A Collaborative approach in working with people striving with substance abuse and addiction
By, Luuk L. Westerhof, M.Sc
This article attempts to share some light on how we, as professionals can be together with people striving with substance abuse and addiction in a way that it makes sense and a possible difference. The question is raised as to how can we as professionals be together with people striving with substance abuse and addiction in a manner that our practice has relevance for them in their everyday lives? We are living in a fast-changing society and world, often too fast, by that meaning that we not always know what we mean by relevance, and who determines what is relevant? In working as a therapist with people battling drug- and alcohol addiction, I have witnessed many times that professionals possess the notion, that they know the answer to questions such as, what are proper codes in being together with…, and who defines what is relevant or not in treatment? As a clinician, I prefer a more collaborative approach -the nature of postmodern thinking, as opposed to exercise interventions. I will shed some light on how to understand psychiatry and psychotherapy as a contrast to the postmodern collaborative approach. People change all the time, systems comprised by people change rapidly all the time socially, culturally, economically e.g. Instead of thinking that we know it all, we rather should acquire a more curios position in which nothing is certain, but much is possible.
Understanding psychiatry and psychotherapy
Working with people striving with substance abuse and addiction most often takes place in an inpatient context; too, outpatient facilities offer great help as well. To gain a greater understanding on how these professional treatment facilities influence treatments I like to continue how to understand psychiatry and psychotherapy as a contrast to the postmodern collaborative approach.
Psychotherapy has developed in sync with how we understand psychiatric problems. Today, Psychotherapy is the leading approach in working with people experiencing psychiatric difficulties.
A psychotherapeutic process can exist in many forms and is thus not a homogenous alternative for treatment. How psychotherapy and our understanding of psychiatric issues have developed, must be understood within a context on how psychology as a profession and society and culture has developed over time.
In 1959 scientist C.P. Snow (Snow, 1959) problematized the relationship between natural-science and human-science culture. The former aims at explaining behavior through prediction and controll. The latter aims at understanding, i.e. how do we understand the world around us. An interesting question is how have these two cultures created challenges/problems for psychology? Psychology includes both cultures, and that is what makes psychology so difficult to manage. In the core of psychology, we find knowledge-related opposites that create a lot of stir, and the academic community hasn’t been able to handle these opposites adequately.
In the 70-ties psychology resorted under social-science, and at many universities, psychology still resorts under the social-science faculty. But in some cases, psychology is organized and resorts under the medical-faculty, where it assumes more prestige. The highest esteemed of both cultures is the medical, and the medical culture has been at the base for the development and identity of psychology. Due to this focus, there is a lot of research on individuals, yet little on persons; much research on behavior, but little focus on acts; much research on mental issues, but little on subjectivity; much research on cognition, but little on meaning; much on responses and reactions, but little on intentions and a person’s free will (Snow, 1959).
In the 1970-ties psychology as a profession emerged as being a part of social-science, this in opposite to physics and behavioral psychology which were the prevailing orientations at the time. Then came the IT revolution, and the cognitive perspective entered the arena with full force. Today we live in the “brain” age. We have gained new technology which enables us to understand a human being from different angles and perspectives. Society has become more individualistic and individually oriented, and with that the interaction between the individual and society has been disturbed and weakened (Valla, 2014).
I the 70-ties there emerged a fierce criticism against psychiatry, mainly aimed at how psychiatry was exercised in institutions in the 50-ties and 60-ties. This criticism lead to the downsizing and in many cases dismantling of institutions, and too, there emerged a conviction that this movement would lead to the restriction of the medical model. That didn’t happen. Instead psychiatry reoriented itself. Psychiatry which had established its identification related to institutions became now occupied with reestablishing its confidence. The pivotal aim was to strengthen the scientific platform and a return to natural-science.
A power struggle within the American Psychiatric Association resulted in the revision of the American diagnostic system in 1980 (Diagnostic and Statistical Manual of Mental Disorders – DSM), and one returned to the biomedical approach as the basic model. With that the amount of diagnosis increased dramatically. “Diagnosis has had great significance in psychiatry”, says Ekeland in (Valla, 2014), and they have changed over time.
