It’s 50 years since Carl Rogers published his Client Centered Therapy with it’s claim that no person is essentially bad or ill, but at worse merely working out their natural potential to find the healthy goodness that all people are. Roger’s philosophical base was perhaps not robust enough to weather the passage of time; but at the same year that he published (1951), another book appeared which is now generating a paradigm shift throughout the social sciences, and bringing back to the fore Rogers’ working ethos for therapists – to privilege the client’s goodness and expertise in resolving their own problems. These newer schools of therapy, sometimes called strength-based or solution-focused approaches, which search for the solutions that client’s have found work for them (albeit these solutions may not have been noticed by the client), and enhance them, owe much to Ludwig Wittgenstein’s Philosophical Investigations.
PI, as the book is sometimes referred to, is not an easy read, as it is an attempt to help us understand the snares that language continuously and repeatedly traps us in; but of course it has to use the very thing that traps us, language, to help us gain this understanding. At the end of PI Wittgenstein points out that psychology makes the error of thinking that because it has experimental methods it has the means of solving human problems. But it is not a subject like physics because, as Wittgenstein shows us, more often than not human problems stem from confusions generated by language use, and so in much of so-called ’scientific psychology’ “problem and method pass one another by” (xiv-2). I understand this to mean that we can pretty much tie down the difference between say a carbon atom and an atom of copper; but in psychology we can never know whether two people are using a word, such as ’pain’, to refer to the same thing. The word ’pain’ is certainly used differently in rugby locker room conversations than it is in an arthritis support group (as Professor Tom Strong in Canada constantly points out).
Wittgenstein begins the Investigations by noting that we have been ensnared by the notion that words gain their meanings by representing things (the idea that they lead us to form a picture of a ’table’ in our minds when someone says ’table’). However it turns out that in the majority of cases words gain their meaning by getting us to do something e.g. direct our attention in a certain way, adopt an attitude towards something. Far more than we realise it, words are prescriptive (instructive) rather than descriptive. Or we might want to say that words are far more “verb-ish” in the way they work than “noun-ish”. The error, Wittgenstein and his followers note, that the positivistic social sciences and philosophers make, is that they are constantly endeavouring to tie down meanings like dictionary makers do. For psychologists attracted to PI, psychology is more like law than physics; for law is based upon precedents and conventions humans have agreed to rather than fixed rules about nature. This begins to become obvious when you “let the use of words teach you their meaning” (220).
The middle part of PI is about dissolving human and philosophical problems rather than solving them in the sense of providing an empirical answer; for our problems come about when we cannot see a way to go on because we are talking about (’languaging’) something in a confused or muddled way. Postmodern psychologist Harlene Anderson talks of the emotional significance (a state of alarmed objection) we assign to an experience, rather than the experience itself, as being what gives a sense of something being problematic. We don’t know how to go on so we become alarmed. Being broke and with bills to pay is not so much the problem, as not knowing or remembering that I can borrow some money from Aunt Helen is. If I had remembered that, or known that, the sense of it being a problem would never have arisen. Most human and philosophical problems are not resolved with answers in quite the same way as mathematical problems (e.g. what is the square root of 632?) or scientific problems (at what temperature does water boil?); there is more of a sense of the problem being done away with. If you think action-wise for a moment, you will perhaps realise that a human problem is when we come up against some obstacle that is blocking our progress. Because a problem can be put into words, or ’languaged’, we are lured into thinking (especially if we think that words ’picture the world’) that the solution lies in words. What’s needed is getting rid of the block. We now call this the act of deconstructing problems. The result is, as Wittgenstein simply said “now I can go on”.
