Clients as Teachers: Reciprocal Influences in Therapy Relationships

The value of the continuing education industry for therapists is questioned, as is the usefulness of therapy books and journal articles, as a means of engaging therapists in life‐long learning. Instead, it is argued that our clients are our best teachers and that therapists learn most effectively from their clients. Drawing on research studies with prominent theoreticians and therapists, and on case studies from clinical work, a number of important themes are identified as ways in which therapists are influenced by their therapeutic encounters with their clients. The themes explored in this article include: (1) intimacy and high emotional arousal with clients as we witness profound change; (2) being challenged by clients; and (3) allowing for boundary ‘crossings’ in order to develop more flexible ways of working with clients. The implications for professional development are discussed.     

Talking about culture in social work encounters: immigrant families and child welfare in Finland

This article aims at analysing the ways in which people talk about ‘culture’ in social work encounters involving child welfare in immigrant families. The empirical material includes conversations between immigrant clients, their social workers and co-operating professionals at six Finnish social service offices, as well as interviews with the persons participating in these meetings. The theoretical and methodological frames of reference are social constructionism and discourse analysis. The study suggests three ways in which the concept of ‘culture’ is used by social workers and their clients: firstly, as a means of explaining ‘the ordinary and normal ways’ of raising children; secondly, as ‘a difficulty’ in the interaction between social workers and clients; and thirdly, as ‘a methodical tool’ in creating dialogue with clients. As far as the practical implications for social work are concerned, it is emphasized that in order to avoid ethnocentric practice or ‘culturalization’ of problems, it is important for social workers to be conscious of the various meanings of ‘culture’ both in their own practice and in the ways their clients employ cultural symbolism.     

Enhancing Family Therapy's Relationships With Research

The contention of this article is that systemic family therapy has much to gain from a realistic appraisal of its research base, which is as positive as possible. And that through such an appraisal we can find ways of developing the scope of family therapy to the benefit of the profession and thereby, of our clients. Family therapy will benefit if practitioners can present an informed view of research. As a preliminary approach to this objective, I review reasons why perceptions of family therapy underestimate its research base, and why therapists might resist involvement with research. The article then explores the reasons for regarding randomised controlled trials as a ‘gold standard’, and why they are not well fitted for the purpose of evaluating or developing a relational therapy. Next is a consideration of alternative approaches to research, including a consideration of what clients actually want from their therapy, then a brief review of the positive findings of outcome research. Greater emphasis on researching processes in therapy is proposed, and consideration of the ‘common factors’ debate is shown to support priorities that are specific to systemic therapies. The article concludes with suggestions for increasing the involvement of family therapists with research, both as consumers and as research practitioners.     

The Impact of Family Therapists’ Adult Attachment Styles on Their Career Choice and Approach to Therapy: An Interpretive Phenomenological Analysis

Attachment theorists have highlighted the role of the therapist in providing a ‘secure base’ for therapy. This raises the question of how therapists with insecure as well as secure attachment styles manage the integration of their personal experience and their therapeutic work. This study explored the relationship between family therapists’ adult attachment styles, influences on their career choice and their approach to therapy. Participants’ (n = 11) attachment styles were previously assessed using the self-report Experiences in Close Relationship questionnaire. Three participants were assessed as having a ‘secure’ attachment style; three were ‘preoccupied’, three ‘fearful’ and two ‘dismissing’. They were interviewed about their practice and the impact of past or current relationships on their development as therapists. Interpretive Phenomenological Analysis was used to analyse the verbatim accounts into cluster of master themes and subthemes. The analysis identified two master themes: understanding one’s self and the impact of family of origin experiences, and the integration between personal experiences and therapeutic work. There were differences in responses relating to the therapists’ attachment styles. Therapists with ‘secure’ adult attachment styles were aware of their challenges and able to utilise their experiences in their practice and respond sensitively to their clients. Conversely, those with ‘insecure’ styles have difficulties in mentalisation and in using counter-transference responses in their practice. We suggest that family therapists, social workers and others engaged in therapeutic work with families should undertake an exploration of the ‘self’ of the therapist in the context of their own family relationships and adult attachment styles as part of their training and continuing professional development.     

