Selasa, 17 September 2013
Guiding Priniciples of Practice
A Lion was awakened from sleep by a Mouse running over his face. Rising up angrily, he caught him with his paw and was about to kill him, when the Mouse cried
'Forgive me this time and I shall never forget it.'
The Lion took pity on the Mouse and let him go. As he was leaving the Mouse said
'Who knows but I may be able to do you a good turn one of these days?' The Lion laughed at this idea saying
'How could you a little Mouse help me the King of the jungle?' Some time later the Lion was caught in a trap by hunters who wanted to take him alive to a zoo. The Lion roared out in fear and he was heard by the little Mouse who came to his aid. The little Mouse quickly gnawed through the ropes that bound the King of the jungle and freed him.
The Lion and the Mouse, Aesop
The story of the Lion and the Mouse illustrates some key aspects of a resource and strengths focused approach to helping people. Even though the tiny mouse appeared to have little to offer the great Lion, in a different context the mouse provided the ideal help - a little friend that proved to be a great friend. When working with children and families, often the most helpful ideas can come from the youngest or least powerful person in the family. Some time ago I was working with a mother and her three children, referred because of the aggressive behaviour of the eldest son who was 12. A turning point in the third session was when I arrived late to see that the youngest girl, who was six, had sat in what was normally my seat and I was left to sit in her smaller 'child' seat. This prompted me to ask 'Would you like to run the meeting?' In a playful mood she answered yes. 'Well, what do you think we should talk about?' I asked her. She thought for a moment and then said 'I think we should talk about why Dad doesn't come home very much.' This opened up a conversation in the family about how they felt about their father's absence and it freed up the older son to talk a little more about his feelings, which proved to be of great benefit to him. This little girl, who might have been excluded from the therapy because of her age, was able to make a valuable contribution.
Similarly, people in the system who have been previously 'written off' or deemed to be a negative influence in a child's life can, when included more constructively or within a different context, become a resource to a child. Many times I have worked with families where a live-away parent, because of allegations of violence or abuse, has been excluded from therapy, only to discover that this person can make a contribution and return to a more constructive role with their
children. For example, one father who had left the family home after a violent relationship and who had limited contact for several years, rose successfully to the challenge of caring for the children full-time when they were about to placed in residential care. Even parents who have seriously abused their children can make a contribution to creating a constructive path forward. For example, one father I worked with who had sexually abused his two children began letter contact with them, where he took responsibility for what happened and apologised to them. This small act was of enormous value to the children and very helpful to them in coming to terms with what had happened.
The Lion and Mouse fable also teaches us another helpful lesson. In the story, the mouse returned to help the great Lion because of the mercy the Lion had originally shown him. If the Lion had killed the mouse, then the mouse would have not been there to help him. The kindness or mercy the Lion showed was repaid (with interest!). As therapists, it is important that we should treat all people in the system with respect and kindness, not only because it is the 'right thing to do', but also because this respect is often repaid in kind. So often I have seen therapists get into unnecessary conflict, either with members of the family or with the professional system. These conflicts, which could have been healed by respectful dialogue and understanding, severely hamper collaboration and reduce outcome. For example, we could be critical (and inadvertently dismissive) of a teacher who has referred a child to be assessed on account of his behavioural problems, because we believe the problem is related to her classroom management skills. Yet such an attitude will diminish her cooperation in any treatment plan and not be in the child's best interest. Alternatively, we can go that extra distance to understand and appreciate the difficulties she experiences in the class with this boy and to value the steps she has taken to solve it (for example, contacting you). This respectful approach is much more likely to elicit her cooperation and involvement. The respect you show to her is likely to be repaid - and she is likely to forgive the many errors you make in your therapy! (We all need this level of compassion and understanding!)
In this chapter we consider three of the basic principles (see Box 2.1) of working with children and families, from a collaborative, client-centred and strengths-based perspective.
• Building a therapeutic alliance.
• Focusing on strengths, skills and resources.
• Making client goals and preferences central.
Building a therapeutic alliance
Being able to form a collaborative relationship or alliance with children and the key members of their family is essential to effective therapy. The necessity of a therapeutic alliance as a precondition of an effective helping relationship is one of the few undisputed conclusions from outcome research over many years (Bachelor and Hovarth, 1999; Garfield and Bergin, 1994). Specific research studies have repeatedly found that a positive therapeutic alliance is the single best predictor of positive outcome (Krupnick et al., 1996; Orlinsky et al., 1994). This result is independent of the model of therapy or its mode of delivery, whether family or individual. Even in group therapy, there is compelling evidence that the analogous concept of group cohesion - namely the sense of belonging or attraction a client has for the group - is essential to gaining effective outcome (Hurley, 1989; Yalom et al., 1967 as cited in Yalom, 1995). So central is the therapeutic alliance that many writers argue that all other aspects of helping relationships process such as gathering information or carrying out assessments should also be secondary. As Alan Carr states regarding an initial psychological assessment:
All other features of the consultation process should be subordinate to the working
alliance, since without it clients drop out of assessment and therapy or fail to make progress. (1999: 113)
So as a therapist, how do you establish a therapeutic alliance with the family who comes to see you? How do you create enough trust so that they will become partners in the therapeutic process?