The impact of PI has perhaps been slow coming, given the pace of change in the latter half of the 20th century, but a revolution in the social sciences is now with us, as more and more writers in-formed by PI make their way to prominence. To give but one example, Michel Foucault, writing in the 1970’s and 80’s, influenced by PI, was able to show us how the development of disciplinary practices in the asylum, the prison, the schools, the factories, the hospitals, the barracks, and the clinics, over the course of 3 or 4 centuries created the modern sense of self, which is subtly and not so subtly constructed by ’normalising judgements’. Because these institutes used methods of surveillance which were not predictable to the people in them (surprise inspections, guards being able to see the prisoners but not the reverse, etc), the people began to constantly gaze upon themselves, adjusting their behaviour to various discourses about what was ‘normal’ in that institution. In time these disciplinary practices became central to culture at large, and Foucault’s work indicts the armies of psychologists, psychiatrists, advertising agents, and film-makers who continue to put into discursive circulation various ‘truth’ claims about human normality and abnormality.
In therapy the first 2 major schools of practice influenced by this post-positivism to gain some prominence, were the Solution Focused Brief Therapy of Steve de Shazer and Insoo Kim Berg in North America, and the Narrative Therapy of Michael White and David Epston in Australasia. Narrative Therapy resurrects a form of the ancient discursive practice of demon possession, which has the effect of immediately separating the person from the problem; and asks the client to reflect upon Description: Macintosh HD:Users:nickdrury:Documents:KnoNews:white & Epston.pngmoments “when you have been able to defy the dictates of anorexia, and do something which is not in it’s plans for your future”. By exposing the discursive structure of anorexia as rooted in various cultural discourses, it is deconstructed; and as the client begins to identify an audience to her preferred sense of self, a hero emerges. SFBT begins by waiting for the client to finish explaining why they have come, and then asking them some variant of the miracle question – “if when you were asleep tonight a miracle occurred and the problem went, what would be different in the morning that would let you know this miracle has occurred?” The conversation then turns to the exceptions to the problem story which are already occurring, “given that following the miracle you said that you would be getting out more; can you tell me about times when you have been able to get out recently?” “What special attributes or strengths have allowed you to do this?” …..
Since SFBT and Narrative Therapy sprang into existence in the 1980’s a raft of other post-positivism solution-focused therapies have followed in their wake. Perhaps in common with Carl Rogers some 50 years ago, these newer therapies presuppose that the solutions to clients problems are already present and available in their lives, a presupposition which invites the therapist to a high level of positive respect for the client. (This does not prevent the therapist from introducing ‘new ideas’ into the conversation – “I knew someone else who was going though something similar and they found X helped, would you be interested in knowing more about this?”) What’s new and different from Rogers, is the understanding gleaned from Wittgenstein that solution-focused language games may be quite separate and unconnected to problem-focused language games. In the past 2 or 3 years there have even been a number of solution-focused forays into medicine.
This shift to solution-focused language games entails a shift in the sense of expertise that therapists bring to the counselling situation. No longer are they the experts on how people should live their lives, or what constitutes good or bad mental health, faulty cognition, etc.; for that is now in the domain of the expertise of the client. The therapists’ expertise is now in being able to conduct solution-facilitating conversations. Because of this shift therapists frequently discuss with each other how they can avoid or minimise their involvement with discourses that claim to offer an objective measurement or assessment of people – especially the DSM, which they sometimes refer to as the Dark Side of Man. Unfortunately 3rd parties to the therapeutic conversation, such as health managers, insurance companies, and current interpretations of professional ethical codes, all demand some documentation from the Dark Side.
One of the newest books in client competency-focused therapy is Scott Miller and Barry Duncan’s The Heroic Client (May 2000); which is sparking ‘thick’ discussion on the collaborative therapists list on the ’net. Miller and Duncan are calling for therapists to be assessed on effectiveness rather than the competency-based focus currently utilised by professional bodies.
