Gains and Losses in Family Therapy

Aine O’Reilly

Introduction: Exploring the Gains and Losses in Therapy

There are considerable difficulties involved in examining the impact of
 professional practices on clients. Gains and losses always appear to be judged from
 the inside, where there is an unquestioned belief in the Tightness of one’s own 
theory and practice, and frequently an associated belief in the wrongness of other,
 different theories and methods. Psychological and psychiatric interventions with 
clients with mental illness; social work, therapeutic and legal interventions with
 children who have been abused seem to pit professionals against each other, with
 each profession believing in the gains associated with their ways, and frequently
 the losses associated with other ways. And all of us appear to remain so convinced
 that our way, whatever its drawbacks, is ultimately useful and productive, perhaps
 not with all our clients, but at least with most.

We have methods available to us that attempt to give us objective, impartial,
 truthful answers to these questions. Empirical evaluations of services and 
interventions can produce useful information about gains and losses, but are also 
limited, both in the kinds of questions they can ask, and in the kind of answers that
 can be obtained. Interviews and surveys can provide useful information, and
 indeed can give important insights into the clients’ perceptions of gains and losses 
they experienced. However, the information tends to be restricted to the agenda set 
by the researcher, and to that which can be extracted through statistical analysis.
 Case studies provide a wealth of information about the process of therapy, and the 
perceptions of patients (families, therapists, teams) of gain and loss in therapy. 
However, cases have limited use in assisting generalisation to other cases, and case
 studies like other methods of research, are bounded by the frame of reference. It is 
the researcher/practitioner who decides which cases are reported, the manner in
 which they are reported, what is spoken about and what is not spoken about.
 Ultimately, these methods of research provide researcher/practitioner views of
 gains and losses in therapy, and attempts are being made to find different ways of
 seeing research and different methods, which can help us more effectively to
 access the views of clients. In systemic therapy in particular, where one tends to
 deal with complex systems composed of different perceptions and judgements of 
gain and loss, methods which begin to allow us to access all of these views are
 particularly important.

The Contexts of Judgement: Valuing Change as Gain and Loss


Therapy from a systemic perspective involves seeing clients in the various contexts 
in which they are imbedded (for example individual, nuclear and extended family, 
community, society). Frequently, different people from sub-systems are included in
 therapy sessions, and each person has their own view of change and its usefulness. 
For example, in my work with clients with learning disabilities, I might include the identified client, parents, siblings, partners, care workers, managers of residential
 units, and professionals from extended systems such as social workers or gardai, in
 various combinations. Any change in the client’s life, however positive it might
 seem in conversation with the client, may reverberate throughout the client’s
 system in ways that impact substantially. For example, involvement in a sexual
 relationship which is seen by a couple as consensual and mutually supportive and
 satisfying, may be seen by parents, friends, siblings, or care workers as a threat to
 safety, or as a support to growth and development. Where lives are intensively 
governed, as they tend to be with people with learning difficulties, continuing a
 relationship without the support of the key people in their lives can be extremely
 difficult. Where people with learning difficulties have tended to be excluded from
 information about and experience of sexuality throughout their development, 
informed choices about sexual relationships can be difficult to make. Where people 
feel themselves to be in love, where they have felt intimacy with a friend, where
 they have reached a stage of comfortableness and understanding with that person,
 where physical contact feels good and comfortable, not to get the blessing and 
support of those around you can feel very unjust. Add to this the many complexities
 that are so frequently a part of the lives of people with learning difficulties – a 
history of abuse; a psychiatric diagnosis; legal, psychological and psychiatric
 questions about ability to consent, issues around contraception, agency 
responsibility for improving quality of life and for safety and protection – and the
 complexity of making a judgement about gain or loss becomes apparent. Whatever
 the outcome for the client, it is likely to include both gain and loss, and the gains 
and losses associated with any decision or lack of decision is likely to form a good
 part of the conversations that take place in therapy.

The therapeutic conversation is also likely to include a different discussion of gain 
and loss; the gains and losses associated with the therapeutic conversation itself.
 Questions that I might ask could include: what have you found useful and what 
have you found not useful about coming here? If you were me, what would you do
 differently? Do you think I was wrong or right to do that? This, I think, is 
particularly important in working with client groups who are marginalised or who
 have a history of being silenced. It is also particularly important, I believe, when 
working from a systemic perspective, where the inclusion of many voices in 
therapy, and the focus on interaction patterns rather than individuals, can obscure 
marginalised voices.

