructuralists also point to resistance strategies used by marginalized individuals and groups to manage the institutionalized and hegemonic discourses (metanarratives) that suppress them” (Miller, 2006, p. 271; see also Wade, 2007).

A Clinical Example

In the following example from my own work, I show how it reflects a poststructural thinking and positioning on the part of the therapist, even while using a systems theoretical concept, coconstructing pattern within a poststructural understanding.

Recently in a workshop entitled Narrative Therapy with Couples: Working with Power and Privilege, I was describing how I find it helpful to coconstruct a pattern of interaction with a couple. This is a concept that I utilize from my systemic thinking: the idea of reciprocal invitational pattern. I find it very helpful as a way to move from what each member of the couple describes as the problem (their complaint) to how this description of what the other does affects them (the problem as one end of a reciprocal interaction). So, with a heterosexual couple, if she describes the problem as his absence or lack of presence, and he describes the problem as her continual upset, I then ask each in turn: “How does what he/she does affect you?” They often respond with something that is very close to what the other person's complaint might be. He would say, “Well, when she's that upset, I pull away”—which could be construed as “absence.” And she might say, “The more absent he becomes, the more upset I get.” The reciprocal invitational pattern is fairly easily constructed as absence/upset or upset/absence. Although the work is usually more complex than what I describe here, a pattern often emerges. One could argue that I am a social constructionist systemic therapist, positioned in a structural epistemology. However, the following description belies that argument and situates my work and my thinking centrally in a poststructural/social constructionist epistemology.

In this particular workshop one of the participants asked: “Doesn't constructing a pattern somehow fail to account for the power differential and assume that the relationship is 50-50?” If I am consistent with my social constructionist/poststructural perspective, I always keep in mind discourses about gender, culture, and power. Thus, I hold the belief that heterosexual relationships in a patriarchal society always lean toward the male possessing more power. (See also Knudson-Martin, 2010.) Because this is foremost in my thinking, I can coconstruct pattern with a couple and deconstruct meaning in a way that makes the power differential more visible (e.g., Hare-Mustin, 1994).

If, for example, I think from Foucault's perspective and focus on power, I might start with the male member of the couple and ask: “What do you think is the effect on her of what she calls absence on your part?” He might respond with something like: “Well that's what I'm talking about, she gets so upset.” And I: “Do you think there is a connection between what you call upset and her experience of absence on your part?”

Of her I could ask, “Is absence on his part apt to increase or decrease upset?”“Oh, increase it for sure,” she might respond. I could then ask, “If you know upset is apt to increase absence, what happens when there is less upset?” What I often hear in response is some version of: “He doesn't listen anyway; at least sometimes when there is upset I get a reaction.”

I could then ask him, “How is it that she thinks she might need to express upset in order for you to respond to her?”

These are all possible conversations that deconstruct—make visible—the arrangement of power, of what is often the experience of women of not being heard, of having no voice, and thus having to be “loud” to make known what is important to them in the relationship. Vice versa, these questions can address the experience of men of feeling criticized and thus incompetent, which can often engender defensiveness and withdrawal, somehow justifying their point of view as well as their position of entitlement and “rightness” (Neal, Zimmerman, & Dickerson, 1999).

If I were to also attend to what is “absent but implicit”—a perspective from Derrida (Carey et al., 2009; White, 2000)—I would be attending to what is not being expressed, those experiences that lie outside the problem story. In line with the example above, I write about this in a recent book chapter (Dickerson & Crocket, 2010) where a couple is struggling with the absence/upset pattern. At one point the husband, Steven, talks about his wife, Mari, “missing out” when he comes home from work and spends time playing with their sons (p. 164). Often couples can get captured by fixed roles: women thinking they need to attend to home and hearth duties, cooking and cleaning, for example; and men having fun with the kids, believing they are “helping” by doing so. By engaging in what narrative therapists would call “… a radical listening for a possible ‘duality’ in what appears to be a singular description” (White, 2000, p. 36), I could hear the possibility of care and a wanting to connect in Steven's description of Mari “missing out.” By attending to the “absent but implicit,” I could say to Steven: “How do you think of her as ‘missing out’?” And “If you wanted her to not be ‘missing out,’ does that mean you want her somehow to be ‘in’ it with you? What would you call that: your wanting her to be a part of this play with you and the boys? What would that look like to Mari? What is it that you might do to make it possible for her to participate with you and the boys? How do you think Mari would experience it?” And so on. These conversations not only could deconstruct the dominant cultural discourse about roles, it also could lead to a construction of quite a different understanding of their relationship: one of partnership, connection, and caring rather than absence/upset.

This example demonstrates that, although I might be using a systems concept—that of reciprocal invitational pattern—I am approaching it from an epistemology that is situated in poststructuralism. I do not understand this as crossing epistemologies. I think of it as being firmly positioned in a social constructionist/poststructural perspective. I am using a systems concept, while simultaneously deconstructing the experience of power and privilege held by the male member of this heterosexual couple. Further, I am noticing other possibilities of caring and connection, which he might prefer but be less likely to perform. In addition, utilizing externalizing conversations as well as attending to what is absent but implicit are practices of a narrative approach, which is situated in a poststructural understanding.

