Sociopolitical activist or conversational partner? Distinguishing the position of the therapist in narrative and collaborative therapies

Centering the Voice of the Client: On Becoming a Collaborative Practitioner with Low-Income Individuals and Families

Despite current interest in collaborative practices, few investigations document the ways practitioners can facilitate collaboration during in-session interactions. This investigation explores verbatim psychotherapy transcripts to describe and illustrate therapist's communications that facilitate or hinder centering client's voice in work with socioeconomically disadvantaged populations. Four exemplar cases were selected from a large intervention trial aimed at improving shared decision making (SDM) skills of psychotherapists working with low-income clients. The exemplar cases were selected because they showed therapist's different degrees of success in facilitating SDM. Therapist's verbalizations were grouped into five distinct communicative practices that centered or de-centered the voice of clients. Communication practices were examined through the lens of collaborative approaches in family therapy. The analysis suggests that cross-fertilization between SDM and family-oriented collaborative and critical approaches shows promise to illuminate and enhance the challenging road from clinician-led to client-led interactions. This paper also stresses the importance of incorporating relational intersectionality with individuals and families who may not feel entitled to express their expectations or raise questions when interacting with authority figures.

Navigating Critical Theory and Postmodernism: Social Justice and Therapist Power in Family Therapy

The family therapy field encourages commitment to diversity and social justice, but offers varying ideas about how to attentively consider these issues. Critical informed models advocate activism, whereas postmodern informed models encourage multiple perspectives. It is often not clear how activism and an emphasis on multiple perspectives connect, engendering the sense that critical and postmodern practices may be disparate. To understand how therapists negotiate these perspectives in practice, this qualitative grounded theory analysis drew on interviews with 11 therapists, each known for their work from both critical and postmodern perspectives. We found that these therapists generally engage in a set of shared constructionist practices while also demonstrating two distinct forms of activism: activism through countering and activism through collaborating. Ultimately, decisions made about how to navigate critical and postmodern influences were connected to how therapists viewed ethics and the ways they were comfortable using their therapeutic power. The findings illustrate practice strategies through which therapists apply each approach.

From Therapeutic Power to Resistance?

Four ideas are used to conceptually link local therapeutic practices with macro sociocultural arrangements, and to question the feasibility of therapeutically derived resistances against them: power as a productive force; the power–knowledge integration; the power–resistance relationship; and power in context. Narrative therapy is presented as an example of a ‘therapy of resistance’, which at a micro level challenges the therapist–client power relation and privileges clients’ local knowledges, and hence, at a macro level, promotes resistance against dominant discourses and practices. However, at least two fundamental problems face therapies advocating resistance. At a macro level, they are vulnerable to neutralization when they engage in broader power relations. And at a micro level, they cannot escape the institutionalized therapist–client power imbalance, which renders ethically problematic the use of the therapeutic encounter to promote resistance. Strategies for addressing these problems are discussed.

‘Talking about my experiences … at times disturbing yet positive’: Producing narratives with people living with dementia

Background

This research investigated narrative production and use with families living with dementia. We hypothesised that the process of narrative production would be beneficial to people with dementia and carers, and would elicit important learning for health and social care professionals.

Method

Through third sector partners, we recruited community-dwelling people with dementia and carers who consented to develop written, audiotaped or videotaped narratives. Audio-taped narratives were transcribed verbatim and handwritten narratives word-processed. After checking by participants, completed narratives were analysed thematically using qualitative data analysis computer software. A summary of the analysis was circulated to participants, inviting feedback: the analysis was then reviewed. A feedback questionnaire was subsequently circulated to participants, and responses were analysed thematically.

Results

Twenty-one carers and 20 people with dementia participated in the project. Four themes of support were identified: ‘relationships’, ‘services’, ‘prior experience of coping’ and having an ‘explanation for the dementia’. Three themes were identified as possible additional stresses: ‘emotions’, ‘physical health’ and ‘identity’. We suggest a model incorporating all these themes, which appeared to contribute to three further themes; ‘experience of dementia’, ‘approaches to coping’ and ‘looking to the future’. In participant feedback, the main themes identified were ‘emotions’, ‘putting things in perspective’, ‘sharing or not sharing the narrative’ and ‘actions resulting’.

Conclusions

Producing a narrative is a valuable and engaging experience for people with dementia and carers, and is likely to contribute to the quality of dementia care. Further research is needed to establish how narrative production could be incorporated into routine practice.

Responsive persistence part I: therapist influence in postmodern practice

Feminist and social constructionist developments in family therapy highlighted the importance of attending to therapist-client power relations and incorporating clients' understandings and preferences as a part of therapy. Significantly, less attention has been given to how postmodern therapists do use their power and influence. This is an important topic because it is therapists who have the major responsibility for guiding the interaction with clients and persisting in this so that change is facilitated. Therapist persistence in various forms and across dimensions of therapy process is examined to expand understanding of therapist influence in postmodern and collaborative work. An analysis of responsive persistence in a session with Karl Tomm as the therapist is presented to illustrate this conceptual framing.