After the 2th world war diagnosis had little status. It was psychodynamics that ruled, and one understood problems as something connected to a person’s life history and context. Diagnosis was not pivotal in the understanding of human problems instead human problems were understood from a cultural human science perspective. In the 70-ties and 80-ties there was a turn-around.
The diagnostic manual and its supporters gained much power and influence as to how the field profession was to develop in the years to come. It became much easier to sell individual diagnostics rather than contextual perspectives (Ekeland I Valla, 2014). What we must fear is the fact that the biomedical model is raining within the field of mental health services, something that lies within the paradigm of natural-science culture, and scientists and researchers are occupied with developing treatment knowledge which can tell us that if we apply a specific method on a defined problem, one obtains a specific outcome. Diagnosis becomes the base for what type of treatment can be offered, and causality (cause-and-effect) lies on the basis for the offering of treatment.
Health authorities put strict demands on professional practice and documentation, and professionals are expected to use methods that are proved scientifically. An Evidence-based approach as a concept has become the domineering quality concept for health services, and aims at discovering “what” works, so that health services can apply correct psychotherapeutic knowledge. The problem with this approach in exercising mental health is the fact that there is no such thing as a stable relationship within psychotherapy. Too, diagnosis has little support in research.
Diagnostics should allegedly help us to establish greater clarity and an expanded understanding of a problem, but if that is to happen the prerequisite must be that the diagnosis is valid; the diagnosis must be able to detect the sickness and must be able to predict what treatment will be best. Yet, this approach is problematic as opposed to somatic deficiencies that can be objective detected, psychiatric diagnosis are constructed invisible entities, which refer to social data (thoughts, feelings, behavior) and based on consensus between professions on what is healthy and what is sick.
A diagnosis supplies us with little information on what should be the appropriate treatment, for the simple reason that it doesn’t tell anything about a patient as a person or subject. To put it in other words, one is not able to treat sicknesses, like in somatics, just “sick” people (Ekeland I Valla, 2014). And this is the reason why psychotherapy as a treatment option for psychiatric problems never will have the same effect as a treatment approach for somatic problems. Psychiatric help must therefore be offered from a different cultural stance, the human-scientific approach, where there is a much higher regard for subjectivity and context (ibid).
Understanding Modernism, Post-modernism and the Narrative approach
Post-modernism has become an omnipresent term in academic circles and contemporary culture (Boston, 2000). It too is a term that has caused consternation, especially within the systemic family therapy community. One of the pivotal and unifying features within the post-modern approach is the importance of understanding psychological challenges and difficulties in relation to, and in the context of social relationships. Another key feature is the significance of drawing distinctions and marking “difference” as an aspect of creating change. A third feature is the working in teams; reflecting processes e.g. (H. Anderson & D. Gehart, 2007; Jensen & Anderson, 2008).
Within the post-modern paradigm (Anderson, 1997; H. Anderson, 2002; Goolishian & Anderson, 1992) there are two major orientations: the post-modern model and the narrative therapy model (White & Epston, 1990). The post-modern stance places importance on keeping a critical and questioning attitude about knowledge as fundamental important.
Anderson & Goolishian (Goolishian & Anderson, 1992; Prichard, Morris, Shelp, & Goolishian, 1988) define their therapeutic practice as a post-modern approach. What has played a pivotal role in the development of post-modern practice is social constructionism (K. Gergen, Gergen, & Gergen, 2013; K. J. Gergen, 1974, 1991, 1997, 2009).
Too, the philosophical culture of hermeneutics, the science of interpretation and explanation. The principle components in the post-modern approach are the emphasis on the therapist as a participant and manager of the dialogue/conversation: he is not the “expert!” Importance is attributed to language as being the system, as opposed to given interactional pattern. The post-modern approach is occupied by generating meaning and understanding and that this is achievable through continued efforts. What is perceived as a problem is constructed in the language system and can be “dissolved” through language (Anderson & Jensen, 2007).