CONCLUSION AND IMPLICATIONS

  1. Top of page
  2. RESUMEN
  3. AN ORGANIZATIONAL MAP
  4. QUESTIONS
  5. EXAMPLES OF INTEGRATIVE APPROACHES
  6. CONCLUSION AND IMPLICATIONS
  7. REFERENCES

If the argument can be made that one can indeed integrate theories within epistemologies and cross practices and/or theoretical concepts across epistemologies, but one cannot cross or mix-and-match epistemologies, how does it matter? What does it mean for the clinician? What might it mean for the future of psychotherapy? There are four responses that bear merit in answering the question “Who cares?” These are in the realms of philosophy, pedagogy, research, and clinical practice.

The philosophy reply considers the importance of being cognizant of our stance within a particular epistemology, because then we are in a position to critique it. It is all too easy to critique that which came before; for example, in Roger Lowe's (1999) conversation Between the “No Longer” and the “Not Yet” he speaks of the postmodern critique of modernism, but what about the postmodern evaluation of postmodernism? Thus, by extension, a poststructuralist position is effectively a critique of structuralism; and a systems approach was incidentally a critique of individualism. Conversely, if one can position oneself within a stance, no matter what it is, and knows what that stance is, then one can stand outside it and question its assumptions, presuppositions, and settled certainties.

The second argument is in the arena of pedagogy; how do we teach our students to “know what they know” and to “think about how they think” unless we help them make distinctions in the domain of epistemology? Winslade et al. (1999) discuss the importance of creating a template for understanding for students, rather than simply “teaching counseling theory (in a way) that resemble(s) a bus tour through a dozen different theoretical territories.” They go on to say, “The challenge then is to teach counseling theory in relation to the underlying paradigmatic assumptions.” Although their paradigm distinctions are different from the ones mentioned here—they use Gergen's (1991) listing from Saturated Self of Modernism, Romanticism, and Postmodernism—the point they make is similar, which is that integration cannot take place across paradigm differences, citing Kuhn (1962) to defend this position.

A third implication raises the question of how to approach clinical research for poststructural therapies. The evidence-based therapies are structural, and more recent research in systemic approaches (see Lebow, 2006 and Liddle, 2010) also reflects their structural epistemology. A conventional research design depends on structural assumptions; thus it would seem contradictory, if not paradoxical, to consider creating a design to assess the efficacy of poststructural therapies. Nevertheless, there are efforts underway to create appropriate designs. A research fund called “Shine a Light” exists with the sole purpose of supporting research efforts for narrative therapies. A group meets regularly at the American Family Therapy Academy annual meeting to consider possible design strategies for poststructural therapies. There are some qualitative research studies available (e.g., Gale, in press; Young & Cooper, 2008). And, on the Dulwich Centre website (the original home of Michael White) there is a listing of current research projects. How these efforts will serve to validate poststructural approaches remains to be seen.

The fourth, and in my mind most significant, reason for the importance of being clear about one's epistemological positioning is how it shows up in clinical practice. The therapeutic position from which I operate influences greatly what it is I attend to in my conversation with a client. If I operate from a structural (individualizing or systemic) position, then I am working with my clients in fairly well-formed, often standardized, ways, listening for words as signifiers of some mutually agreed upon meaning, and subsequently assuming I understand. Often theorists and therapists find this way of working quite helpful, as there seems to be some clarity about what is happening, what to do, where to go—an understanding of problem development and a structured process of change as well as a theory of personality. These ways of working have been operationalized and standardized, by the DSM for the individualizing perspective, by a variety of systemic theories for the systems thinker and practitioner, and by evidence-based practices. If I operate from a poststructural/social constructionist stance, however, I am listening for different things, curious about the client's understanding, questioning taken-for-granted ways of knowing, wondering about here-to-fore invisible possibilities. Many therapists from a structuralist perspective might say they similarly listen, implying a collaborative, social constructionist approach. As previously argued, the conversational space would look different. A reflexive clinical practice suggests that we attend to what the effects are on our clients of how we involve ourselves in conversation with them. The question is: what are they experiencing as helpful or useful?

How might all of the above inform us about the future of psychotherapy—how can we “remember” it?—(Dickerson, 2007). If we can be mindful of how we position ourselves, perhaps we will continue to critique not only how we think but also what might be helpful to our clients. That is, after all, the final measure.

REFERENCES

  1. Top of page
  2. RESUMEN
  3. AN ORGANIZATIONAL MAP
  4. QUESTIONS
  5. EXAMPLES OF INTEGRATIVE APPROACHES
  6. CONCLUSION AND IMPLICATIONS
  7. REFERENCES
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