Clients’ perceptions of marriage and family therapists’ way‐of‐being: a phenomenological analysis

Previous research highlights the influence of therapist factors on treatment outcomes. One therapist factor proposed as fundamental to the process of therapy is the therapist's way‐of‐being, a relational concept that refers to how the therapist regards a client—either as a person or object (Fife et al., [2014] Journal of Marital and Family Therapy, 40, 20–33). Although this case has been made conceptually, there is little empirical research on therapists’ way‐of‐being with clients. The primary purpose of this research is to investigate clients’ perceptions of their therapists’ way‐of‐being. Utilizing a common factors perspective, the study seeks to explore: (a) how clients experience their therapists’ way‐of‐being and (b) the influence therapists’ way‐of‐being has on clients’ engagement. Phenomenological methods were used to gain a nuanced understanding of the phenomenon. Qualitative data were collected through semi‐structured face‐to‐face interviews with clients (N = 10) who received individual therapy from a marriage and family therapist. Results were organized into two main themes: core tenets (attunement, congruency, and aligning with clients) and operational tenets (providing affirmation and validation, balancing flexibility and structure, and accomplishing goals). Findings are used to make a case for adding the concept of way‐of‐being as an overarching construct for several well‐established therapist factors. Clinical and training implications are discussed.     

Systemic Practice in the Time of COVID: Conversations Among Culturally Diverse Therapists

The COVID‐19 pandemic has changed the delivery of clinical services and education of health professionals, including family therapists. This paper distils two separate Zoom conversations between myself (as the lead author) and two eminent family therapists, Professors Maurizio Andolfi and Harry Aponte, where challenges and opportunities for the profession during and after the pandemic are discussed. Creativity and resourcefulness are two important elements therapists and educators have needed to access during the pandemic to find alternative ways to continue to provide clinical services and teaching. Most therapists have transitioned using online technology and various platforms such as Zoom and Skype; for some this has been a somewhat familiar experience, for most it has been a novel one. Key themes emerged from the conversations including the personal and professional ‘lived experiences’ of the pandemic; the financial impact on clients and students; the importance of touch for human social connection; the use of ‘self’ as an instrument of change and alternative platforms of service delivery and teaching. We reflected on what has been lost, such as the nuances inherent in face‐to‐face human interactions, and what has been gained, such as observing families in situ in their own environments.     

Creative Solutions and Development for Social Workers Treating People with Serious Mental Illness - Contributions from Supervision

Social workers who are engaged in a therapeutic work with clients who have serious mental illness often face specific challenges and find themselves in crisis states in therapy, which stem from the return of the clients’ symptoms and their cognitive impairments as well as social stigma. These crisis states cause dramatic changes in the way social workers mentalize their clients and they are propelled to draw from covert, unformulated, and dissociated knowledge that they have about the client’s experience, which contributes to achieving new, surprising, and creative ways to mentalize the client. Such crisis resolutions enhance therapists’ personal and professional development and serve as an identification model for their clients.     

‘Care is not a dirty word!’ Enacting an ethic of care in social work practice

While ‘care’ has been positioned as a core value of the social work profession since its inception, the increasing influence of neoliberal rationalities have placed care on the periphery of social work theory and practice. Social work scholars have promoted the incorporation of ethic of care theory into direct social work practice as a means of countering the effects of a context that is antithetical to caring practice. I present findings from my Australian study, providing an original contribution by presenting concrete understandings of how social workers enact care in everyday direct social work practice. The study was guided by a grounded theory approach. Fifteen social workers were interviewed using a semi-structured interview schedule. The interviews were analysed using constructivist grounded theory techniques. ‘Meeting needs’, ‘just being there for clients’, ‘building relationships with clients’, and ‘going the extra mile’ were some of the ways that participants demonstrated care in their practice. Constraints on care were challenged and resisted by ‘taking a stand’, ‘bending the rules’, ‘picking battles’, ‘justifying care’, and ‘taking risks’.     

How Do the Professional Lives of Family Therapists Affect their Private Relationships: A Qualitative Study

This article is based on a qualitative research project about how the professional lives of family therapists affect their private relationships. The overarching research question was: How does your professional work as a family therapist affect your private relationships? To answer this question, semi‐structured qualitative interviews were conducted with four therapists from two different Family Counseling Services. Through the use of interpretative phenomenological analysis, three main findings were identified: (1) family therapists’ knowledge and values are a basis for interpersonal encounters; (2) participants describe resonance in relation to clients’ stories; and (3) therapists can be challenged in managing confidential knowledge particularly where they belong to the same communities as clients. The study also explores societal expectations and discourses that accompany the role of therapist, which can affect therapists’ freedom of movement in their private lives. These issues are discussed in relation to family therapy theory and relevant research.     

