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.
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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Dobash, and Dobash, R.E. (1963) The Context-Specific Approach.’ In Finkelhor, D., Gelles, R.J., Hotaling. G.T and Straus, MA (Eds.) The Dark Side of Families; current Family Violence Research (pp 261-277) London: Sage Publications.
Gergen, K. J. (1995) Social Construction and the Transformation of Identity Politics, in Draft Copy for New School for Social Research Symposium, 7 April 1995.
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Leone, P.E. (1990) Toward Integrated Perspectives on Troubling Behaviour’ in Leone (Ed) Understanding Troubled and Troubling Youth (pp 15-22) London: Sage Publications
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Minuchin, S. (1991) The Seduction of Constructionism. Family Therapy Networker 15:5
Olafson, E., Crown, DL, and Summit R. C. (1993) Modem History of Child Sexual Abuse Awareness: Cycles of Discovery and Suppression Child Abuse and Neglect. 17:7-22.
O’Reilly, A. (1994) ‘Towards a Child Centred Framework’ Journal of Child Centred Practice. 1:1
Richer, P. (1992) ‘An Introduction to Deconstructionist Psychology’ In Kvale, S. (ed.) Psychology and Postmodernism (p.l 10 -118) London: Sage Publications.
Rose, N. (1985) The Psychological Complex: Psychology, Politics and Society in England, 1(1939). London: Routledge.
Rose, N. (1989) Governing the Soul. The Shaping of the Private Self. London: Routledge.
Seligman, M. E. P. (1995). ‘The Effectiveness of Psychotherapy: The Consumer Reports Study.’ American Psychologist 50, 965-974. World Wide Web: http/www.apa.org/journals/seligman.html
Shotter, J. and Gergen, K.J. (1989) Texts of Identity. London: Sage
[Aine O’Reilly works as a counsellor in Sunbeam House Services with children who have learning difficulties.]