O F
FAMILY THERAPY
Journal of Family Therapy (2011) 33: 153167
doi: 10.1111/j.1467-6427.2010.00501.x
Paolo Bertrandoa
Today the extent of the difference between theoretical models of therapy
is under discussion. There have been proposals to abandon such models
altogether, or to create others, such as integrative or meta- theoretical
models. This article proposes, through the analysis of a clinical situation,
the possibility of building a theory of practice which could account for
most of the aspects of the therapeutic process that remain tacit and
implicit. Such a theory could help us explain what concretely happens
when a therapist is doing therapy, and also how theoretical models
interact with the everyday practice of therapists.
Keywords: systemic therapy; narrative therapy; clinical theory.
Introduction
As therapists we all share a conviction that our favourite theory
provides the best guide for clinical practice. Theory is supposed to
give us a worldview that directly dictates our actions. The therapist
has learned from books and training situations what she should
observe in clinical practice and this is meant to accord with her
favourite model. She then translates these observations into a set of
therapeutic actions which she believes are coherent with the
model. The terrible complexity of therapeutic events is thus reduced
to the simplicity of theories, and manuals may then be constructed
that allow novices to perform therapy in the right way, avoiding
mistakes. From this perspective the relevant theory is all that matters:
the ignorance about clinical realities is hidden.
Theory, therefore, would dictate practice. Donald Scho
n (1983)
described this model of practice as the model of technical rationality.
In Scho
ns work on the epistemology of the professions, this model of
technical rationality implies that professional activity consists in
a
Direttore, Associazione Episteme, Torino Piazza, Sant Agostino 22, Milan 20123, Italy.
E-mail: pbertrando@gmail.com.
r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.
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Paulo Bertrando
r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.
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Paulo Bertrando
157
might limit the discussion. I will focus instead on two other models:
those of cognitive and narrative therapy. Clearly there are many
variants on these traditions as well; hence I will use in my example
Aaron Becks cognitive therapy (Beck, 1967, 1976) and Michael White
and David Epstons narrative therapy (Epston and White, 1992;
White, 1995; White and Epston, 1989). These may appear to be
very different from each other, but operationally are they so dissimilar? I will first describe the probable pathways these therapies might
take in Norberts case.
Cognitive pathway. First of all, if I were to follow this pathway, I
might look for a diagnosis. The most appropriate diagnosis, which
includes the repetitive compulsive behaviours aiming at a reduction of
anxiety, would be that of obsessive-compulsive disorder (OCD) (DSM
IV-TR: American Psychiatric Association, 2004). I cannot exclude a
concurrent Axis II (personality disorder) diagnosis altogether, but for
clinical purposes the OCD diagnosis may be sufficient.
The second step would be to delineate the major maladaptive
patterns. On a macro level, I might map out Norberts feelings and
reactions, understanding the overall relationships between external
events and internal distress. More micro-level attention would be placed
on specific cognitions, thus identifying and modifying misconceptions
and wrong syllogisms that lead to maladaptive reactions. In Norberts
case, I could use questioning and guided discovery in order to help him
realize that his compulsive, self-harming behaviour is not closely connected to some specific event, but rather to a certain set of events linked
to studying. I could then reconstruct the stages of the development of
his symptoms (this is comparatively easy, since he is vividly aware both of
his symptoms and of the surrounding circumstances).
Tracing back his patterns of response, Norbert could become more
and more aware of how he developed his hostile inner audience.
This could be linked to a pattern of reaction from others, fixed in the
past, in which he has not been acknowledged for himself and his
needs have not been met. At this point, I may be able to help him
neutralize his automatic thoughts, the cognitions that generate his
symptoms. This should help him see a pattern where external events
give rise to cognitions which, in turn, stimulate the rise of a negative
affect. Higher level cognitions could now be substituted for automatic
cognitions, enabling Norbert to distinguish ideas (idiosyncratic
cognitions) from facts (actual events).
These automatic thoughts would now have to be checked against
actual evidence, with a careful, piecemeal exploration of events in
r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.