In trying to answer these questions, it is important not to be proscriptive or definitive. At the heart of the therapeutic encounter are human relationships that bring together the unique mix of the clients' and therapists' personalities and histories. These therapeutic relationships are always unique interchanges between two or more people and it is impossible to generalise about what will work in all cases. A way of connecting with one client may not work with another. Two different therapists are likely to connect differently with the same client and two different clients are likely to call for different styles of connecting from the same therapist.
There are five principles that can help guide this process:
1 Empathy, acceptance and genuineness.
2 Respectful curiosity.
3 Problem-free talk.
These principles should only act as guidelines to you as you attempt to form alliances with your clients. What counts is being sensitive to each client you meet and finding what works in each individual situation.
Empathy, acceptance and genuineness
Carl Rogers, one of the most influential figures in modern counselling, pioneered the studies into the qualities of an effective therapeutic relationship. Initially he focused on the therapist skills which could contribute to this process and conceptualised a 'non-directive' approach to counselling that emphasised active listening on the part of the therapist. Active listening included skills such as reflecting back, summarising, paraphrasing and so on. In his later work, he reframed his approach as Person Centred Counselling and moved from a focus on therapist skills to a focus on the quality of the relationship. He came to realise that what was essential was not necessarily the listening skills the therapist used, but the core attitudes of empathy, acceptance (or unconditional positive regard) and genuineness that these communicated to the client. If the client felt empathically understood, accepted unconditionally and that the therapist was genuine in their responses, then therapy could begin. Active listening skills would not work if they did not communicate these core attitudes (for example, if they were parroted, undertaken rigidly or disingenuously, and were not sensitive and responsive to the client) and conceivably other modes of communication (such as humour) could also be effective if they were imbued with empathy, acceptance and genuineness.
Interestingly, many studies show that it is the client's perception of the therapeutic alliance as opposed to that of the therapist or external observers (who rated video-taped sessions) that is most linked to successful outcome (Bachelor, 1991; Gurman, 1977). As therapists, we need not to rely just on skills and ensure that the core attitudes are actually communicated to the client; what counts is not whether we judge that we are being non-judgemental, accepting and empathic, but rather whether our clients actually feel supported, not blamed, accepted and understood.
When counselling families, we have the challenge of communicating these core attitudes to more than one individual at the same time. It is not effective to empathetically understand a child if this understanding alienates a parent. Nor is it effective to construct a position where you are 'on the side' of the parents if this pits you against the child. When working with families it is important to seek deeper understandings which are inclusive of both children and parents and to construct positions where you are 'on everyone's side'. You are seeking to understand each person's perspective and to construct ideas and ways forward that include everyone's needs and preferences. For example, when meeting a teenage girl and her mother who are in conflict over the teenager staying out late, you can seek to understand both the mother's need to ensure her daughter's safety and the daughter's need for independence. From an inclusive understanding you can begin to construct mutually beneficial ways forward. Often this process is described in family therapy as remaining 'neutral' (Jones, 1993), though this can be misleading as neutral can sound as though you are uninvolved or that you 'don't care' as the therapist. Perhaps a better conception is that you do care, but that you care for all people at the same time.
Maintaining this stance towards all members of a family can be very difficult, especially when there is a lot of conflict. It is essential, however, in order to be effective. Sometimes it is not possible in a family meeting to establish an alliance with all family members. In these situations, individual meetings can be arranged to give you time to build up an alliance and understanding of each viewpoint before a family meeting is embarked upon.
A strengths-based or solution-focused approach to therapy builds on Rogers's three basic attitudes of empathy, acceptance and genuineness, while adding one other - respectful curiosity. Interestingly, Rogers himself alludes to this attitude as he describes the development of a 'sense of awe' towards the client:
As therapy goes on the therapist's feeling of acceptance and respect for the client tends therapist's to change to something approaching awe as he sees the valiant and deep struggle of the person to be himself. (Rogers, 1961: 82)
Strengths-based therapists attempt to cultivate this sense of awe towards their clients by adopting an attitude of respectful curiosity towards their lives and the stories they tell. They are interested in them as people who are more than the problem; they want to find out more about their talents and strengths, and they are interested in their values, desires and preferences for their future. Much of this respectful curiosity is communicated by the questions that the therapist asks to guide the therapeutic process, such as:
• I'm interested in how you managed to get through that difficult situation?
• I'm curious about what you would feel when things were different (or better)?
