David van der Want
MA Clinical Psychology (RAU)
He who knows others is wise. He who knows himself is enlightened. - Lao-Tzu
Three lenses and BPD: Towards a narrative metaphor
The essential feature of Borderline Personality Disorder is .... instability in a variety of areas, including interpersonal behaviour, mood and self image..... Interpersonal relations are often intense and unstable. Frequently there is impulsive and unpredictable behaviour that is potentially self damaging. A profound identity disturbance may be manifested by uncertainty about several issues relating to identity, such as self image, gender identity or long term goals and values. There may be problems tolerating being alone, and chronic feelings of emptiness and boredom. (Extract from DSM-IV: The clinical picture of Borderline Personality Disorder) (APA, 1994)
A solo yacht off Hout Bay - David van der Want
Gergen’s (1994) adaptation of Shakespeare’s sonnet expresses a dissatisfaction with the clumsy, individualistic and blatantly pejorative language used by mainstream psychology to describe individual experience. This dissatisfaction with the dominant paradigm provides a context for the issues raised in this essay which explores the tensions between three conceptually distinct approaches to psychotherapy. The three approaches, which represent the author’s current thinking about, and practice of psychotherapy, are here classified as models of deficit, cybernetic models and the narrative approach. The understandings of what constitutes therapeutic change proffered by each of the approaches are discussed and the implications of these understandings for the role of the therapist explored. Alternative conceptualisations of a case study of an individual diagnosed as having a Borderline Personality Disorder offered by each of these approaches are put forward and implications for effective intervention discussed.
Models of deficit
The classification of people into categories of mental disorders is a logical consequence of approaches to psychotherapy which implicitly or explicitly are informed by the dominant Newtonian approach to scientific inquiry. Such traditional approaches view the therapeutic process as linear, commencing with rigorous assessment leading to diagnosis which in turn informs the selection of an appropriate treatment strategy. Therapeutic outcome is measured against one principal criterion, the elimination of the behaviour which has been discerned as symptomatic. Implicit in these approaches is a construction of the client as being deficient or damaged in some way. The description of difference between persons classified as normal and those deemed abnormal is based on the presence of diseased or damaged psychological processes or the lack of some factor deemed necessary to psychological well being. Further, this deficit or damage is located inside of the individual, as a quality or trait possessed by her. This tendency is perhaps no where so evident as in the Axis II diagnoses of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) which ascribe symptomatic behaviour to deeply ingrained maladaptive characteristics of personality, a construct which is defined as, to all intents and purposes, immutable.
One such model of deficit is the dialectical behaviour theory put forward by Linehan (1987, 1993; Linehan & Wasson, 1989). This model suggests that Borderline individuals begin life with a constitutionally inherited physiological deficit, in the form of an hyper-reactive autonomic nervous system. Linehan and Wasson (1989) cite Turkington who found that persons categorised as Borderline show evidence of a low threshold for the activation of the limbic system, a set of brain structures responsible for emotional regulation. The individual so afflicted reacts with strong emotional arousal to even low level stimuli and may be said to be in a state of constant emotional flux. If this individual develops in an environment that consistently negates or fails to recognise her emotional state then she will fail to learn emotion regulating skills. Simply, the developing child, faced with the subjective experience of extreme and powerful emotional arousal on the one hand, and feedback from the environment which does not recognise, or blatantly invalidates this experience on the other, cannot learn to trust her emotional reactions as valid responses to environmental events.
it may be hypothesised that Borderline individuals fail to learn adequate problem solving and interpersonal skills chiefly because of their inability to form stable relationships where these skills are learned. Instead these individuals learn dysfunctional coping skills aimed at the reduction of intolerable emotional arousal.
This in turn has implications for the development of the sense of self. The individual, at the whim of capricious emotion and in the absence of affectual consistency and predictability across time, is unable to develop a stable sense of identity, a hallmark of the Borderline condition. Without such a stable sense of self the Borderline individual is unable to form or maintain stable interpersonal relationships, another core characteristic of the disorder (Linehan & Wasson, 1989). For these theorists then, most of the distinguishing features of this disorder can be explained in terms of this extreme emotional reactivity coupled with inadequate emotion regulation skills. For example, the dramatic displays of emotion displayed by the Borderline individual are construed as problem solving manoeuvres learned in an invalidating environment and in shallow interpersonal relationships, as the only way to mobilise a helpful response from others. Carrying the logic of deficit to its conclusion, it may be hypothesised that Borderline individuals fail to learn adequate problem solving and interpersonal skills chiefly because of their inability to form stable relationships where these skills are learned. Instead these individuals learn dysfunctional coping skills aimed at the reduction of intolerable emotional arousal. Examples of this include self mutilation, para-suicide, and cloying dependence on others.
As a result of the foregoing developmental process the individual finds herself trapped in a cycle involving powerful emotional arousal to environmental stress, the inability to accurately identify and communicate the feeling to others coupled with an inability to find a solution to the stressor. The resultant experience of ineffectiveness leads to the deployment of dysfunctional coping strategies which elicits a further invalidating response from the environment which in turn, exacerbates the subjective experience of extreme emotion. Linehan and Wasson (1989) suggest that, as a result of this cycle, the Borderline is in a state of unrelenting crises which inhibits the ability to learn more effective coping and relationship skills.
Models of deficit dictate a particular role for the therapist. Therapy based on a model which locates a deficit in an individual as the primary etiological factor in maladaptive behaviour, suggests that the therapist’s aim is to correct damage and to remedy deficit. For example, Linehan and Wasson (1989) seek to teach their clients more effective problem solving and relationship skills. Further interventions are aimed at training in emotional regulation and distress tolerance. While these authors locate their particular brand of behaviourism outside of the medical model with its emphasis on observable behaviour rather than categorisation, their approach to therapy reflects the dominant medical method in that they seek to restore a damaged individual to an ideal state, a state of socially sanctioned normalcy.
psychotherapy informed by such models of deficit becomes an unwitting tool of social discourse, a form of social control which sanctions those behaviours that support the dominant social discourses and marks those that do not as bad, mad or deficient.This moral sanctioning of what is "normal" is problematic. Szasz (1978) states that the so called science of abnormal behaviour is comprised of socially constructed myths that are used to maintain a particular social order. Gergen (1994) argues that the labelling of an individual as diseased is a form of cultural sanctioning whereby the mental health profession denotes "the position of individuals along culturally implicit axes of good and bad" (p. 149) and that psychotherapy informed by such models of deficit becomes an unwitting tool of social discourse, a form of social control which sanctions those behaviours that support the dominant social discourses and marks those that do not as bad, mad or deficient.