Conversations also take place on many levels outside of therapy which impact on 
a case, and which judge the progress and outcome of cases. Institutions need to
 judge efficiency and effectiveness of services in order to allocate scarce resources
 in accordance with client needs. Gains and losses may be seen in terms such as 
numbers and throughput of clients, length of waiting list, perceptions of client
 change. Line managers need to ensure compliance with agency policy, good 
practice, and efficient use of resources. Supervisors need to promote good practice
 and guard against dangers. This professional/institutional context and its judgement of loss and gain can reflect the differences voiced in the therapeutic 
system. The conversations that occur in this context not only provide personal and 
professional support, they provide scrutiny and critique of my practices, different
 opinions and perspectives, different judgements which challenge my own beliefs 
and actions.

Theoretical Framework: What Can Be Seen and What Can Not Be Seen

My assumption is that therapy is about change, and that change happens both
 within and outside of therapy. The manner in which we see change and assess its 
value is rooted in our theoretical framework – the manner in which we make sense
 of our therapeutic world. This framework both highlights and obscures different 
aspects of change, and leads us to judge change in positive or negative terms. 
Clients and others impacted on by therapy, may have different frameworks for
 understanding therapy and change, and as such might assess value differently. For
 example, to say that a child’s aggressive behaviour towards his siblings has
 decreased and that parents are now providing a more consistent form of parenting
  is a change, and one that is usually identified by all parties as creating a difference. 
To assume that this change is positive, and automatically represents a gain for all 
members of the system is to place a value on this change, which might not
 necessarily fit with the perception of everyone in the system. The child’s
 perspective – how he sees changes impacting on them, what he believes he has lost 
and gained – may be obscured by our theoretical framework (O’Reilly, 1994). If we 
are required as professionals to examine the impact of our work on our clients -
which I believe ethically that we must be – then we need to examine our
 understanding of change, and our method of placing value on this change.

Empirical Studies of Change in Therapy


The manner in which institutions and the professional community judge gains and 
losses in therapy is of considerable importance. Increasingly, funding, referrals and 
inter-professional recognition are based on (empirically) proven effectiveness and
 efficiency. In addition, as Seligman (1995) states,
”It is easy to assume that, if some form of treatment is not listed among the many
 which have been “empirically validated,” the treatment must be inert, rather than 
just ‘untested’, given the existing method of validation… This is a challenge to
 practitioners, since long-term dynamic treatment family therapy, and more 
generally, eclectic psychotherapy, are not on the list of treatments empirically
 validated by efficacy studies, and these modalities probably make up most of what
 is actually practised. The usual argument against the inertness assumption is that 
long-term dynamic therapy, family therapy, and eclectic therapy cannot be tested
 in efficacy studies, and thus we have no hard evidence one way or another. They 
cannot be tested because they are too cumbersome for the efficacy study
 paradigm…. The ethical and scientific problems of such research are daunting, to
say nothing of how much such a study would cost. While this argument cannot be
 gainsaid, it still leaves the average psychotherapist in an uncomfortable position 
with a substantial body of literature validating a panoply of short-term therapies the
 psychotherapist does not perform, and with the long-term, eclectic therapy he or
 she does perform unproven.

“
Indeed, the ethical considerations of most therapeutic and medical professions
 require that where we intervene in the lives of clients that we provide some benefit 
to them. Seligman (1995) argues that conclusions other than lack of gain for clients 
are possible. Efficacy studies tend to equate gain with symptom alleviation, which 
requires that “symptoms can be readily identified, quantified, and their change
 tested”. Different forms of enquiry, even within an empirical approach, provide
 different information about gains and losses. He describes how survey methods
 can help us to understand factors that influence not only how people come to
 choose between different ‘mental health’ options, but also the factors which 
influence how they feel they have gained from these options. For those of us 
interested in shaping our practices in accordance with feedback from clients, this 
provides information that is useful.

In contrast to an efficacy study, Consumer Reports (1995) referred to in Seligman,
(1995), used a survey method to examine client perceptions of usefulness of 
therapy. In this study, most respondents reported themselves as feeling a lot better 
since they began therapy and no specific modality of psychotherapy did any better 
than any other for any problem. Some of the results of this study provided
 information that was quite different to that produced by efficacy studies. Long-
term therapy produced more improvement than short-term therapy, that there was 
no difference between psychotherapy alone and psychotherapy plus medication for
 any disorder, for example. Family doctors did just as well as mental health
 professionals in the short term, but worse in the long term. The advantages of long-
term treatment by a mental health professional held not only for the specific 
problems that led to treatment, but for a variety of general functioning scores as
 well: ability to relate to others, coping with everyday stress, enjoying life more,
 personal growth and understanding, self-esteem and confidence.

The Limits of an Empirical Approach


While an empirical approach provides useful information, it is also important to see
 what such studies leave out. An empirical approach for example, tells us trends
 which inform practice, but it does not tell us what is or is not useful in individual 
cases, or how we need to shape our practices to fit with the clients and
 circumstances with which we are dealing. It focuses on the gains of our clients; 
losses tend to be seen in terms of lack of gain. In addition, even within the survey
 method, which is aimed at obtaining client perspective, it is the researcher/clinician
 who sets the questions, who defines what is relevant and what is not.

