Tying Knots around Academic and Clinical Reflections

Reflections on Brief Solution-focused Therapy 12 Feb 10

I was inspired by how the tutor, Matt Ellis, during the role-play at our Academic Seminar, in the way he 1) managed a common response to the Miracle Question, eg. "dunno", "that's impossible" or "how would I know?" by agreeing with a twist, eg. "yes of course you won't know, let's just use some imagination here..." 2) expanded the Miracle Question with a series of questions that elicit very specific observations and sensations, eg. how do your feet feel getting out of the bed? how different does your face look in the mirror? does your body feel light? how light? what do you think the first person who saw you notice different about your tone of your voice? etc The point of it is to have almost a hypothetical visualisation exercise so vivid that the very moment when part(s) of the sensation/observation were to happen, the client could quickly relate to the "Miracle" and start noticing exceptions!

I can now draw connections between the Miracle Question and the visualization of a problem-free future, the importance and power of making clients describe as vividly and concrete as possible what they would see, feel, smell, touch, do, say, etc, which could be as nitty-gritty as the sensation of the feet on the group immediately after getting out of bed. 

Matt has also answered my question about the feminist critique on solution-focused approach’s oblivion to power issues well - the critique that solution-focused therapists would still work with perpetrators of domestic violence even if these clients choose to  not address the violence issue in therapy but on other therapeutic goals –  he opined that this would not happen as the therapist would be answerable to professional ethics and legal implications. 

I also like Matt's acknowledgement of the limitation of the Solution-focused approach – if applied strictly in the manualised way, it would be ineffective in workingwith problem-saturated clients, or in other words, those still very caught up in the pre-contemplative phase of change. Adequate joining and empathy need to be given before moving on to explore problem-free exceptions.

Reflections on Research 20 Feb 10

Most clinicians are scared or put off by “research”, mainly because of the headaches and inferiority from not understanding and hating research-related tatistical jargons and analyses. To a great extent, I feel so too! I’m guilty too; when reading research papers,, I would often skim through Synopsis, Introduction, Literature Review, after which  I would skip Methodology and Results but jump straight to Discussion and Conclusion. Even though I do have the awareness and previous training to critique on the methodology, I still feel crippled by the jargons like regression analyses, etc. Very few of the many things taught before in my social work degree remained in my pea-brain now!

Some key learnings for me from this Academic Seminar by Prof Ivan Eisler I hope to document here as part of my learning journey (will be interesting to review them when I start writing my dissertation at the MSc level):

• Falsification: One observation can disprove a theory, no numbers of observation can prove, only prove consistency in observation; Inductivism: One observation can prove a theory, eg. White swans.
• Most people do not like randomness, so they will try to make sense of things that happen. Yet making sense does not equate to causality or even co-relation! Many lay people and even researchers generate hasty generalizations or quote research findings out of context. Two good examples cited was MMR’s faulty claim of the causality-link between immunisation and autism which was retracted subsequently, as well as the question on the research on effectiveness of Debriefing for people who went through traumatic experiences. I could also think of the unethical research done by a clinician who claimed success in therapy for intersex persons who were operated at birth to decide on their gender, and 
• Prof Eisler came to the seminar with a goal, which he hopes to be able to shift the above mindset through examples, some basic discussions and illustrations of research concepts and their connection to systemic therapy. I still find the distinction between research and clinical hypotheses kind of blurry, only went away with the understanding that they are different in their timeframe and structure, yet this applies more in the difference between clinical hypotheses and quantitative research hypotheses; clinical hypotheses are actually very similar to qualitative hypotheses.
• When there is a team of therapists observing a family, they would each generate a different hypothesis of the situation. How do we know which ones are not generated from the observations, or fit less with the family situation? A way proposed is to do a reverse testing, i.e. get a team to select which hypotheses generated fit best when they review the family session. Sound rather effective but I went away from the seminar wondering if the same problem would arise – even if there could be a hypotheses that this second team identify as best fitting, from a second-order cybernetics and social constructionist point of view, how would we know for sure that’s the best? What if there is the issue of groupthink?