The model of deficit is apparently blind to the implication of power in the didactic stance that the therapist is obliged to assume as a consequence of their construction of the client as damaged. The potentially toxic effects of this become evident when we consider that one of the clinical features of the Borderline personality is dependence on others. The therapist, already socially marked as an authority figure, communicates this stance to the client who is then encouraged to adopt a dependent position. The therapist then locates the quality of "dependence" in the client and connotes her as resistant to the therapist’s social skills training model which has as its aim, making the client more independent. The client is trapped in a powerful paradox the almost inevitable result of which is a confirmation for the therapist of her (the client’s) "Borderline" nature. This then necessitates the development of a host of dependence discouraging therapeutic strategies which, far from alleviating the situation, perpetuate a relational dance of deficit, dependence and diagnosis.
A further difficulty lies in the tendency of these models to locate the quality of madness or badness in the individual; that is, these qualities are seen as attributes of the person that are generalised across contexts and are peculiar to her. In stark contrast to this is the cybernetic or systemic approach to psychotherapy.
The Cybernetic approach
In applying this biological metaphor to human relationships, many authors have found it instructive to use the stereotyped example of the nagging husband - withdrawing wife (Keeney, 1983; Haley, 1967; Watzlawick et al, 1976). The wife punctuates her withdrawal as a response to her husband’s nagging while the husband punctuates his nagging as a response to his wife’s withdrawal. A monadic view would locate the quality of nagging or withdrawing in the individual exhibiting these behaviours. This might lead the naive practitioner to "diagnose" a "Generalised Nagging Disorder" or a "Dis-inhibited Withdrawal Response" in one or other party. The search for abnormal or diseased processes would then begin and, needless to say, these processes would be found. In contrast, the systemic therapist shifts attention from the nature of the behaviours exhibited by each individual to the qualities and organisation of relationship. In this view descriptions of individuals have no meaning outside of the context in which they are interacting. This necessitates a "double description" (Keeney, 1983, p. 38) or binocular view of relationship. Descriptions of personality attributes located inside a person are disconnected halves of a larger pattern of relationship. Individual behaviours are seen as functions of an interactional game, the rules of which are continually revised or reinforced through circular patterns of communication.
This de-emphasises the search for cause as each event or piece of behaviour is simultaneously a cause and an effect of another piece of behaviour. In contrast to the model of deficit, this approach therefore does not base its therapy on the correction of a deficit which has arisen as a result of an etiological process but on the detection, description and interruption of patterns of relationship that connect members of the system. Similarly, it de-emphasises diagnosis and description of behaviour in favour of description of interaction. It is not the nature or kind of behaviour or symptom that is the focus of attention but the interactional effects of that behaviour. For example, the behaviour of the phobic client who cannot open a door may have a similar interactional effect in relationship to the compulsive client who cannot stop opening and closing the door (Haley, 1963). The question for systemic theorists then is not "Why does the person behave in this way?" but "What is the function of the behaviour in the context of an ecology of relationships?". The systemic therapist searches for pattern in the interactions of a system of individuals and asks, "How does this problematic behaviour contribute to the maintenance of the patterns of interaction observed in the system?".
It is important to note that this approach involves more than the extension of the area of inquiry beyond the individual to include investigation of the context. Linehan’s (1993) dialectical behaviour model does this by referring to the influence of systems external to the individual yet still remains within the realm of traditional scientific inquiry. Cybernetic or systemic description requires a change in epistemology from the linear to the circular. The systemic approach suggests that the individual and her context function as an organic whole in a state of dynamic equilibrium. The actions and behaviours of members of a demarcated system, be it a family, an individual or a collection of nations, are seen as recursively connected attempts to maintain equilibrium or homeostasis of the system. Keeney (1983) following Bateson has termed this interconnectedness the "ecology of mind" (p.91).
What then is pathology for the systemic theorist? Keeney (1983) states, "The cybernetic view does not necessarily suggest that we shift our emphasis from a disturbed individual to a disturbed family. Rather it identifies particular ways in which individuals and families maintain an organisation through recursive process." (p.125). As Becvar and Becvar (1996) assert, "Systems do what they do, and what they do is not pathological unless we so define it" (p. 123). In terms of the biological metaphor underlying this approach however, health can be discerned in any systemic organisation which allows for a range of emotional and behavioural experiences for all of its members. Any effort to maximise or minimise one kind of experience leads to an "escalating sameness" (Keeney, 1983, p. 124). Biological ecosystems are characterised as healthy when there is sufficient bio-diversity. Biologists use the term ecological climax to refer to the dynamic balance of an optimum number of species in an ecosystem. An ecology is regarded as ill when one species predominates over all others. Pathology can be discerned therefore in any systemic organisation of individuals which seeks to minimise or maximise one variable over others.
While the above does not constitute a clear definition of what the nature of pathology is, it does have implications for therapeutic intervention. Psychotherapy informed by the linear epistemology of the models of deficit is aimed at the elimination of a class of behaviours punctuated as pathological. Such interventions overtly seek to minimise pathology and maximise health. For the systemic theorist such interventions constitute a threat to ecological climax. Stated differently, the danger is that the therapist insensitive to ecology will become part of a systemic organisation which maintains the behaviours regarded as pathological. In contrast, interventions informed by systemic thinking focus on the perturbation of the system’s equilibrium in an attempt to change the rules that govern the systemic organisation of recursively linked behaviours. The role of the therapist, rather than the hierarchical one of a teacher or corrector, is viewed as a collaborator with the client system (Becvar & Becvar, 1996; Keeney, 1983). Keeney (1983) stresses that the therapist is both a participant in, and an observer of the therapeutic process. Whereas the linear therapist locates herself outside of the client, the systemic therapist forms a new system with the family that in turn is subject to its own processes of change and stability; its own homeostasis. From this vantage point the therapist becomes part of a system observing itself. Further, the distinctions drawn by the therapist in her search for pattern in the ecology of relationships in this new system are acknowledged as being a function of the observation process. Stated differently, the observations made include the process of observation. The observer is in the observed (Keeney, 1983). In keeping therefore with the principle of recursivity any description of therapy as the therapist treating the client is a partial one. A cybernetic conceptualisation describes the behaviours of both therapist and client as simultaneously being both intervention and problem. The systemic therapist therefore attempts to move away from definitions of the therapist as a power broker possessed of objective expert knowledge of problems and their resolution to a change agent equipped with self reflexive lenses for detecting and changing pattern. While both the models of deficit and the cybernetic model have change as their ultimate therapeutic aim, the difference lies in the conceptualisation of what constitutes change. The former directs change towards a predefined state expressed in terms of more of one variable (social skills, coping resources) and less of another (dysfunctional behaviour, extreme emotional lability) while the latter views change as a process of stochastic evolution recursively linked to the therapist’s perturbation of homeostasis.