Changes thus occur through the development of new langue. Dialogue aims at the development of new language. Finally, reflecting processes are used to participate in the co-construction of alternative meanings ( Andersen, 1987).
The pivotal components of narrative therapy are that every individual’s identity is embodied in a personal narrative that include different and multiple versions of the self. When people come to therapy, they often come with a “problem-saturated narrative” that has become internalized as their primary self-description (White & Epston, 1990).
Problem-saturated stories (Gergen, 1991) and identities are created, and kept alive by their connection and relationship to important others (ibid). Externalization aims at disconnecting the problem from a person’s self-descriptions. Every problem in a person’s life influences that person at an individual and societal level. The influence of the problem is “mapped”, and connects the problem narrative to relevant others. Narratives are created at societal levels, thus problem ideas held by a person require “deconstruction.” In practicing narrative therapy from a post-modern perspective implies that the therapist looks for ‘unique outcomes’ – positive exceptions to the problematic story- and aims at amplifying change using letter-writing, benefitting from others who have successfully conquered identical issues – specific audiences, and personal enthusiasm.
Summarizing, contrasting modernism with post-modernism, modernism places value on societal progress. Modernism resorts under natural-science causing it to be occupied by rationality. Modernism accepts only absolute and measurable knowledge (positivism) through science and technology. It places value on the belief in the true self, universal structures, usually containing binary opposites.
Post-modernism at the other hand places value on multiple versions: there are no single definitions. A post-modern dialogue aims at looking for what is between binary opposites and what has been overlooked and excluded by the distinctions. From a post-modern perspective one respects and values the importance of variation over coherence. As opposed to modernism, working from a post-modern perspective is adhering to the notion of a socially constructed self (Gergen, 1991).
Conversation, Collaboration, Listening and Dialogue
In working collaboratively with people battling substance abuse, I often wonder how my participation and practice can have relevance and meaning for that other individual. Increasingly I become aware of the fact that people look for input in their lives, the question though is what affects it…? What change, and difference does it make…? People that are battling addiction have often revolved, like a swing door, in the system for a long time. They have met all sorts of professionals, some rigid some more cooperative.
Too often I meet people striving with addiction, who have lost faith in the different practices in which they have been treated as categories, diagnosis and numbers. Too, often I meet people that feel dehumanized by professionals by being ignored for their feelings, needs, pain e.g., too often their humanity is ignored (Westerhof & Knutsen, 2016) and their humanity violated.
In relation to my work I increasingly encounter people that demand services that are more humane, respectful, flexible e.g., and too often professionals approach complex human issues in a linear and causal way, not understanding that this can lead to the dehumanization of a person. There are no quick “happy-meal” answers as to why people have become addicted to drugs, alcohol, prescription drugs, etc. Complex interpersonal and intra-psychiatric issues should therefore be met with complexity, in the sense that it takes all off my senses i.e. feelings, smell, hearing, tasting, touch, speech, in order that I might have the best prerequisites to understand…? We need to create, together with that other individual an environment for change, and that takes time.
Understanding that other person isn’t derived from explanations on how dependency and abuse allegedly have occurred, but more from information generated within the collaborative context and activity; being-together-with (Anderson, 2007) in such a way that it becomes beneficial and meaningful for that other person.
Being in dialogue often demands a lot of effort, self-discipline, and curiosity (Harlene Anderson & Goolishian, 1995). Dialogue in conversation isn’t always easy – it’s often tough labor. People accuse one another and with that they are moving themselves away form great and doable solutions that can be constructed in conversation and dialogue ( Anderson, 2003; Anderson & Goolishian, 1995; Gergen & ProQuest (Firm). 2001).
Often professionals think that they have a dialogue with that other person, yet not realizing that they both are sitting in their trenches loading their rifles for the next round; and while you are talking I am contemplating as to how I can trap you, interrupting you before you are finished. And of course, you don’t feel heard then, and of course you are loading your gun for the next round. A conversation doesn’t turn into a dialogue by simply calling it that way. Dialogue demands a special attitude and behavior, which easily can be hijacked by defensive- and attacking mechanisms within us. Therefore, dialogue is tough labor, demanding that we discipline ourselves as a prerequisite to fruitful dialogue.