The impact of postmodernism on systemic thought and practice and the emergence
 of constructionist views of the world have changed how we examine issues such as 
loss and gain in therapy. Questions such as which model of therapy works best and
 is systemic therapy useful in particular types or disorders are being subsumed in
 different types of questions, such as:

How do we measure and value loss and gain in therapy?

How do the different participants in therapy view the impact of therapy on them.

Who is silenced by our theory, our practice?


Different methods of enquiry based on an interpretative rather than an empirical 
paradigm can utilise methods of enquiry that yield different types of information
 (Dobash and Dobash, 1983; Henwood and Pidgeon, 1992). Indeed, the use of
 methods such as open-ended interviews and case studies, that are so frequently 
used to describe the process and outcome of therapy, can be used to explore
 individual perceptions, descriptions and valuations of loss and gain. There are, of
 course limitations to the usefulness of these methods (in addition to the lack of 
generalisability) and there appear to me to be difficulties in the usual way of
 describing cases. We usually describe our successful cases, (rarely the ones we feel
 uncomfortable with); we fit our theory with process and outcome, we describe how 
our theory, and our practices shape, this theory, resulted in some gain; we rarely 
examine the limitations of our theory, or allow our clients to challenge our theory 
and practices, at least as a central part of our examination. And rarely we examine 
the place of our theory in society, how our freedom, growth and self-actualising 
goals fit with a need to help our clients live in a society which is fundamentally 
experienced as unjust by a large proportion of those who live in it.

Gains and Losses in Therapy: What Clients Can (and Can Not) Tell Us

In their introduction to Therapy as Social Construction (McNamee and Gergen,
 1991) the editors describe the traditional view of the individual knower who 
possesses the capacity to know the world and to act adaptively within it. If 
individual capacities and processes are functioning normally, the individual will
 confront life’s challenges as adequately as possible. When there are inadequacies 
in meeting these challenges, there is reason to believe that the capacities and 
processes are malfunctioning, (p.l) Therapists, from this point of view are the
 experts who observe and judge the adequacies and inadequacies of their clients.
 Loss and gain in therapy is measured in terms or change as constructed by the
 theoretical framework.

Such modernist views have been subject to much criticism, not only within therapy
 (e.g. McNamee S. and Gergen K J., 1991), but in varied disciplines (for example, 
research, social sciences, physical sciences. See, for example, Leone, 1990). In
 therapy such criticism has come not only from therapists, but also from the
 consumers of practices. Significantly, in the latter category, those who have
 experienced abuse have challenged the manner in which professionals’ practices 
failed not only to help them find protection, but also failed to hear them speak
. Those who had believed in the usefulness and success of their ways were now
 confronted with their failures. Where case descriptions had described gains for the
 family (in terms of symptom alleviation, or a change from dysfunction to function) 
these cases were now described, by some individual clients, not only in terms of failure to succeed, but also in terms of the actual destructiveness of the
 intervention. Not only had professional interventions failed to stop abuse, but also
 the therapeutic encounter had colluded with the abuse. Such damning re-analysis
 of losses and gains associated with professional interventions in cases of abuse was 
not confined to family therapy (Olafson et al, 1993) and hopefully, such
 examinations have lessened the risk of such destructive and unjust interventions.

While abuse is one area where clients have questioned assumptions about gain and
 loss, it is not the only area. It does, however, focus us on other questions – how was
 our judgement of loss and gain so different from that of our clients? How did (and
 still does) our theories and practice obscure something so important to our clients?
 And what still remains obscured? Systemic theory, in particular, has been subject 
to long standing internal (Leupnitz. 1988) as well as external criticism regarding its 
stance on abuse. Its focus on interaction patterns rather than individuals, its failure 
to provide a useful description of power, its lack of concern for people’s rights, and 
its a historic and idealistic view of the family limited its usefulness, not only in
 responding to abuse and violence, but also in being able to see the different 
perspectives and conflict of interest that might arise within families. Women,
 children and men have different experiences of living in families; to see gain and 
loss in terms of family gain and loss obscures the differences in these perspectives 
and experiences.