Responsive Persistence Part II. Practices of Postmodern Therapists

This article, a companion to Part I of this series of articles, discusses how therapists informed by social constructionist and postmodern ideas enact persistence in their work with families. Transcripts and video-recordings of therapy interaction facilitated by selected major champions for three postmodern (collaborative) therapies: Michael White (narrative therapy), Harlene Anderson (collaborative language systems approach), and Bill O'Hanlon (solution-oriented therapy) were examined for persistence practices. The article offers a range of possible ways in which postmodern therapists may enact their influence in facilitating generative and helpful conversations with families and remain responsive to clients' preferences and understandings. Implications for family therapy practice, training, and supervision are discussed.

Core competencies in social constructionist supervision?

Family therapy is moving increasingly toward evidence-based practice and competency-based training. This article explores what might seem to be an unlikely link between social constructionist supervision, which is based on dialogic and fluid processes of meaning-making, and the increasing reliance on discrete core competencies in the education and training of family therapists. We propose an alternate approach to competencies for supervision with therapists in training that, among other things, invites accountability and provides evaluative props. The approach we propose is based on a set of orientations that we hope reflect the dialogic and contextual nature of social constructionist practice and supervision. These orientations consist of reflexivity and attention to power, fostering polyphony and generativity, collaborative stance, and focus on client resourcefulness. Ideas and questions for supervisors and therapists in training to address the orientations are articulated.

Clients as conversational agents

OBJECTIVE

Conversational agency is our invented term that orients us to ways in which clients participate in therapeutic dialogues. In this study we examined how clients' conversational correctives and initiatives influenced collaborative therapeutic consultations.

METHODS

Thirty-five single-session lifestyle consultations were videotaped in which adult clients volunteered to discuss concerns of non-clinical severity with a counselor. We discursively microanalyzed excerpts where clients initiated topic shifts or corrected counselor misunderstandings and how counselors responded to them.

RESULTS

Clients were actively involved in co-managing conversational developments during the consultations. They influenced the content and course of the conversations with the counselors by correcting, interrupting, or speaking from positions contrary or unrelated to those of the counselors.

CONCLUSION

Clients observably influenced the conversational agenda through their correctives and initiatives if counselors were responsive during face-to-face consultations.

PRACTICE IMPLICATIONS

Clinicians should demonstrate increased sensitivity and relational responsivity by intentionally engaging with clients' agentive contributions to consultative dialogues.

Towards a grounding of the agentive subject in narrative therapy

This paper examines the tensions between narrative therapy’s self-identification as a Foucauldian poststructural practice, and its attachment to the notion of personal agency. Michael White—narrative therapy’s primary author—used Foucault’s work as a theoretical foundation, moving us to pose a question that White did not address: Can the narrative therapeutic commitment to an agentive subject be sustained alongside White’s loyalty to the Foucauldian notion of power/knowledge and its account of the constituted subject? I argue that while Foucault is often criticized for not making space for freedom or agency, something like an agentive subject is implicit in, even required for, his constitutionalist perspective to work. Working through this problem could be useful for the developing field of narrative therapy. Three proposals are offered as a way of imagining this agentive figure, and their relevance to narrative therapy practice is discussed.

Moving beyond the blame game: toward a discursive approach to negotiating conflict within couple relationships

The concept of discourse is an important tool in negotiating conflict and facilitating conversations within therapy. This article offers a useful framework for negotiating conflict in a couple relationship by highlighting the manner in which individual's expectations are mutually emergent from particular discursive positions. Specific discursive practices and approaches that make more visible the cultural production of conflicts are presented via a case illustration. These practices provide more freedom to couples in relationships to explore conflicts with less totalizing descriptions of the other as blameworthy. In addition, a discursive analysis of conflict invites therapists to be more intentional, reflexive, and socially responsible in their work.

The heart of the matter 2: integration of ecosystemic family therapy practices with systems of care mental health services for children and families

Many children in this country do not receive the mental health care they need. At the same time, a nationwide movement known as systems of care is providing innovative services for families and children. This article links the ideas inherent in systems of care with ecosystemic family therapy principles and practices. Based on a study of nine innovative systems of care pilot projects in Massachusetts, it describes how these innovative programs, and others like them, have been most successful in increasing access to services and providing for coordinated services. They have been less successful in accomplishing positive clinical and functional outcomes. Change in these systems is often described in terms of how services are provided. Not enough attention is given to the conversations that take place between families and case coordinators and how these conversations lead to long-term change. This article contends that the ways in which services are delivered in these systems of care fit well with ecosystemic family therapy principles and practices. We, as family therapists, have an opportunity to link these two sets of ideas, which share common assumptions and values and increase the likelihood of positive clinical outcomes for children and families.

Small steps and big leaps in an era of cultural transition: a crisis in a traditional Kosovar Albanian family

This ethnographic vignette details the way a difficult crisis in an extended Kosovar family was managed by its own members within the mandates of that overtly patriarchal culture while creating important avenues for change. The cultural and historic context for these events is provided, and the nuances of this solution-oriented, culturally congruent, "natural" (i.e., not in a therapeutic context) process are discussed.