What is dialogue? Dialogue is conversing together being curios and inquisitive on what the other person(s) thinks, feels knows, and is occupied with. Dialogue is being inquisitive as to how I can understand the other person’s interests? Dialogue is gaining greater understanding due to listening to that other person. Dialogue is thus inquisitive in nature rather than instructing ( Anderson, 1997; Anderson & Gehart, 2007; Anderson & Jensen, 2007; Anderson, Jensen, Jahr, & Reichelt, 2008; Maturana, Lettvin, McCulloch, & Pitts, 1960; Humberto R. Maturana & Varela, 1980; Maturana & Varela, 1987).
Being in dialogue is being more interested in learning about the other person rather than being-right and winning. Dialogue is difficult when we don’t agree on things that are important to both persons. When we are strongly emotionally attached to and engaged in something, we easily become consumed by the desire to “win” this battle, losing the ability to listen to that other person. Yet, listening is one of the core-values and prerequisites in dialogue.
Dialogue must in no way be compared with passivity. Dialogue is more about “giving relevance to all the involved voices included one’s own” (Andersen, 1987; Andersen, 1990). Dialogues become fruitful and are signified by, that all participants can combine “the expressive”; one’s own meanings clear and with clarity with curiosity concerning the other persons thoughts, ideas, feelings etc.
Dialogue from this perspective is a valuable attitude, a way of learning about the other person’s distinctiveness. It’s easier to be curios when we perpetually assume that the other person can see or know something worth seeing and knowing. Curiosity in dialogue should provide us with a greater understanding as to how working collaboratively with people striving with substance abuse and addiction can become more relevant and effective.
In dialogue with a person I am interested in how this person perceives himself to be. At the same time, I know a question like who are you is grammatically incorrect in that the suggestion of the individual as being singular is raised. It’s more appropriate and in congruence with the collaborative spirit to ask questions in plurals. Singularity violates all that a human being is supposed to be in plurals.
The pronoun “I” is pretty much misleading since it carries the suggestion that “I” is a person independent from context, while life is based on interdependence: a person does not exist as a singular entity floating independent in space: a person always exists in relation to contexts that connect that individual with the world he lives in (Bateson, 1972): The great Batesonian question was, What are the patterns that connect? (ibid) “I” as separated from context erases the multiplicity of perspectives. A person is not just his personality, but too he is his emotions, history, legacy, culture, personality, and always in relation to...? “I” from that perspective is never rigid, always fluid and interrelated with contexts that connect.
Working collaboratively with people striving with divers addictions and abuse means showing interest inn that persons preference for music, daily habits, taste for clothes, educational orientation, family and life history e.g. Working collaboratively implies that we scrutinize together, both the innumerable reasons why substance abuse has entered the arena, too, how can we work together that minimizes or erase the addiction and abuse? As professionals we must contribute to a developing and save environment wherein languages can develop and compiled across time and movements. This is a language that helps a person to develop knowledge about himself as to how he can define and separate himself.
A person is never a rigid creature but rather someone who is because of what he knows. Since knowledge is dynamic, so too is what a person perceives himself to be at any given time. And we never know who we are for sure since clarity of what knowledge is, is arguable. But what will help a person in understanding himself and to edit his place in the world around him, is viewing life through multiple lenses like family history, culture, context, settings, relationships e.g.
Rehab often doesn’t work because the approaches applied are separating the individual from those multiple lenses, isolating that person from the world he lives inn and is a part of. Too often, and too much emphasis is placed on methods and interventions rather than collaborative togetherness and communication.
I used to work at a rehab facility where they used an audiovisual supervision intervention program, as a tool in helping parents to enhance their parental role and to understand their child’s behavior in a more adequate manner. Yet, over time, these models turned from being one approach among an arsenal of many other useful approaches into a “holy cow” overshadowing and neglecting other meaningful approaches. When we focus on just “one” approach, all the other possibilities are relegated to the background (Andersen, 1987; Andersen, 1990; Andersen & Weine, 1991).