The process of examining such questions was, I believe, of considerable 
importance to changes in thinking about therapy. While many disparate voices are
 emerging, McNamee and Gergen (1991) refer to the integrative vehicle of social
 construction and its understanding of reality (e.g. truth, values, loss, gain, the self)
 as constructed in conversation. Some (of whom I am one) see this as a significant
 change, substantially influencing how we think about and act in therapy. Social
 constructionist views focus us on how we as therapists, and our clients, construct
 ourselves and our world. In a framework which sees knowledge as constructed, a
 person’s sense of self, their identity as a person is seen as being formed in their 
interactions with others. ‘The narrative or sense of self arises not only through 
discourse with others, but is our discourse with others.’ (Lax, 1992, p.71) The 
interactions within which personal narratives are formed are seen as reflecting
 already constructed social meanings – such as what it means to be a woman, a child,
 disabled, homeless – which become part of that person’s identity. There are many
 possible constructions of the self – to view oneself as a victim, a failure, is a 
construction that can change, rather than a description of what the person is. 
However, the person alone does not construct their own meaning; the construction
 of that person’s story occurs in conjunction with others, where there are already
 social meanings which precede us. A person is born into an already established
 social structure, and develops a sense of self in interacting with others who are a
part of that structure. Our knowledge of our selves and our world is shaped through
 these interactions, which serve to create and maintain this pattern of social
 relationships, and to structure our way of knowing ourselves (Shotter & Gergen,
1989). It is not possible to construct any narrative:

“The boundaries of our narrative are constructed through political, economic,
 social and cultural constraints and potentials, with our choice of narratives not 
limited, but existing within prescribed contexts” Lax, 1992, p.71

The process of therapy, from this theoretical perspective, is similar to the process 
of deconstruction and reconstruction of any narrative. In therapy, the self,
 constructed in conversation with others throughout a person’s life, can be 
deconstructed and reconstructed in ways that provide more and different
 possibilities of seeing and of acting. However, they also focus us on seeing the
 limitations on the construction of alternative stories. To speak of allowing or
 facilitating clients in the construction of alternative stories can also be seen as 
obscuring the power relationships within interactions, and the influence of these
 relationships on the possibilities for the construction of knowledge. As Minuchin
(1991) states:

“Families of poverty have been stripped of much of the power to write their own
 stories. Their narratives of hopelessness, helplessness and dependency have been 
co written, if not dictated, by social institutions. When the institutional and societal 
co-authors are made invisible, when the family narratives are presented as if
 constructed by the family alone, family members become even more depressed,
 helpers am confused and everybody becomes less effectual.” (p.49)

The focus of therapy becomes that of description rather than prescription (Hoffman 
1991) on reconstructing identities (McNamee, 1991), on constructing therapeutic 
possibilities (Cecchin, 1991). However, the place of the therapist in therapy takes 
on a central focus; the therapist’s belief systems, value systems, way of knowing
 the world, becomes a part of the conversation. Gains and losses in therapy are
 constructions which are given meaning and value in therapy, but are also shaped 
(in meaning and value) by the therapeutic context (the professional and personal
 meaning systems of the therapist) and the individual context of the client(s). It is 
not possible to move outside of these meaning systems, but it is possible to 
challenge and critique, to be aware of and make visible.

Conclusion

Facilitating clients to tell their story in different ways, so that new possibilities 
might emerge is one of the central ways of social constructionist therapy. When the 
story of psychology and of therapy is told differently we can begin to see and judge 
our practices in new and different ways. Authors such as Foucault and Rose (1965,
1989) describe how the ‘therapies of freedom operate to construct the self and its 
desires in ways which are aligned with social, economic and political objectives.’
(Rose, 1989) Our practices, from this perspective serve to obscure conflict, and the 
injustices on which conflict can be based, to personalise political issues to legitimise existing power relationships. This exploration of the gains and losses (to
 society, to professionals, to the subjects of its practices) of therapy (rather than in
 therapy) remains an important area to be explored by all of us concerned with the 
impact of our practices. My concern is that the possibilities for discourses about
 therapy presented within a social constructionist framework will be obscured in the
 very practices they seek to highlight and challenge:

‘The family therapy movement has had substantial success in shifting the focus 
from defective individuals to systemic processes Now, strongly influenced by
 constructionist writings, the field has become focally concerned ‘with the co-
construction of meaning in therapy, in families and communities. The shift is away
 from who or what is defective, to how it is we come to interpret life patterns as 
defective and what alternative forms of construction may enable relations to 
proceed more congenially. Therapy, then, is not intent on locating evil and
 correcting it, but on co-ordinating meanings within relationships such that the evil 
is rendered obsolete.” (Gergen, 1995)

“We imagine that by avoiding objectification and medicalisation, the hermeneutic,
 psychodynamic and humanistic trends in psychology somehow transcend the job 
of social control that is explicit in other forms of psychology. Nothing could be 
further from the truth. In the end, the prying interpretations of humanistic and
 psychodynamic approaches are far more efficient at normalising than are either 
anti-psychotic drugs of the medical approach or the shaping techniques of 
behaviourism. Psychology – all of it – is a branch of the police; and humanistic
 psychologies are the secret police.” (Richer (1992) p.l 18)

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[Aine O’Reilly works as a counsellor in Sunbeam House Services with children 
who have learning difficulties.]