Partners in the Spiritual Dance: Learning Clients’ Steps While Minding All Our Toes

We present four case illustrations highlighting the complex interplay of therapists’ and clients’ spirituality in therapy. Complexity, in these cases, results from (a) degrees of similarity and difference, both real and perceived, between clients’ and therapists’ spiritual beliefs and practices; (b) degrees of spiritual disclosure; (c) characteristics of the therapeutic relationship; and (d) geographic and cultural influences. Practicing therapists and therapist training programs can benefit from addressing how therapist and client spirituality intersect and influence therapy, how both similarity and difference present obstacles and opportunities, and how ambiguity and assumptions can contribute to misunderstandings. We believe that both the therapist’s and the client’s spiritualities are key influences in therapy that can contribute to the frustration, and the growth, of clients and therapists alike.     

User Involvement in Therapy: Couples' and Family Therapists’ Lived Experiences with the Inclusion of a Feedback Procedure in Clinical Practice

User involvement in therapy includes some form of feedback from the clients. The feedback guides the therapist and the clients toward a best possible result through a best possible therapy process. In recent years many different procedures for collecting feedback have been developed. In a previous study presented in this journal we explored the expectations therapists had before including the comprehensive clinical feedback procedure, Systemic Therapy Inventory of Change (STIC), in their clinical practices. Our aim with this present study is to explore couples' and family therapists’ experiences with STIC from the perspective of user involvement. We found that the term ‘using STIC’ represented many different variations both between therapists and between the families each therapist worked with. Likewise user involvement, combined with a feedback procedure like STIC, was also a many faceted area. We discuss how therapists’ experiences may relate to the different aspects of user involvement in therapy.     

A Thematic Guide To Bulimia Nervosa

This article offers a thematic guide to bulimia nervosa for both therapists and clients. It explores the relationship of common themes — developmental, interactional, sociocultural and behavioural — to the central issue of control. It uses examples from therapy sessions to highlight the themes as they emerge in therapy and to illustrate the ways in which the problem may be addressed.     

Integrating gender on multiple levels: a conceptual model for teaching gender issues in family therapy

As the field of family therapy has evolved, there has been growing recognition as to the importance of gender in family therapy. To prepare the next generation of family therapists adequately, it is important that they recognize the many and complex ways in which gender permeates their work. In this article we present an integrative model to help educators teach family therapists about gender issues. The model examines how gender influences clinical work on multiple levels, including contextual levels such as society and the marriage and family therapy field. The model also acknowledges how gender can influence individuals, including clients, therapists, and supervisors. Finally, the model attempts to capture the complexity of how gender can impact the relational dynamics between two or more individuals.     

La metafora: the power of metaphors and creative resources in working systemically with families and children with autism—a conversation with Carmine Saccu

Metaphors are valuable tools of expression, which give meaning to situations and allow the spontaneous processing of feelings and emotions. As therapists, we can support clients to develop and create their individual metaphor to explain their own meaning of experiences or communicate their perception of problems. Creativity provides us with a rich landscape to explore, expand, and enrich ourselves as therapists and consequently our clients. As systemic therapists, we are responsible for the co-creation of a human process, which has at its core safety in allowing expression, connection, and movement. Through a respectful and curious approach, we can develop pathways to tap organically into our ‘creative selves’ while reaching into our clients' creativity and selves as catalysts for connection and positive change. Creative resources and therapies have been successfully used in psychotherapy to enhance the mental and emotional well-being of children, particularly children with autism who have limited verbal capacity or who are non-verbal. These children also wish to be understood in expressing their thoughts and feelings; however, they use other methods of communication – sometimes obvious, sometimes not. Therefore, it is important that a therapist can access diverse ways to support the child through this process. The creative use of animals in therapy neutralises spaces, eliciting calm, safety, and healing. This is particularly the case when working with this group of children. This paper is derived from my conversation with an elder statesman of the family therapy profession, Professor Carmine Saccu. He is a jovial master storyteller who craftfully communicates via metaphors. Through creative means, play, and humour, he has developed a remarkably unique way of working with children, especially non-verbal children with autism. He uses his canine, co-therapist Mafalda, as a powerful resource and intervention strategy to safely elicit engagement and connection in the therapeutic space.     

Family Therapy for Kids Without Families: Working Systemically With Children and Young People in Residential Care

A significant proportion (4%, Australian Institute of Health and Welfare, 2008) of children and young people in Australia live in some form of residential care, usually in small group‐homes staffed by residential care workers in shifts. However, as Hawkins‐Rodgers (2007) points out, these placements are often not resourced to heal the effects of trauma and multiple attachment disruptions in their residents. The lack of an archetypal ‘family’ has led in the past to family therapists considering that there is little work to be done with such clients. This leaves such placements to be supported most frequently by clinicians who specialise in behaviour management and other linearly founded models of practice. The Alternate Care Clinic (ACC) is the first mental health service in New South Wales dedicated entirely to children and young people in out of home care with a high level of complex needs. This article examines the systemic therapeutic model the clinic has developed in the last two years. In particular, the article seeks to explore the importance of ‘meaning making’ in a diffuse parental system, particularly with regards to the term ‘family’. The complexities of working in this area and possible ways forward are illustrated with a closely worked case study.     