Systemic theorists refer to first and second order change to articulate the difference between the two approaches (Becvar & Becvar, 1996, Keeney, 1983, Watzlawick et al, 1967). First order change is defined as attempts at problem resolution that occur within the rules governing the system in question. From a second order perspective such change can be defined as more of the same. Second order change is discontinuous and represents a shift in the patterns that connect the members of the system. This is a change in the way in which a system maintains its stability and conceptualises healing as a transformative experience rather than as a return to normality.
In contributing to the evolution of second order change, the therapist constructs models based on the patterns of interactions she discerns in the presenting system and packages these as interventions. Eliciting second order change often requires the therapist to construct an intervention that sounds illogical in the context of the problem. At the heart of these interventions is the therapeutic paradox pioneered by Palazzoli, Boscolo, Cecchin and Prata (1978) in their work with the families of diagnosed schizophrenics. In constructing a paradoxical intervention the therapist positively connotes the homeostatic tendency of the system by positively framing the behaviour of the identified patient as supporting the integrity of the family system. Similarly, since the behaviour of all other members of the system is recursively linked to the behaviour of the identified patient, the therapist positively connotes all of their behaviours, again drawing attention to the ways in which these behaviours support the stability of the system. These authors stress that approval of the behaviours is not communicated. It is the homeostatic tendency, the systemic move towards equilibrium that is positively connoted. This message to the family is followed by a paradoxical injunction to remain the same, that the family should change nothing. In support of this invocation not to change, the therapist again reinforces the positive connotation of the family’s present organisation.
Paradox is not the only intervention available to the systemic perspective. According to Becvar and Becvar (1996), systemic approaches constitute a meta-theory capable of drawing on any strategic intervention put forward by any school of therapy; the only requirement being that the therapist bear in mind the ecological consequences of the intervention.
The Narrative approach
While both the narrative and cybernetic approaches to therapy make use of the notion of recursivity and circularity, there are significant differences. Before exploring theoretical independence of these views, it is necessary to explore a "powerful" criticism levelled at the cybernetic approach.
Within the ranks of the cybernetic theorists, Hoffman (1990) was one of the first to voice concern about the relevance of a cybernetic, biological metaphor for psychotherapy. She expresses concern that the cybernetic lens is blind to issues of gender, in particular to instances of abusive violence. The emphasis placed by this approach on circularity implies that the abusive behaviour does not exist in isolation and is complementary to the behaviour of the abused. Keeney (1983) states that a manipulative person can only manipulate in the context of another person’s allowing themselves to be manipulated. "This view.... asserts that everyone participates in a mutual causal pattern of behaviour that eventuates in the violent episode" (Hoffman, 1990, p. 10). The cybernetic view therefore lacks an adequate mechanism to describe the experience of abuse and oppression.
This relates to a broader criticism of the cybernetic metaphor that has to do with the view it holds of power. The field of family therapy is struggling to disengage itself from the influence of the Batesonian conceptualisation of power as a self validating epistemological error. This view holds that power is a linear notion locating a need in an individual rather than examining a process of relationship between individuals. Keeney (1983) confirms this stating, "Belief in the myth of power is self verifying since it is a habit of punctuation" (p. 131). In support of this is the argument addressing the assumption that more power is always more powerful. Such a position he asserts, is incompatible with systemic thinking which dictates that, in terms of the ecological metaphor of relationship, any maximisation of a variable in an ecosystem will become toxic and subject to higher order processes of corrective feedback. Whatever the rationale for its censorship of power in psychotherapy, its blindness to this issue is problematic in two ways. Firstly, as mentioned, it steers the practitioner’s observation away from the pejorative effects of dominant social and cultural discourse in the lives of clients. The therapist’s "eyes are bandaged" (Hoffman, 1990, p.11) to issues of race, gender and culture.
Secondly, the therapist herself is a power figure. While Keeney (1983) asserts that power is only an issue if we construct an understanding of the therapeutic interaction in terms of power, most therapists would agree that the interventions, recommendations and judgements made by an "expert" have a powerful capacity to influence others. Many authors find the constructivist logic employed by Keeney to make the issue of power disappear, unsatisfying (Anderson & Goolishian, 1992, Gergen, 1994).
What then does a conceptualisation of therapy that addresses this issue of power look like? In contrast to the cybernetic approach which defines humans as information processing machines, the narrative approach views people as meaning generating beings (Anderson & Goolishian, 1992, White, 1991). The position taken here is that, through relationship and communication humans generate meaning which informs experience; that people live their lives through co-constructed narrative. "Not only do these stories determine the meaning that people give to experience ... but ... [they] largely determine which aspects of life they select out for expression (White, 1991, p. 28). In constructing narrative we draw on culturally available discourses which delineate the nature of relationship and which have evolved through time in communities and social structures and organisations (White, 1991) as well as dialogical interaction with intimates (Anderson & Goolishian, 1992). As meaning is dialogically co- constructed it is most accessible to description by the participants. From this perspective there is no privileged position for understanding, observation or description.