Reflection on Structural Family Therapy 22 Feb 10

There’s always new learning revisiting previously learnt concepts! We revisited Munichin’s structural techniques today while reviewing a video-taped therapy session with a couple. The session was conducted back in the 1980s. I now have a clearer idea the meaning and application for the following structural techniques:

• Enactment (I’ve somehow always remember it as re-enactment, good to know the distinction now!) – replay what happened at home. “Show me what happened when…” Could then proceed with some coaching or intensifying;

• Intensifying (I now understand this as the outcome of re-enactment technique, but relooking at 2 readings on the Structural Model I have, strangely no mention of re-enactment but only intensifying!) pro-long or shorten conflict (hmm, could shorten be more of interrupting? Guess it depends on therapist’s intent and outcome), pushing beyond threshold. Our tutor emphasized time as the key factor here but I later clarified that changing the degree of conflict is true too. Another colleague highlighted a good point about the risk of backfire or what if the conflict go beyond control. What I gathered from our tutor’s subsequent explanation is that this threshold pushing is not so much as to spit on the fire but to precipitate a crisis in the session a bit, just enough to introduce a difference, eg. it could lead to saying, “No, what you are doing (verbal argument) is not helping to resolve the conflict, try it again (in a different way).”

• Unbalancing Put relationships systems out of balance by siding those who lack a voice in the family, may switch from member to member at different time. I also like the way Nicholas and Shwartz (1995) put it: realign relationships between subsystems.

Key learnings from the case example:

1. To a man immersed in gang-cultured aggression against his grilfriend’s family’s threats to her and seeing it as the only solution and way to protect her (a “Tarzan and Jane” belief system), helpful to positively reframe his “death before dishonour” belief, “He has a strong code of conduct”. More impactful if this could be indirectly addressed to him by saying it to the girlfriend. 
2. Unbalancing, giving a voice to the girlfriend, “Your boyfriend needs to know if killing your family is what you want?" Therapist at this point read non-verbal cues and surfacing feelings and said, "I think you’re frightened. Tell him how far you want him to go.” She replied that she’s confused and did not want him to get into trouble. 
3. Therapist harnessing the man’s and woman’s voices from the observing team to give feedback (I guess in today's context this could be said directly by a reflecting team): 
   

   a) Woman’s perspectives - affirm girlfriend for breaking away from her family’s cycle of violence, “You have been more successful than your mother in leaving home (from domestic violence). By achieving something nobody else in the family could do, your family will continue to put pressure on you to stop you for doing better than you (implying she has actually broken the house rule by leaving violence).

   b) Man’s perspectives - using the girlfriend’s experiences, challenging the man’s beliefs aggressive solution belief by respecting it and agreeing with a twist, “Your girlfriend is asking you to do something more difficult than you have ever yet faced with your motto of death before dishonour, so as to protect her without her losing you.

4. Session was called for an end here, without answering the man’s subsequent question of “how to?” so as to allow the couple sub-system to work out the “solution” on their own. I think it has a bit of “throwing a bomb and leave” strategic effect that the Milan Team used.
   
   

I see that 3b and Matt Ellis's strategy in addressing clients’ disbelief of a Miracle have a similar point; when people reject our suggestion or opinion, the very usual response would be to challenge or  reject, yet this often elicits others’ defense mechanism and very likely make them stop listening to us. I caught myself doing this a few times recently too when hearing feedback on what I did or said. To some extent I think it could be a man's pride issue too. This realization is very important to me as a therapist and as a person, to be mindful of joining with others before giving feedback, at the same time, when at receiving end, to also join with the person giving feedback first, to catch my reaction before I react.

Reflections about Time and Personal Agency

Reflections about Time 10 Feb 10 

 ‘… it is not strictly true to say there are three times, past ,present and future. It might be correct to say that there are three times, a present of past things, a present of present things, a present of future things. Some such different times do exist in the mind, but nowhere else that I can see. The present of past things is the memory; the present of present things is direct perception; the present of future things is expectation.’ (Italics added by Hugh Jenkins)

Augustine of Hippo (1961) Confessions. London. Penguin Books. 269.