Systems in Settings: The Therapist as Power Broker*

Family therapy discourse has given little recognition to either the specificities of the settings in which family therapy is employed or to the specificites of our clients. Clients are frequently constituted into the culturally subordinate position of ‘other’ to the therapist. This paper examines the ethical imperatives of the position therapists occupy in relation to their others.     

The Challenge of Leadership in Front Line Clinical Teams Struggling to Meet Current Policy Demands

Teams, and their managers, working at the interface between government policy and service to clients are subject to high levels of anxiety arising out of the persecutory manner in which well-intended policy demands are delivered and cost efficiencies imposed. Informed by Bion's ideas about group behaviours, these responses can be understood as a form of defensive behaviour and identified as Basic Assumption Me-ness. Basic Assumption Me-ness in team managers takes the form of managerialism at the expense of leadership, developing a shell that acts as a protection for the lonely, overburdened, vulnerable and soft inside. This hardness, evident through increased unavailability and a rather sadistic use of boundaries, is communicated to staff, who in turn pass it onto clients. In this manner, it infects all relationships thus stifling emotional engagement, creative thinking and practice. This paper then explores ways in which team leaders, courageous enough to take up their authority in an emotionally engaged manner, can reverse these dynamics to the relief and benefit of all concerned. Leaders need to insist on attendance at meetings and supervision where cases can be properly considered; demonstrate an ability to think about risk as ever present in the work because, as all are well aware, no amount of form filling can eliminate this; and acknowledge that the work requires constant assessment and judgement as well as an ability to stay with the unknown. The aim is to be responsive to the daily struggles of team members working face-to-face with clients and to remain aware of ‘the reality on the ground’ when engaging in an equally lively way with senior management.     

‘My Child is Anxious Because We Might Get Deported’: Brief Therapy from MRI with an Immigrant Family in the United States

As we go to press in a COVID-19 world, the topic of anxiety is foremost on our minds. While each situation has to be considered in its own context, how to manage different anxieties has common denominators. There is currently a sharp increase in forced migration around the globe so mental health professionals must develop effective skills, like the ability to adapt services to different contexts and cultures, to manage the needs of immigrant people. Problem-Solving Brief Therapy, as developed at the Mental Research Institute in Palo Alto, is a systemic model of therapy, which aims at promoting change in the complaint the presenting client (the ‘talker’) cares about. The model’s roots in Constructivism foster integrating the clients’ beliefs and values into therapy to allow the therapists to adapt to the clients’ particular needs. This paper is the analysis of a single case where the therapist worked with an immigrant family because their child suffered from severe anxiety related to the parents’ threatened deportation. The paper focuses on premises and strategies that allowed minimising cultural barriers between therapists and family members, thus facilitating a strong therapeutic alliance conducive to improvement.     

Learning to Collaborate: An Application of Activity Theory to Interprofessional Learning Across Children's Services

This paper investigates the pedagogy of a continuing professional development (CPD) programme to develop interprofessional learning (IPL) and collaborative practice for professionals across children's services, using a framework underpinned by Activity Theory. The aim of the study was to establish which pedagogical features enabled successful interprofessional learning and subsequent changes in collaborative, interprofessional practice. Activity Theory was used as a theoretical framework to analyse and identify the ways in which pedagogy impacts upon the development of collaborative practice. The qualitative study found that pedagogies designed to harness the ‘multi-voicedness’ of activity systems and the contradictions of multi-disciplinary practice can be used to inspire learning and practice change. From our analysis, ‘community’ and ‘division of labour’ were important contextual influences on the learning process. We propose that the ideas underpinning Activity Theory are useful guiding principles when looking at the design of CPD that aims to build collaborative, multi-disciplinary practice across agencies and professionals in children's services.     

Three Journeys Toward The Reflecting Team

The experience of familiestrainee and supervisory therapists involved in reflecting team work are explored through the metaphor of ‘journey’ and by asking a small number of our colleagues and clients about their experiences. Ideas gained from this approach are tentatively used to raise some questions about the reflecting team specifically and the current direction of family therapy. More rigorous research into this area is invited.