A consideration of Sluzki’s (1992) paper is instructive in exploring the nature of narrative change. This author invites the reader to consider the way in which a therapist might selectively amplify elements of a therapeutic encounter with a hypothetical family based on the psychological text she had been re-reading the night before. If she had been reading material on the developmental life cycle of the family, she might place more emphasis on evolving a description of the problematic situation in terms of the empty nest syndrome. Alternatively if the "bedside book" had been about loss and mourning the therapist might find that the therapeutic conversation highlights aspects relevant to this model. He continues in a similar vein and concludes by posing the question, "How is it that change may have been generated through so many different conversational avenues?" (Sluzki, 1992, p. 218). A similar question is posed by Adams and Sutker (1989) who, after reviewing empirical evaluations of variables influencing therapeutic outcome, conclude that success is most highly correlated with, what they term, the "therapist’s personality". His (Sluzki’s) answer is articulated in terms of narrative. "Each alternative story or narrative was structured around an available cultural myth or theme, each contains a new cast of characters, themes, and plot sequences; each has its own new logic, its [own] moral, ethical, and behavioural assumptions and consequences." (Sluzki, 1992, p. 218)
For adherents of the narrative approach change is represented by the dialogical creation of new narrative (Anderson & Goolishian, 1992, White, 1991, Sluzki, 1992). These authors state that therapy is a "problem organising problem dis-solving system" (Anderson & Goolishian, p. 27). Their hyphenation of the term "dis-solving" implies that problems of living, which are a function of co-constructed narrative and exist only in the context of that narrative, are addressed through the creation of a new narrative in which the problem either does not exist, or through which new capacity for action is generated.
Anderson and Goolishian (1992) state that the role of the therapist shifts from that of being an expert knower and interpreter to one of being a conversational artist with expertise in the creation of a free and open dialogical space. They refer to their therapeutic stance as being one of "not knowing" (p, 28). For these authors the primary conversational tool is the question which is asked from this position of "not knowing". While this does not imply that the therapist enters therapy with an inexperienced judgement, it does imply that she suspends the search for commonalities across clients and situations. Hoffman (1990) states that the therapist enters therapy without any idea of what structures, patterns or psychic artefacts to look for. The therapeutic questions are asked from a position of being genuinely informed by the client. For Anderson and Goolishian (1992) failure to adopt this attitude results in the therapist asking questions protecting her own narrative structure, her own expert theoretical understanding of human behaviour. The questions are therefore informed by what has just been said rather than in the search for the validation or disconfirmation of an hypothesis based on an understanding derived independently of the present therapeutic relationship.
These authors distinguish between rhetorical questions, which generate their own answers, pedagogical questions, which imply a correct response and socratic questions which reflect their hermeneutic stance of "not knowing" (Anderson & Goolishian, 1992). The therapeutic aim is not to challenge or correct the narrative but rather to learn about it, to allow it to be retold in a conversational space allowing new meaning to evolve and emerge. The therapist’s aim is therefore not to change narrative structure or offer alternative stories but to create and enter into a dialogical space of which the co-construction of new meaning through conversation is inevitable. This highly non-directive approach has been characterised by Hoffman (1992) as "imperceptible therapy" (p.18).
The narrative approach, as articulated by Anderson and Goolishian (1992) therefore locates itself within the postmodernist and poststructural intellectual traditions (Hoffman, 1992). It acknowledges that there is no privileged position for knowing and as such presents a powerful challenge to the philosophical foundations of western thinking about healing. While the cybernetic model posits a structure for explaining human agency, the narrative approach de-emphasises knowing in favour of a focus on continually and continuously evolving meaning arising from and always in, the context of subject-subject relationship. While in the cybernetic model the therapist engages in a recursive process of hypothesis generation informed by an ecological metaphor the narrative therapist enters the therapeutic relationship without notions of what needs to change in order to solve the presenting problem. The result is a hermeneutic stance where any hypotheses generated by the therapist are meaningless outside of the co-constructed narrative of that particular therapy. The narrative therapist abandons technique informed by theory in favour of an "abundant curiosity" (Anderson & Goolishian, 1992, p.30). Where the cybernetic therapist focuses on change through perturbation of homeostasis, the narrative therapist focuses on the creation of a dialogical space.
While drawing on the same narrative metaphor and placing similar emphasis on the therapeutic question, White and Epston (1990) explicitly align their therapeutic stance with the ideas of Foucault. Flaskas and Humphreys (1993) note that, in common with Bateson, Foucault developed a circular conceptualisation of power as embedded in social relationships. However, whereas Bateson used the impossibility of conceptualising power in a linear manner as a rationale for prohibiting further analysis, Foucault elaborated on the recursive nature of power at great length, focusing on its productive role in the creation of knowledge and subjectivities (Flaskas & Humphreys, 1993). Further, Foucault’s emphasis on an ascending analysis of power, that the origins of the mechanism of power are at the local level, allows the narrative approach as explicated by White and Epston (1990) to use his ideas in psychotherapy. These authors also embrace Foucault’s notion of subjugated knowledges, those which have been hidden and disguised by the global truth claims of dominant discourses by stating that when individuals present for therapy, they selectively filter out experiences of life which do not conform to the tenets of their dominant narrative (White, 1991, White & Epston, 1990).
For White and Epston (1990) then, an individual’s understanding and expression of self and other are determined by a stock of culturally available discourses which present truth claims dictating the nature of experience open to them. White and Epston (1990) extend slightly Anderson and Goolishian’s (1992) conceptualisation of what constitutes a client’s "problem". "Persons experience problems .... when the narratives in which they are storying their experience .... do not sufficiently represent their lived experience and that in these circumstances there will be significant aspects of their lived experience that contradict this dominant narrative. We could further assume that those narratives which do not sufficiently represent lived experience are significantly informed by the ’truth’ discourses of the unitary knowledges." (p. 28, my emphasis). The difference centres around the punctuation of a deficiency or inadequacy in the client’s narrative. The necessary implication of this is that the therapist occupies a position of knowing more about the client’s narrative than she (the client) does as opposed to the therapeutic stance of not knowing advocated by Anderson and Goolishian (1992). While this difference may at first glance appear insignificant, it does have ramifications. In addition to implying an expert role for the therapist, it reifies the narrative to the level of structure; it becomes something possessed by the client or client system as opposed to a co-created dialogical construct. The therapist therefore locates herself outside of the process of meaning generation, a position incompatible to the narrative metaphor. The inevitable result is a moral decision on the part of the therapist as to the adequacy of the client’s narrative. The questions asked by the therapist become pedagogical rather than socratic in nature. They suggest a more correct answer; one sanctioned by the therapist. As Lowe (1991) states, "One paradoxical aspect of postmodernism is that it may itself fall prey to the same problems which beset modern thought. It is in danger of becoming a new totalising metanarrative of the very kind it sought to repudiate" (p. 47).
