Tracing lines of flight: implications of the work of Gilles Deleuze for narrative practice

Medical students' experiences and needs from written reflective journal feedback

INTRODUCTION

Reflective ability is an important skill for enhancing professionalism and developing communication skills. To improve reflective ability, medical educators encourage use of written reflective journals, for which feedback is important. It is difficult for educators to anticipate how their feedback will be perceived. Therefore, this study examined students' experiences with educators' written feedback on reflective journals.

METHODS

A qualitative, immersion/crystallization analysis of 60 written feedback texts to 15 medical students (30 identified by students as meaningful and 30 as less meaningful) and in-depth semi-structured interviews with these students. We did not define 'meaningful', to leave room for students' own interpretations. We analysed the feedback to identify what it includes (its components) and analysed the interviews to learn about students' experiences of receiving the feedback and the specific components.

RESULTS

Students experienced five components as meaningful: supportive and encouraging statements; legitimisation of their emotions; educators sharing personal-professional experiences; asking questions to enhance reflection; and focusing on the students' main concern. These components enhanced students' willingness to read and learn from the feedback. Three components were experienced as less meaningful: detached, impersonal feedback; negative tone (criticism); and technical issues, for example brevity. These disappointing and hurtful components led students to pay less attention to the feedback or to invest less effort in future written assignments.

CONCLUSIONS

The present study identified components in written reflective journal feedback texts and the experience and needs of students who received them. It showed the complexity of writing reflective feedback because of the need to support students through it, help them deal with emotions, identify and focus on personal content that matters to them, and provide opportunities to develop and enhance their reflective ability, while being mindful of their emotional state. To help educators in this challenging task, a self-assessment mnemonic ('FEEDBACK') for use before sending the initial feedback was developed.

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.

[Becoming Another: Transformations in the Therapist Who Works with Gay and Lesbian Couples]

OBJECTIVE

To recognise the changes experienced by the therapist who works with gay and lesbian couples.

METHOD

Qualitative with biographical-narrative method. Seven therapists were interviewed in Medellin.

RESULTS

Three moments in the life trajectory of the participants were identified: Before: closeness and distances between families and the school were found (distances, makes reference, among others, to discourses about homosexuality. During: showed the conspiracy of silence in the undergraduate and postgraduate training of therapists, and in the clinical approach with homosexual couples they perceive in the reasons for consultation, a spectrum between everyday conflict and imposed exclusion. After: makes reference to the changes that this clinical work has generated in them, how they have become different, while others have been defined as: political subjects who resist normalization and become learners of artistic territories and artisans of their own lives.

CONCLUSIONS

The task of becoming another is a poetic, aesthetic and ethical process like the beautiful creation of the own existence. These transformations are connected with presence, social, politic and artistic contexts, reflexive labour and criticism about themselves.

Narrative Therapy's Relational Understanding of Identity

We describe how we think of identity as relational, distributed, performed, and fluid, and we illustrate the use of this conceptualization within a narrative worldview. Drawing on the work of Michael White, we describe how this relational view of identity leads to therapeutic responses that give value to interconnection across multiple contexts and that focus on becoming rather than on being. We show how a narrative worldview helps focus on the relational, co-evolving perspective that was the basis of our early attraction to family therapy. We offer detailed examples from our work of practices that help us stay firmly situated in a relational worldview that is counter to the pervasive influence of individualism in our contemporary culture.

The Cocreation of Crazy Patchworks: Becoming Rhizomatic in Systemic Therapy

In the field of systemic therapy, there has been much discussion recently about the narrative self. This concept refers to the idea that the self is narratively constructed in and through the stories which someone tells about him/herself. The story is thereby not only viewed as a metaphor for selfhood: Selfhood is not compared to a story, it is a story. But what kind of story are we talking about here? If the self is a story, what does that story look like? These questions are explored in this article. Starting from the possibilities and limitations of traditional and postmodern visions on the self as a story, an alternative vision is illustrated. By considering the self as a rhizomatic story, we not only create a useful view of the way narrative selfhood is constructed within a therapy context, but we also stimulate therapists to coconstruct-together with their clients-patchworks of self-stories. By using story fragments of our own practice, we illustrate the rhizomatic thinking and its possibilities in therapy.