• I wonder what was different last week when things went well?
• Suppose things were to get better next week, what would that look like?
Even if these questions aren't directly asked of the client, the wonder and respectful curiosity that underpins them is what changes the dynamic of the therapeutic relationship.
Strengths-based therapists start from a position of 'not knowing' and see each session as an opportunity to learn from the clients who are the real experts in their lives. In preparing to meet a new family, Jonathon Prosser (2001) describes a number of preparatory questions that therapists can ask themselves to free their minds from the negative expectations of a problem-dominated referral letter and to replace this with a respectful and more optimistic curiosity. These questions include:
• What new, wonderful and surprising things will I find out about this family in the next session?
• I wonder what I will learn, and how much I will be inspired?
• I wonder how much fun I will have in the process?
These questions can help free us as therapists from a problem-focused mindset and give us a freedom to discover new perspectives and ideas that are more useful in helping the family move forward. For example, many of the children referred to child and family clinics are described exclusively in terms of their problems, such as 'failing at school', or being 'aggressive' or 'oppositional'. Yet on closer examination, we may discover that they also have many positive qualities such as being a great cook, having a specific talent for football, or being very caring towards an invalid grandparent. In addition, we may discover that many parents labelled as 'limited' or 'deprived' have their own unique strengths, as is illustrated in Case Example 2.1.
Case Example 2.1 A talent for singing
When working as a community social worker, I was referred a family from a very deprived area, headed by a single mother who had a mild learning disability. There was a long history of concern about her ability to be a parent and the school would frequently report that her children were neglected in very basic ways (for example, being inappropriately clothed, poor hygiene, regularly missing school and so on). However, the mother was also very suspicious and hostile towards services and rarely engaged with workers for long periods. Frequently the case would be closed, without substantive change, only for new concerns to emerge at a later date. On reading the long 'problem focused' file, it was easy for me to feel pessimistic about engaging the family in a helpful way.
However, a turning point in being able to establish an alliance with the mother came from a conversation at the beginning of a session when she explained her interest in singing. It turned out that she had a great singing voice and people in her family reported that she could 'sing like Mary Black' (a traditional Irish singer). She spoke about her long-standing interest in singing and how she was pleased that her ten-year-old daughter was taking an interest in singing (this was one of the few areas where the daughter succeeded in school).
This new information helped change the nature of my relationship with the mother and helped me 'see' her differently, as not simply a deprived limited single parent, but as an individual person with talents and aspirations. As a result the context of our interaction began to change. By not only focusing on her problems but also valuing her talents in a more balanced way, my therapeutic alliance with this mother was transformed and our work together could begin. Over time she trusted me enough to co-create with her a practical child protection plan for her children to establish routines in their care.
An important way of establishing an alliance with clients in solution-focused therapy is to start the session with problem-free talk (George et al., 1990; Walsh, 1997). This means that the therapist engages the family in a conversation about things that are going right in their lives and which do not necessarily have a connection to the problem that has brought them to therapy. The aim is to get to know the clients as people, who are distinct from the problem and who have talents, hopes, values, hobbies and interests just like other people. On meeting a family for the first time, the therapist may spend some time talking to them about what they like to do as family, what trips and holidays they like, and even what they like about each other. This may be done informally, as part of a 'getting to know you' conversation or it can be done as an exercise or a fun game; for example, family members could be invited to name a favourite family trip or work together on drawing a picture of their strengths or motto as a family.
Informal problem-free talk can resemble social chitchat, though it has a constructive orientation; a skilled therapist is listening carefully for strengths, skills and resources that can be useful later in solving problems. For example, in a recent case working with a family who was referred on account of the son's out-of-control behaviour, the therapist engaged the father by talking about his work as a carpenter, rather than immediately talking about the presenting problem. This conversation revealed that the son also shared a strong interest in his father's work and liked to help him on jobs. This problem-free talk identified a connection between father and son that became central to the eventual solution.
As well as identifying strengths and resources, problem-free talk often has a subtle effect on the therapist's view of the family and thus the therapeutic relationship. Many children and families referred to professional services are surrounded by a negative story that details failure deficits and layers of problems. It is very easy, as therapists, to connect into that story and to become deflated and pessimistic about change (in turn adding to the family's pessimism). Problem-free talk allows therapists to connect with clients as people who are much more than the problems that bring them to therapy, and to note the many positive aspects of their lives that may often be overlooked and undervalued. This is often the beginning of a different positive story emerging that points to new hopes and possibilities. In this way, the therapeutic relationship can be altered to one that is based on an appreciation of strengths rather than just deficits and one that inspires optimism for realistic change.
Laughter is the quickest distance between two people.