A similar criticism may be levelled at Soal and Kottler’s (1996) description of the narrative approach to family therapy in the case of a South African family. Using a narrative approach informed by Foucault’s knowledge/power formulation, these authors ascribe the family’s experience of difficulty to an over-investment in dominant discourses of society. The particular discourses isolated as significant or problem-saturated by these researchers in their relationship with this family include discourses of civilisation, the desirability of middle class lifestyle, the aspiration to a normal loving family and discourses of therapy as an arena for exploring and alleviating deep-rooted emotional pain. The point of criticism is not that these punctuations or constructions about the causes of the experience of difficulty are faulty, but in the view of the family as damaged or deficient that they unwittingly perpetuate. The paradox evident here is that the family arrived for therapy with narratives which created an experience for the family of themselves as "damaged and deficient and therefore in need of expert intervention and healing" (Soal & Kottler, 1996, p. 125). By locating the quality of over-investment in discourse in the narrative of the family, the broader social discourse of damage and deficit, the very thing these authors attempt to address in the therapy, is perpetuated. Again, narrative becomes a reified structure thereby moving these authors out of the poststructuralist tradition to which they ascribe. The epistemological error here is that the narrative approach does not constitute yet another theory upon which to base hypotheses about the causes of the experience of difficulty. Psychology has enough of those. Rather the narrative approach allows for a different conceptualisation of therapy, one that moves beyond the modernist / structural constructions of the models of deficit.
Before returning to White and Epston’s (1990) operationalisation of the narrative approach it is necessary to note that the above criticism does not detract from the elegance and effectiveness of the techniques employed by these well respected practitioners. Rather it (the criticism) is an academic argument stemming from this author’s perception that the punctuation of deficit in the client or any structure which is theorised as influencing the client’s life, is to avoid the challenge of postmodernism, poststructuralism and hermeneutics to our conceptualisation of what psychotherapy is.
White (1991) refers to the process of creating change in psychotherapy as "the deconstructive method" (p. 27). The aim of the deconstructive method is the subversion of realities and "truths" which are separated from their context of production and which therefore subjugate certain aspects of lived experience while giving primacy to others (White & Epston, 1990). The mechanism that these authors propose for the subversion of narrative realities which construct problems of living for clients is objectification or the "exoticising of the domestic" (Bruner cited in White, 1990). Broadly, this term describes a process whereby the client is invited by the therapist to consider the personal narratives and culturally available knowledges through which she (the client) is currently experiencing her life by encouraging her to provide an account of the effect of the present problem on her life. Through this "externalising conversation" (White & Epston, 1990, p. 49) the client explores the ways in which the problem has impacted on their family, work and peer relationships as well as their view of themselves. The distance provided by the externalisation and objectification of the problem producing narratives affords the client space to explore alternative narratives and knowledges of self and relationship. Tomm (1993) has characterised White’s psychotherapy as an attempt to incite political rebellion in his client. He makes this comment referring to the way this author makes use of his landscape questions to encourage clients to think about ways in which they have been co-opted into living their lives through unitary truth.
White (1991) proposes that there is a conceptual continuity between the structure of literary texts and the narrative stories constituting personal experience. Following Bruner he posits that narrative stories are made up of landscapes of action and landscapes of consciousness. Landscapes of action refers to the constitution of stories as being made up of events that are linked together in particular sequences through time according to specific plots. Landscapes of consciousness are constituted by the interpretations of the reader of the text and the characters in the plot and reflect the meanings drawn from the landscape of action through their reflection on unfolding events. Having intersected these ideas derived from literary criticism with the idea of personal narrative, White and Epston (1990) propose the use of the therapeutic question within the context of the externalising conversation. Landscape of action questions assist persons to plot the history, present and future of alternative landscapes of action and allow them to re-author the plot of their narrative. These questions focus on events in different time frames and encourage the individual to consider alternative narrative content. An example of such a question is, "Just prior to taking this step, did you nearly turn back? If so, how did you stop yourself from doing so?" (White, 1991, p. 30). Landscape of consciousness questions encourage the client to explore the implications on new landscapes of action and to narrate the implications of these for her vision of selfhood and the qualities of her relationships. As such they invite the client to articulate the new landscape of action in terms of personal meaning. For example, "How would you describe the qualities that you experienced in your relationship at this earlier time when you managed to support each other in adversity?" (White, 1991, p. 31). White (1991) adds experience of experience questions to the repertoire of narrative technique. These questions require the client to reflect on what they view another persons experience of them to be like. For example, "If I had been a spectator to your life when you were a younger person, what do you think I might have witnessed you doing then that might help me to understand how you were able to achieve what you have recently achieved? (p. 32).
Through the use of these questions the therapist is able to participate in a process of generating new landscapes of action and to explore the ramifications of this new narrative structure for the client’s experience of herself, others and past and present life events. Through these three classes of therapeutic questions, White (1991) consciously focuses on developing alternative meaning and invites the client to articulate and support a different view of life and its difficulties.
To reiterate; the criticism discussed in the preceding pages does not imply that these interventions are ineffective or flawed but it does distinguish White and Epston’s (1990) approach to the narrative metaphor from that of Anderson and Goolishian (1992). While the narrative approach is new on this author’s theoretical and practical horizons and he is therefore not in a position to elaborate on Anderson and Goolishian’s (1992) position with any authority, it is argued that these authors present a far more serious challenge to the role of the therapist than do the Dulwich authors. The nature of this challenge is a shift from practice informed by theory to practice informed by client experience.
Humans generate meaning as an inevitable consequence of consciousness and its concomitant ability to use language. As a human the therapist has this ability to create and discern meaning which is constructed in the form of stories; the chronological sequencing of events and emotions into a narrative structure which is continually evolving and shifting as we relate and re-relate them. Hence the word relationship.