Diagnoses, Relational Processes and Resourceful Dialogs: Tensions for Families and Family Therapy

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), given its psychiatric focus on mental disorders in individuals, presents families and family therapists with challenges. Despite considerable controversies over its adoption, the DSM-5 extends a process of standardizing a language for human and relational concerns. No longer a diagnostic language of professionals alone, its use is medicalizing how mental health funders and administrators, as well as clients, respond to human concerns. For family therapists who practice systemically, particularly from poststructuralist and strengths-based orientations, many tensions can follow when use of the DSM-5 is expected by mental health administrators and funders, or by clients who present concerns about themselves or a diagnosed family member. In this paper, I explore how such DSM-5 related tensions might be recognized, navigated, and negotiated in the practice of family therapy with clients, and with administrators and funders.

Don't end up in the fields: identity construction among Mexican adolescent immigrants, their parents, and sociocontextual processes

This grounded theory study of 16 Mexican immigrant adolescents and 20 of their parents examines how they construct relational identities within their families, at school, with friends, and in the larger society. Results focus on a core identity bind faced by the adolescents: immigration messages from parents that say, "don't be like me" and the societal message, "you're not like us." Response to this bind was guided by two contrasting sets of identity narratives: Empowering narratives invited an intentional approach to school and life choices. Restricting narratives maintained an ambivalent approach to school and life choices. Resolution of the identity bind was a collective, ongoing process that has implications for Mexican immigrant families and the professionals who work with them.

The advance of poststructuralism and its influence on family therapy

Postmodernism began to influence family therapy very early in the 1980s with articles referencing postmodern ideas, focusing on meaning and multiplicity. With the appearance of narrative therapy on the scene in the 1990s there was a shift toward poststructural thinking, which refined the movement and politicized the clinical work. Even with a bit of a backlash, whether because this was a new idea or it somehow threatened a positivistic culture, a poststructural view has continued to have effects on family therapy. This article explores the variety of influences: the expansion of narrative ideas, the innovation of Madsen's collaborative helping, and also more nuanced effects. I argue that a poststructural view has effectively changed how many family therapists think and may also be subtly influencing how they might work.

Beyond the bounds of the dogmatic image of thought: the development of critical, creative thinking in the mental health professions

Reflections upon what it might mean to think, and about what inherited presuppositions or images might influence what thinking is thought to consist of, are not readily considered in the mental health care literature. However, the work of the 20th century French philosopher Gilles Deleuze and, in particular, his account of 'the dogmatic image of thought' can be employed to illustrate how such considerations can be of relevance to the theoretical and practical concerns of mental health professionals. In doing so, Deleuze's work can be understood as seeking to sensitize mental health professionals to the dangers of unreflectively adopting a restrictive notion of what it means to think, as well as an exhortation to develop critical, creative thinking in the mental health professions that moves beyond the bounds of the traditional, dogmatic image of thought. Considerations about what it might mean to think, and about what inherited presuppositions determine what thinking is thought to consist of, are not readily reflected upon in the mental health care literature. However, this paper will propose that such considerations are of relevance to, and possess important implications for, the mental health professions, and it will do so within the context of the work of the 20th century philosopher Gilles Deleuze. In particular, the paper will provide an accessible exposition of what Deleuze refers to as the 'dogmatic image of thought', along with an examination of his suggestion that this traditional image, and its associated presuppositions, not only determine what is considered to be the ostensible 'nature' of thought, but also delineate what the activity of thinking ought to be concerned with. Moreover, it will be argued that Deleuze's exposition and critique of the image of thought can be understood as seeking to sensitize mental health professionals to the dangers of unreflectively perpetuating a restrictive notion of what it means to think, as well as being an exhortation to develop critical, creative thinking in the mental health professions that moves beyond the bounds of that traditional, dogmatic image of thought.