L.G. Boldt, 1997
Humour is probably the most common way that people connect and join with one another. Many interpersonal relationships, whether intimate or otherwise, are built upon or sustained by a shared sense of humour. Indeed, it is hard to conceive of any effective human relationship that is devoid of a sense of humour. In fact, making jokes and sharing laughter is probably a more frequent human interchange than rational argument or active listening. Despite the omnipresence of humour in human relationships, it is notably absent in the literature describing the therapeutic relationship. If you were only to read the literature, you would be led to believe that therapy is exclusively a serious, worthy and weighty process, when in practice it is not always this way.
In my experience, humour is a very useful way to connect with clients and to communicate a sense of non-judgemental understanding. A moment of shared laughter can cut through a sense of being blamed, can even reduce the oppression of the problem and crucially can help build the therapeutic alliance. In addition, the lightness, creative imagination and positive energy that underpins humour is very useful when it comes to a creative envisioning of goals or solution building with clients. Therapy that is marked by an exclusively serious or heavy approach can often inadvertently reinforce the heaviness and seriousness of the problem and restrict access to the client's imagination and creativity that is needed to solve the problem. It is my experience, whether with children or adults, that therapy characterised by a lightness of touch and a playfulness as well as seriousness and earnestness is the most effective.
Of course, we're not talking about any type of humour (as much is about belittling people and putting them down). Consider the following sample dialogue to illustrate this process, taken from a child mental health setting. Many parents feel very blamed and judged when their children have problems. In fact, this is often the greatest obstacle to forming a therapeutic alliance as it causes them to be defensive or feel oppressed (naturally this is not helped by the fact that many mental health professionals actually do blame parents in how they diagnose and treat childhood problems!). In the following dialogue the therapist uses humour to overcome this defensiveness of a mother who has brought her six-year-old son to the child and family clinic because of his behavioural problems. When she goes into the therapist's office, the child sits quietly while the mother talks at length about their problems.
Mother: He's really a demon at home, he throws tantrums all the time and never does what I ask. [She looks at child sitting quietly] Of course he is making a fool of me here, sitting so quietly here, good as gold.
Therapist: Would you believe that this often happens here.
Therapist: When parents bring their children here, they often behave very well in my office, even though their parents are coping with really bad behaviour at home.
Mother: [Interested] Really?
Therapist: And to be honest, I'm glad that your child is behaving well in
my office. [Pauses and then adds self-mockingly] I really don't think I could cope if he threw a tantrum in my office.
Mother: [Laughs] You'd find it hard to cope, too.
The above joke indirectly communicated to the mother that the therapist understood how difficult it was to manage tantrums and how he understood what it was like to feel incompetent in the face of them. This helped break the mother's sense of being judged and create an alliance that helped her let go of engaging in problem talk (to make sure the therapist understood how bad things could be) and move to consider solutions with the therapist on her side.
Probably the reason that humour is not often cited as a way of connecting in the psychotherapy literature (unlike listening) is the fact that humour is risky. It can be taken up the wrong way or add to a sense of being misunderstood. What is essential is to use humour in a sensitive and skilled way, that builds people up, reduces isolation, makes the problem look small and ridiculous and helps communicate to clients that you understand their predicament and are on their side.
A therapeutic relationship is based upon a two-way human connection between the therapist and the client(s). As a therapist you bring your own personality, feelings, thoughts and personal history to the process. Often this is very helpful, providing you of a way of being empathic, identifying with or understanding a client's experience. Sometimes, however, it can act the other way and cause you to have negative feelings towards clients. As Wilson notes:
Therapists may experience powerful feelings such as a desire to punish a child for behaving badly or to rescue a child from negligent parents. (Wilson, 1998: xx)
Depending on our own personality and history, certain children and certain families will hook us in and cause us to feel strong negative (and positive) feelings and be tempted to react in unhelpful ways. For example, our ability to respond constructively is compromised if we feel strongly critical towards a parent that is likely to be communicated through our tone of voice or body language. Equally, our anxiety or expectation of problems may cause us to react too quickly and thus we can contribute to the likelihood of a child acting out in a session. As a result, therapists need to be self-aware of their input to the therapeutic relationship; they need to work hard (through self-reflection, supervision and consultation) to be aware of how their own thoughts and feelings are contributing to the process. The more self-aware we are, the more we can make choices about how best to respond. For example, if we realise that the critical feelings we feel towards a parent stem from the fact that her behaviour reminds us of patterns from our own childhood, then we can work hard to put these feelings to one side and to understand the unique perspective of the parent in the room. Or if we realise that the feelings of criticism are a reflection of how professionals often react to this parent, then we can use those feelings to empathically understand the parent's perspective and to respond more constructively.
In psychodynamic terms, this process of teasing out the therapist contribution to the therapeutic relationship is framed as analysing and understanding counter-transference. From a strengths-based perspective the aim is first to be aware of and understand these feelings and then to try and respond to them in the most constructive way to help the client and to maintain the alliance.