These stories are embedded in every sphere of human activity from the level of social organisation; from culture and patterns of government to marriage and family relationship. To be a psychotherapist in this narrative age requires an appreciation of this aesthetic quality of life, the ability to detect narrative pattern coupled with the desire to enter the narrative with no agenda other than the creation of new dialogue and story. This author would add that this is augmented by an ability to comment on the process of meaning generation, the process of relationship (the relating of story) in a manner meaningful to the protagonists. Psychology’s struggles with issues of objectivity and subjectivity, power and control, theory and technique, the intrapsychic and the extrapsychic, linearity and circularity, pathology and health are attempts to move towards this aesthetic appreciation. In the integration of all of these areas of inquiry lies the ability to detect and construct story in the same way that we would read a novel or watch a piece of theatre. There is one important difference; we are part of the play and the role assigned us by the great author, the aesthetic itself, is one of narrator; of a participant in the text with the ability to question in an informed way. The questions we ask are informed by our search for meaning and sense for ourselves and not by an attempt to impose or create meaning for our clients.
This implies that the therapist must be critically aware of the mechanisms, the clumsy theories, that our discipline uses to make sense of the experience of life. The true guide that informs our questions is not the narrative of the client or a pre-existing theory, but the evolving and shifting eddies of meaning created in the relating and re-relating of story, the process of construction itself, the relationship with the client.
Adding the idea of therapist as commentator sparks a debate about the role of theory. The ability to comment on the lives of clients through questions informed by the search for story rather than pattern; not out of intention to detect and change a fiction created by theory but informed by curiosity to discover the next landscape, is the window for theory in therapy. Theory informs the choices in terms of which our questions are framed. It is the mechanism we use to encounter narrative and comprises the expectations of meaning unfolding in a predictable plot that the therapist brings to the encounter. While Anderson and Goolishian (1992) state that the relegation of theory does not imply that the therapist exhibits an uninformed judgement, their emphasis on therapy as new meaning generation as opposed to a relationship focused on change, tempts their approach towards simple humanism; the Rogerian idea that a human, driven by an actualising tendency will heal when given an accurate reflection of experience delivered by a therapist acting as a kind of psychic mirror. Theory forms our intent in therapy, it signals to the other participants in the plot what kind of character we are to become. The cybernetic therapist, on receiving a referral, invites the whole family to come. As the first act by a new character in an unfolding story this is quite an opener. Anderson and Goolishian (1992) suggest that the "system" in therapy is those individuals who have dialogically coalesced around a problem. Assuming a narrative stance would require the therapist to ask the client in the referring call, "Is there anyone you would like to bring?". While frank and open, this is certainly a bold introduction into the narrative. It does however challenge the dominant social discourse of therapy as an intensely private and personal event separated from community life and divorced from the social. Gergen (1994) asserts that this discourse contributes to the erosion of community’s ability to incorporate and deal with problematic behaviours as it results in psychotherapist’s laying claim to the expert capacity to solve problems of living.
These examples aside, what dictates when, how and what we ask in our questions is the internal dialogue the therapist conducts with herself about the client; her theory. It informs which events and feelings will be clustered together in the curios questions. If the language of our theory is constructed in terms of deficit and damage then our questions will reflect our search for story of this kind, thereby co-constructing an evolved reality comprising these elements. A character speaking in terms of illness and health will provoke action around these themes. Some authors (Hoffman, 1992) have suggested that the solution is not to banish theory but to extend our definition of what constitutes it. She suggests that we extend our post-graduate training programmes in psychotherapy to include literature (the study of story), sociology and anthropology taught by lecturers aware of the productive nature of observation. While this may appear tempting in an elitist kind of way, it is hardly appropriate in a South African context.
However, the role of theory is a barrier for this author to the narrative approach. As a starting point in overcoming this barrier it is suggested that our theories abandon the search for "truth" and turn to the exploration of the creation of truths. Not withstanding the theoretical difficulties with the narrative approach explored here, the assertion made by these authors that the primary truth in psychotherapy is the experience of the client is an ancient "truth" that psychological theory often neglects.
Having examined the three lenses which inform the author’s practice of psychotherapy and explored tensions, distinctions and contradictions between these approaches, a case study will be briefly presented. At the time of seeing this client, the narrative approach was even newer on the author’s horizons than is presently the case and will necessarily be reflected in the discussion of the therapy.
For the sake of brevity, only three of the five sessions that the therapist shared with Tom and his family will be summarised. Each summary will be followed with commentary illustrating the differences between the theoretical models discussed above and discussing the rationale for the therapist’s actions.
Tom is a 20 year old university student referred to the author in his private capacity by Jane, a member of another academic department. He first came to her attention after he had failed to complete assignments and attend tutorials and was therefore in jeopardy of being refused entry to write the mid-year exam which was just two weeks away. Jane reported that in an interview with Tom she had ascertained that Tom had, two years previously, made three suicidal gestures while studying at another tertiary education institution in another city. He had subsequently withdrawn from his studies and was hospitalised for a period of two weeks where he was diagnosed as having Borderline Personality Disorder and placed on a course of anti-depressant and anxiolytic medication. On release from hospital he underwent a brief course of psychotherapy with a local psychotherapist. Jane expressed concern that Tom was anxious, depressed and expressing further suicidal ideation. His current medication included a fourth generation anti-depressant, a strong anxiolytic and medication for a gastric ulcer.
Tom arrived for the first consultation with a badly bruised and swollen face. During the course of the interview he revealed that he had been beaten up on the Saturday evening by a group of individuals who thought that he was "a queer" (gay). Tom stated that he had come to therapy to "sort himself out and clean up his act". He said that he felt that his life was a mess and that if he didn’t do something about it he was going to end up "in the drain". The therapist asked him what he thought he needed to do in order to avoid ending up in the drain. Tom responded by stating that he had too many problems to count but that the biggest one was that he was scared that he was going to "do something stupid". The therapist reflected that Tom was desperate and inquired as to what he meant when he talked about something stupid to which he answered that he thought that he might be going to kill himself. The therapist reflected that Tom seemed to feel that he had little control over whether he would indeed kill himself or not. Tom confirmed this but could not elaborate. The therapist responded by asking Tom if he could think of anyone on whom he could rely for support and encouragement. He gave a non-committal shrug and stated, "My family hates me and I hate them".