Why power matters: creating a foundation of mutual support in couple relationships

Research shows that equal power helps couples create intimacy and relationship success. However, though couples increasingly desire equal relationships, cultural models of mutual support are not well developed. Clinicians often approach heterosexual couple therapy as though partners are inherently equal, thus reinforcing unacknowledged gender inequities. This article examines research that shows why power imbalances are destructive to intimate relationships and focuses on four gender-related aspects of mutual support: (a) shared relational responsibility, (b) mutual vulnerability, (c) mutual attunement, and (d) shared influence. Case examples illustrate how socio-emotional attunement, interrupting the flow of power, and introducing alternative relational experience help couple therapists identify and address power disparities in these important relational processes. Encouraging the powerful person to take relational initiative and introducing alternative gender discourse are especially important.

Patriarchy, power, and privilege: a narrative/poststructural view of work with couples

Poststructural/narrative therapists working with heterosexual couples position themselves to attend to issues of power and privilege and how these variables differentially affect each gendered member of the couple. The poststructural therapist understands patriarchy as the grand narrative that influences us all, often invisibly, and creates conditions for people to respond outside what might be their preferences for performing relationships. This article takes the reader inside the work with couples and demonstrates how the narrative/poststructural therapist attends to aspects of the conversation, asks questions, makes comments, and otherwise intervenes with couples using patriarchy as a lens for understanding. Rather than challenging patriarchy in how it influences men and women, the intention is to bring forth more preferred ways of being that are outside of or on the other side of patriarchal effects. This way of working thickens people's accounts of themselves and of their relationships so that they might live in more satisfactory ways.

Developing a contextual consciousness: learning to address gender, societal power, and culture in clinical practice

Despite the growing number of culturally sensitive training models and considerable literature on the importance of training clinicians in larger contextual issues, research examining how students learn to apply these issues is limited. In this participatory action research project, we systematically studied our own process as marriage and family therapy (MFT) practicum students developing a contextual consciousness. Using grounded theory, we identified a three-stage process: (a) raised awareness through clinical experimentation and developing a theoretical rationale, (b) reflective questioning involving challenging old perspectives and experiencing positive client-therapist interactions, and (c) an intentional new lens based on personal responsibility and commitment. Creating and maintaining a contextual lens required a safe, empowering group dynamic and accessing other forms of support and accountability after the practicum.

Parenting as relationship: a framework for assessment and practice

Parenting tends to be framed as a set of actions directed toward the child rather than as a relationship. This article helps therapists, parent-educators, and researchers conceptualize parenting as a socioculturally embedded relationship. The authors apply the relational orientations typology (Silverstein, Bass, Tuttle, Knudson-Martin, & Huenergardt, 2006) to parent-child relationships. The typology addresses two dimensions: whether the focus is on the child's meeting parental expectations or on expectations of mutuality and whether power between parent and child is expected to be symmetrical or asymmetrical. Four relational orientations are described: (1) rule directed, (2) position directed, (3) independence directed, and (4) relationship directed. These relational orientations describe the nature of the reciprocal relationship between parent and child and offer a framework from which to address parenting issues. A case illustration shows how the relational orientations framework helps therapists incorporate a larger systems/relational perspective into what was originally framed primarily as a child behavior problem.

A socio-emotional approach to couple therapy: linking social context and couple interaction

This paper introduces Socio-Emotional Relationship Therapy (SERT), an approach designed to intervene in socio-cultural processes that limit couples' ability to develop mutually supportive relationships, especially within heterosexual relationships. SERT integrates recent advances in neurobiology and the social context of emotion with social constructionist assumptions regarding the fluid and contextual nature of gender, culture, personal identities, and relationship patterns. It advances social constructionist practice through in-session experiential work focused on 4 conditions foundational to mutual support--mutual influence, shared vulnerability, shared relationship responsibility, and mutual attunement. In contrast to couple therapy models that mask power issues, therapist neutrality is not considered possible or desirable. Instead, therapists position themselves to counteract social inequalities. The paper illustrates how empathic engagement of a socio-culturally attuned therapist sets the stage for new socio-cultural experience as it is embodied neurologically and physically in the relationship and discusses therapy as societal intervention.

Positioning oneself within an epistemology: refining our thinking about integrative approaches

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.