Largely because the professional associations are very concerned with turf and parity issues, especially the non-medical professions, they have developed an allegiance to the medical model, because that is what is dominant in the market place. The problem-focused approach taken by medicine has led the other professions into emulating this and endeavouring to generate a body of ‘scientific’ literature which shows that treatment ‘X’ is the superior method for treating problem ‘Y’. From there phrases like “best practice” and “evidence based treatment” become part of the rhetoric, and therapists begin to be herded into offering the same treatment to everyone who meets diagnosis ‘Y’, because that it claimed to be more competent. Some of the professions are now moving to shore up this problem-focused approach by demanding that therapists be regularly assessed by peers and achieve ongoing educational points so that all utilise ‘scientifically validated’ “silver bullets” (the myth of the superior treatment). In turn Health Managers are dictating the treatment approach to be taken with particular diagnoses. This serves to further undermine client confidentiality. In a recent discussion I had with Barry Duncan about this he noted that there is some risk to practitioners who question this, because the professional associations may well read it as an attempt to undermine their efforts to gain turf and parity for their members.
An alternative is to develop effectiveness based assessment processes. What makes Duncan and Miller’s ongoing work so attractive is that they have been gathering significant amounts of research literature which shows that “therapists can assign diagnoses, complete treatment plans, use the latest treatment methodologies, and dispense psychoactive drugs from now until doomsday and the overall effectiveness and efficiency of therapy will not improve in the least” (THC). Studies of those therapists who have been acknowledged as being particularly effective, such as the late Milton Erickson, have repeatedly shown that most of their treatments are so unique they cannot be replicated as simple “silver bullets”. What made Erickson and his ilk so successful was not due to his creativity, so much as it was in listening carefully to his clients for their directions, their unique ways of solving problems. Actually Erickson said this himself on numerous occasions, but it didn’t stop most researchers and clinicians studying Erickson from looking to Erickson for the source of his apparent creativeness, rather than his clients. “What is needed is the development of a therapeutic situation permitting the patient to use his own thinking, his own understandings, his own emotions in the way that fits him in his scheme of life” (1980). This requires the therapist to have the courage to enter the therapeutic conversation totally open and “not knowing”; carrying no bag of recipes for curing common problems. As Carl Rogers noted 50 years ago, it is in this way that the client is cast as hero in that drama we call psychotherapy.
But it is also necessary to show that we are effective in doing this. Such evidence will emerge says Miller and Duncan “from the formal and systematic recruitment of the client’s experience of outcome as a routine part of the treatment; the enlistment of the client as a full partner in both the therapeutic and accountability process” (THC). There is research to show that when therapists obtain outcome feedback there is an increase in their effectiveness, as one might imagine. And when client feedback is utilised to inform the therapeutic process the client is positioned as at least a full and equal partner to all aspects of therapy. Also the availability of outcome data could pacify 3rd party managers and insurers, and do away with the need to assign and communicate Dark Side talk.
Besides the micro-counselling practice of simply asking the client from moment-to-moment during the therapeutic conversation whether the conversation is helpful or not, there are a number of other feedback mechanisms which can be utilised. Early on in therapy SFBT therapists ask their clients to rate on a scale of 1 to 10 how much of the preferred (behaviour) is in their lives at present. At each session this question is repeated. A questionnaire has been developed, the OQ-45, which, research to date has shown to be able to predict outcome by the 3rd or 4th visit. (This & more information on ways of assessing effectiveness can be found at Miller and Duncan’s web sites.)
Politically, it may well be the Consumer advocates in mental health who will play the major and pivotal role in assisting the professions shift their gaze from competence to effectiveness. In recent discussions with Barry Duncan on the Web a number of practitioners felt that investigatory and legislative bodies in mental health have been largely driven by competency concerns, in part because either consumers were without a voice on these bodies, or unaware of the potentially revolutionary effects a focus on effectiveness may bring. Simply asking what training counsellors and therapists are getting in assessing effectiveness of training schools, what methods particular therapists and counsellors are using to assess their effectiveness, and what protocols agencies have in place to assess their effectiveness, may do much to counter the institutionalising practices which follow from an excessive focus on competence.