It emerged that Tom was living with his two older sisters and his grandmother just outside town. His parents live in a coastal village some 400 kilometres away. He expressed extreme dissatisfaction with his living arrangements saying that no-one in his family has ever understood him or even expressed an interest in doing so. He reported that his whole life he had felt like an outsider, not only in family relationships but in social ones too. He stated that the only person who had ever understood him or to whom he had ever felt emotionally close, was his older brother Simon who had been killed in a car accident while under the influence of alcohol, two and a half years ago. Tom reported that Simon drank far too much while they were at university together and that he was "’n bietjie wild". He reported that at a young age he had been moved away from the home to go to school in another town where he had lived with an uncle whom with whom he had a similarly unsatisfactory relationship. Tom communicated all of this information in a dull monotone and with a flat and rather expressionless face.
The therapist reflected to Tom that he felt overwhelmed and needed to escape. This led to a discussion of suicide as a means of escape from the situation. The therapist then entered into a "contract" with Tom that if, between now and the next time he saw him, he (Tom) felt the need to escape by killing himself that he would telephone the therapist before he did so. The therapist informed Tom that he believed that the right to stop living was the most fundamental right of all human beings and, although he would be sad if he did decide to take his own life, he would respect that decision. If after a conversation with the therapist, Tom still wanted to escape the situation by killing himself, then the therapist would mourn for him, but would remain committed to his belief in his (Tom’s) right to do so. Tom left the session with an appointment scheduled three days hence.
The model of deficit predicts Tom’s suicidal behaviour on the basis of his assumed biological predisposition coupled with his experience of an invalidating family environment which has never "understood" him. It would speculate that he had learned that extreme behaviours were necessary in order to obtain any form of social support or recognition for his extreme physiological and emotional response to environmental events. This hypothesis would be confirmed by the onset of Tom’s first suicidal gestures so soon after the loss of his brother, the person on whom he relied for intimacy and support. The stress of the impending examinations and his negotiations with the university over admission, coupled with his unhappiness with his living arrangements would be viewed as precipitating stressors in the light of what is assumed to be an inflexible repertoire of coping strategies. Tom’s experience of himself as lacking access to social support to mediate the negative effects of this stress would suggest that a suicidal gesture is indeed imminent. Further, the fact that he reports that he is drinking heavily increases the risk of impulsive suicidal action as well as increasing the likelihood that such action may be fatal. Alcohol has a well known amplifying effect on benzodiazepine pharmacological action as well as a dis-inhibiting effect leading to the possibility of accidental overdose. Mediating this is the fact that Tom voluntarily entered a therapeutic relationship and indicated a willingness to continue with therapy. He also articulated his suicidal ideation but did not overtly express a formulated plan of action.
Further, such an intervention would further invalidate Tom’s experience of himself as being desperate and as such an intervention attempting to remove this behaviour from his repertoire, would fail to give sufficient recognition to his experience of life. In contrast the intervention given recognises both stability and change and advocates both homeostasis and the possibility of the new experience of gaining social support and emotional recognition without having to resort to self destructive behaviours.
From the narrative perspective, Tom’s construction of himself as being damaged and as headed for "the drain" would appear to have prohibited him from "storying" aspects of his experience that would contradict this dominant narrative. The use of the question "What do you need to do in order to avoid heading for the drain?" may be seen as a landscape of action (White, 1991) question and reflects the dawning of the narrative metaphor on the therapist’s theoretical horizons. However this question was not consciously asked from this perspective and was asked to elicit information regarding Tom’s aims for therapy.
In terms of systemic theory, the therapist, rather than seeing Tom’s behaviour as the nett result of his experience of invalidation, tentatively formulated an hypothesis that Tom’s behaviour constituted feedback into his family and was part of a broader pattern of homeostasis and maintenance of its current equilibrium. However there was insufficient information at this stage to speculate as to what the "pattern that connects" or the rules of the family game might look like.
More of Tom’s story
In the following sessions, Tom elaborated further on his family circumstances saying that he didn’t think that his family had mourned for his brother properly. He expressed anger towards them for not giving sufficient recognition to the impact that his death had had on them as individuals and as a family unit. In the fifth session it emerged that Tom felt that he was a similar sort of person to Simon. They both regarded themselves as different to the rest of the family, they were both "’n bietjie wild", they had both failed their attempts to gain a tertiary education and they both drank too much. He then related two highly significant events. The first occurred when he was 13 years of age and was "sent", at two ’clock in the morning to the local garage to buy a cooldrink for his brother. On the way to the garage he reported that he was accosted by a gang of youths who gang raped him. He stated that the experience of being repeatedly sodomised made him "feel dirty inside". This led to a discussion of his ambivalence towards his brother; on the one hand he loved him and felt affinity with him while on the other he was angry with him for exposing him to the rape. The therapist reflected that Tom blamed Simon for the rape in some ways. The ensuing conversation revealed that Tom had always felt as if he were following in his brother’s footsteps and was unable to come out from behind his shadow. The second event concerned his brother’s death. Tom was the last person to see his brother alive. He related that as Simon got into the car, some 20 minutes before the accident, he (Simon) had said at the conclusion to a conversation about the family, "Agh forget about the family. They will never change". The therapist responded saying, "I’m wondering what made you decide not to believe him".
This intervention is informed by systemic theory. Firstly, it serves to positively connote Tom’s behaviour as performing a function in the context of his family relationships. As such it is paradoxical in nature advocating stability of his behaviour as opposed to change. Also, it allows Tom to start to think about his behaviour, previously seen as being inexplicable (as evidenced by his experience of being out of control) as having an inherent logic in terms of relationship with others. Secondly, from a narrative perspective it allows Tom to start to think of himself as separate from his brother which allows further room to explore his ambivalent feelings towards him. This intervention precipitated a discussion about what Tom thought needed to change in his family and what it was he wanted from them. The therapist asked Tom to consider alternative ways to negotiate his relationship with his family. The session ended with another appointment scheduled a week hence.
Three days later the therapist received a late night telephone call from Tom who informed him, in a rather incoherent manner, that he had already taken all of his pills and that he wanted to die. The therapist asked Tom what he would like him to do about this. There followed a lengthy and somewhat unintelligible conversation which concluded with the therapist sending an ambulance to collect Tom. Once in hospital it was found that Tom had consumed, without ill effect, a bottle of anti-depressants and approximately 20 Panado tablets.