I especially like the quotation above, cited by tutor, Hugh Jenkins, at our Theory and Practice class today. I am beginning to think that time is yet another social construct. Systemic therapy emphasizes a lot on understanding contexts brought about by gender, ethnicity, sexuality, power, structure and communication patterns, yet time has not overtly emerge in my mind until today. Much more abstract it can be than other constructs, it is not new. Hugh has cited many powerful words about time by many, from scientists Enstein, Hawkings, to philosophers Kant, Pluto, etc. I could also add on Brofenbrenner into the list, the chronological system in his Ecological System model.

There are two interesting perspectives that are very related to therapy: one is that of Aristotle, which Hugh interprets as the recursive relationship of change and time:

‘Not only do we measure change by time, but we also measure time by change, because they are determined by each other.’

Aristotle (1999) Physics. Oxford. Oxford University Press. 109.

While the class discussions surfaced interesting terms like ageing, withering, persons with learning disabilities experiencing a long now without past nor future, I also remember this saying I heard years back (forgotten the source):

`We begin to age starting from the time we were born.'

Another quotation Hugh cited that I like a lot is from Enstein's relativity:

`Time runs slower near a massive body, (like the sun), or farther from earth relative to another clock set at the same time. Does time appear to run slower in ‘heavy’ emotional states, i.e., nearer a difficult / painful emotional mass?'

I have also some reflections to share here about the short film we were shown at the class, "Mary and Mick" that depicts a young couple being stuck in the past as they grieve over Mary's miscarriage. During the small group discussion after watching the film,  a coursemate hypothesized that the husband in the film, Mick, was more stuck and slower in his griefing process than Mary, the wife, I shared my view that it could be just different ways of coping, or that he is more stuck because he had to not just cope with the loss of a child from miscarriage but also his wife's outwardly expressed sadness and pain. 

On reflection, I think it could also be  that in Mick's belief system, there is a limit to the amount of time for griefing, beyond which it would be "abnormal". This is evident from his initial embracement and soothing of his wife, yet months down the road it turned into anger. There are thus multiple possibilities and perspectives to this. With this note, I wonder why  I had assumed that it was only Mick who needs to cope with two griefs? Doesn't Mary need to cope with both the miscarriage and Mick's way of griefing too, which was the other extreme from hers too? Could I have unintentionally put up a defense for the man in the story, in response against my female coursemate's hypothesis?

Being Stuck

On a separate note, at this moment, coming to half a year since I started this  course, I am feeling a bit stuck - which is in a way related to time and change - a feeling that things around me are changing but I'm resisting them, or that a feeling that things are not changing  fast enough for my liking, or it could be both?!  I  feel that my current learning process is familiar yet foreign, new yet old, fresh yet stale. I have yet felt the passion and fire that I expected I would have when I first enrolled in this course. 

Expectations

 

Felt a different stuckness that connects with some emotions when I watched BBC1's "I hate Mum" that featured two families going through family therapy. Certainly I could identify the externalisation and reflecting team approaches used in the feature. Yet somehow I felt the documentary did not do justice in depicting the therapeutic process and the family therapists (quite a large part of the programme was interviewing the clincal psychologist instead). One side of me thought that the programme could have approached the issue from the social constructionist position, where the families themselves are the main change agents, on another side I wonder if it could be bad programme editing, or just my preconceived ideas about what should be good family therapy, thu result in frustration over this unmet expectation?  How is it that I felt the questions posted by the father and cameraman sounded more therapeutic than the questions posted by the clinical psychologist and family therapist featured?

Reflections about Personal Agency 19 Feb 10

A frustrating encounter  on the bus today made me reflect on Mahatma Gandhi’s words, "Nobody can hurt me without my permission." I still believe in this notion but have a slight different interpretation of it now. I was the last person to get on a crowded bus and stood next to the bus driver, listening to my Walkman. For seconds the bus stayed stationary and door did not close even though there was no obstruction or new people getting on the bus. A guy in front of me tapped my shoulder. I looked up and the bus driver glared at me and complained that I need to move right inside. I moved a few inches behind and that was the most I could do given the bus fully occupied.  I was pretty cool about it but did notice a tinge of frustration in me that disappear pretty fast. Of course, the question of racism and injustice ran across my mind. I also think that the feeling came faster than I could think it through  or sooth myself. This makes me rethink Gandhi’s words; that people can actually hurt me without my permission, yet what’s different is how fast my personal agency and social support could sooth and heal. It is thus a matter of time and resilience.