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Paulo Bertrando
2
It is interesting, for the Batesonian therapist, to find in some of Becks writings the term
premises to indicate what other cognitive therapists define as core beliefs (see Beck, 1967).
r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
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Paulo Bertrando
Returning to Norbert
So, what happens to the clinical case I presented, and to the two
pathways I tried to draw, if I look at them from the vantage point of
procedural implicit knowledge? I could describe the process roughly
as follows for both of my possible pathways:
1. I try to create a basic dialogical consensus with the client.
2. Together, we single out a problem.
3. I look for something that is not immediately available in the clients
awareness, helping him to become more aware of it.
4. He is gradually brought to see some patterns underlying what
happened in his life.
5. At the same time, I look for specific examples in order to
substantiate general understanding with actual events.
r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.
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Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.
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of inquiry and work. Her way of dealing with the situation is not
imposed by her theory, but rather interacts with her procedural
implicit knowledge.
In other words: the reflection-in-action of the therapist is her way
of moving among the elements of her theory, each time building anew
a unique model moulded by the therapeutic situation, a model that in
turn remoulds and modifies the situation. It gives the therapist the
agility she needs in order to face the mutability of clinical encounters.4
At the same time, though, the dialogue with the situation will bring
forth similarities in therapists of different orientations, precisely
because their priority is dialogue with the actual situation, rather
than theoretical consistency.
When someone reflects-in-action, he becomes a researcher in the
practice context. He is not dependent on the categories of established
theory and technique, but constructs a new theory of the unique case. . . .
. He does not keep means and ends separate, but defines them
interactively as he frames a problematic situation. He does not separate
thinking from doing, ratiocinating his way to a decision which he must
later convert to action. Because his experimenting is a kind of action,
implementation is built into his inquiry.
(Scho
n, 1983, p. 68)
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Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
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Paulo Bertrando
use the music she has learned (although, obviously, she cannot play
without knowing music), and she can apply pre-existing schemes only
to a limited extent. Rather, she must hear and feel the music the other
musicians are playing while she plays her own, and, at the same time feel
and hear the music she is playing within the overall sound. All in all, the
improvisational musician reflects on music by (and while) playing music,
and she listens to it while playing. But music, even improvised music,
can be transcribed, and the same musician (or another one) can always
get some understanding, albeit a posteriori, of the kinds of rules she
followed during her improvisation. Reflection in action is a process that
can be defined, with nothing mysterious about it.
Such a view of the therapeutic process brings into the picture the
concept of reflexivity which has been called upon by several authors
within the systemic field, such as John Burnham (2005), Carmel
Flaskas (2005; see also Flaskas and Perlesz, 1996), and bears some
resemblance to the concept of inner dialogue of the therapist developed by Peter Rober (2005).
To develop such a reflexivity, the therapist requires the dialogues
she weaves with clients, colleagues, supervisors, as well as situations,
readings and experiences. Any moment of this continuous dialogue
changes the therapists experience, and necessarily changes also her
way of reading her therapeutic work. This is why, whenever I
reconsider one of my sessions, I may find (and usually I do find)
something previously unseen in it. This is why any response by my
clients, in the course of the therapeutic dialogue, may change my way
of seeing what is happening. This also means that my work is always
open to new options. Ideally, I could endlessly review one case, one
session, and go on to find something new in it. In this sense, a theory
of practice is a hermeneutic of practice that allows me (and possibly
others, too) to find new sense in what I do, without ever drying up.
This is also why no practising therapist can be constrained within
the limits of one theory, fascinating as it may be. Any theory, with all its
prescriptions, will have to enter into dialogue with the clinical
situation, and that dialogue will shape practice more than any theory
can. What we saw when we looked at the similarities between the
cognitive and the narrative pathways was precisely that shaping.
The use of theories
Are theories, therefore, substantially useless, as some theorists in the
common factor tradition hold? Not necessarily. The use of theories
r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.
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Paulo Bertrando
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r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.
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