With hindsight this suicidal gesture was predictable. Having opened the discussion to Tom’s behaviour in the context of his family the therapist started to explore alternative ways of articulating his needs in relation to them. In other words the therapist retreated into the language of the model of deficit, punctuating Tom as lacking the necessary skills to obtain support. This conceptualisation ignores the homeostatic function of the behaviour in the family system and advocates change over stability. The logical progression would have been to risk the loss of the open therapeutic relationship with Tom and to allow the therapy to become a family therapy. A more effective intervention may have been to ask Tom if he thought that it might be useful to have a family meeting with the therapist. Such an intervention might have been framed as follows, "I can see that you are really tired and exhausted from adopting this role in your family. I wonder if you are asking me to carry it for you for a while. How would you feel if I arranged a meeting with you and your family?". The paradoxical interventions coupled with the discussion of Tom’s experience of his family had thus far moved the therapy to a point where change in the family system was a viable option. Tom’s task" now was to bring the family together to explore this option.
The family session
When Tom’s family arrived in town they telephoned the therapist who arranged a family session having first visited Tom in hospital and discussed it with him.
Present at the family session were Mr and Mrs P, Dora, their oldest daughter (26) and sole parent of 6 year old Jenny, Emily (23) Tom’s sister, and Tom. The therapist began the session by asking each member of the family how they viewed the current situation. Dora began by saying that while she was sympathetic towards Tom, she was becoming resentful of the fact that she had to continually be on the alert in case he did something stupid. She said that Tom was an adult and should have learned by this stage to shoulder his responsibilities more effectively. She stated that she had her own life to live and that the effect that Tom’s behaviour had on her was to feel guilty when she went out leaving Tom behind because it meant that she wasn’t looking after him properly. Emily echoed these sentiments but appeared more sympathetic towards Tom, stating that perhaps this was because she did not feel the same responsibilities towards him that her sister did.
When expressing his opinion Mr P did not speak directly to anyone. When asked by the therapist what he thought needed to happen to alleviate the situation, he spoke in the third person saying that Tom needed to, "pull himself together". Mr P continued saying that Tom had had ample opportunity to find a path in life and if he did not do so now he would be failing as a man. Mrs P said nothing and when prompted and encouraged to give her opinion gestured demurely for Dora to speak for her. Tom was silent for the vast majority of the session while the family discussed various possible causes for his behaviour. Hypotheses about the causes of Tom’s behaviour put forward by the family ranged from depression to a genetic problem. The therapist intervened and asked Tom if he could shed some light on the problem saying that the family was clearly struggling to understand what was going on inside him. Tom silently declined the invitation to speak. The conversation then moved on to a discussion of the family history and how all the children had, from very young ages, moved away from the family home to stay in hostels and with friends and relatives in other towns. The therapist asked how this had come about. Dora informed the therapist that because of the restrictions of apartheid education, the children had to "go where the education was".
Observing that the family had not discussed Simon at all, the therapist stood up and added a chair to the circle. The family watched and, after a brief pause, Dora hesitantly asked him what he was doing. The therapist stated that it struck him that there was someone missing from the family and that perhaps if he was brought into the conversation it might help the discussion. Hesitantly, Dora asked if the therapist was referring to Simon. At this juncture, Mrs P began to cry quietly. Mr P looked down and was silent. Dora turned to Tom and asked him if he thought that his behaviour had anything to do with Simon’s death. Tom shrugged and replied "Maybe".
An extremely emotional discussion of the effects of Simon’s death on the family ensued. Mr P said, "What is over is over. The past is the past" and was reticent to discuss his feeling further. Mrs P crying copiously, asked Tom if that was what was causing "the suicide business". Tom did not answer. Dora and Emily in tandem informed the therapist that Simon had always "had problems" and that while they were sad about what had happened to him they were not surprised, "The way he was going it was only a matter of time before something terrible happened". Dora stated that when Simon died, it seemed to her that no-one in the family could deal with what was happened. She said that her mother had collapsed in tears and was incapacitated for 3 weeks while her father withdrew. With angry tears she told the therapist how she had had to arrange for the body to be moved and organise the funeral and the wake all by herself because no-one could help her. During this conversation the therapist observed that Tom was becoming increasingly agitated in his seat, shifting his weight and looking uncomfortable. Finally he blurted out with considerable vehemence "Can’t you people see what’s happening. Can’t you see that the same thing that happened to ou boet is happening to me?".
The family was shocked and puzzled at Tom’s outburst and asked what he meant. Tom replied that he was the one who was now in trouble and the family was doing the same thing that they did to Simon when he was in trouble, blame him. Mrs P turned to Tom and said, Mommy is tired my son, mommy is tired, all you can get from mommy is love. That’s all I have left".
At the conclusion of the session the therapist commented that it seemed that everyone in the family had been profoundly effected by the loss of Simon and that this loss was so great that it seemed to leave everyone feeling that the family could not bear its pain. He said that he was touched and warmed by the love that was evident in the decision that everyone had made to avoid telling the other members of the family about their own pain about Simon’s death. He then pointed to the sacrifice that this protection of the family had involved for each individual member, Dora had made the funeral arrangements alone and was now struggling under the burden of responsibility for Tom. Similarly Emily had supported and helped her sister while carrying her own loss privately and that this must have been a strain for her, but a strain she bore gladly out of love and a desire to protect her family. Similarly, Mrs P had grieved privately by becoming incapacitated which was a measure of just how much she did love her family. The therapist commented that Mr P had also, out of a desire to protect his family from pain, kept his loss private. The therapist turned to Tom and told him that from this it was clear that he too was making a sacrifice to protect his family from his feelings at the loss of his brother and that he needed to continue to do this. The therapist said that, while it was extremely difficult for him to stay in this uncomfortable place where he felt like he was going down the drain, but that this was necessary as the family was saying that it needed to protect itself from these feelings. The session concluded with an individual psychotherapy session with Tom scheduled for two weeks time. The therapist received a telephone call from Tom two days later to cancel the appointment as he had decided to go back and live with his mother and father for a while, while he decided what to do next year.