By adhering so strongly to one approach, other ways of dealing with addiction and abuse become neglected.
I had many people in conversation at the rehab that told me that they not always were comfortable with the supervision-intervention program. Yet, they not always felt that they were taking seriously for their ambivalence. Instead they were labeled as treatment-resistant. As a result, many people couldn’t relate to their therapist, psychologist e.g., hampering and disturbing the therapeutic process. Cecchin (Cecchin, Lane, & Ray, 1992) warns us in becoming too infatuated with our approaches and hypothesis as they disturb the relationship between the professional and client.
When professionals fall in love with models, methods and hypothesis they tend to become fierce defenders of what they perceive to be “truth” losing sight of what the client needs, thinks, feels etc. We must never sacrifice people on the altar of alleged “truths!” Truth is only truth to them that defines it as truth! Carl Rogers ones said “The only person who is educated is the one who has learned to learn and change. Collaborative processes are learning processes. As professionals we ought far more to be interested in learning to learn- Bateson called this for Deutero-learning (Bateson, 1972).
Yet we don’t learn that much if we are not listening to our clients. Bertrand Russel said one time that in all affairs it’s a healthy thing now and then to hang a question mark on the things we take for granted. Hanging up question marks are more in line with the nature of conversation and dialogue.
The collaborative approach to regular human challenges and problems can be compared with a tapestry. Suzuki ones said, “Your attitude towards your life will be different according to which understanding you have.” Collaborative practice is derived from assumptions from postmodern social constructionism and theories concerning dialogue ( Bakhtin, 1994; Bakhtin, Holquist, & ProQuest (Firm). 1981; Gadamer, 1975; Gergen, 2009). Assumptions that inform the way the professional approaches therapy.
Dialogue often becomes difficult when we don’t agree on things important to both parties. When we are strongly emotionally involved in something, we tend to lose perspective on what the other person is saying, meaning, feeling i.e., and we often lose the ability to understand the position of the other person. Dialogue is thus a perpetual learning process.
Dialogue: a basic learning attitude
Dialogue is rooted in a basic attitude and desire to learn from each other’s’ differences. It’s much easier to be curios when we firmly are convinced that the other person can see, know something that we haven’t seen or understood ourselves. Dialogue is about clear and not devaluating utterances of meaning: To promote one’s own perception’s in a clear and open manner, that doesn’t devaluate the other person’s perceptions and feelings. When we are in dialogue we explore the perceptions of that other person: Attempting to understand and catch on what the other person is building his perceptions on. This implies that we need to maneuver ourselves between different perspectives. When we maneuver ourselves between different perspectives we must be willing to be affected by…. them! We must have built and rely on one another, placing our evaluations in parenthesis ( Maturana & Varela, 1998).
Too, it is important to remember that even though a dialogue can sometimes start out wry, doesn’t mean that the train for dialogue has departed! All parties have responsibility to make the dialogue working. Sometimes we start out wry due to a lack of interest in that other person’s competencies often leading to underestimating and devaluating that other person.
When we enter the arena of interpersonal dialogue, in many cases it can proof to be expedient to be curious about, and explore the competencies of that other person. Identity and competencies are closely knitted together: competencies reinforce identity. Showing interest in that other person’s education, profession, competencies can proof itself to be a “door-opener”; when people feel addressed, recognized, shown interest in, they more likely tend to open-up for deeper conversation.
People striving with dependencies and substance abuse are generally used to, that people just see the effects of abuse and addiction, not showing interest in other parts of their live, such as competencies. Taking enough time to listen and learning from that other person about that person can proof to be essential in a therapeutic process and dialogue.
Basically, it doesn’t take that much to torpedo the conversation and dialogue. What is important in preventing the dialogue from being torpedoed is to give the conversation and dialogue relevance by allowing all voices to be heard on equal basis; to be open and humble (Andersen, 1994, 2013; Andersen & Seikkula, 2005; Anderson, 1997; Anderson & Gehart, 2007; Lock & Strong, 2010; McNamee & Gergen, 1999, 2013).
One of the core features in dialogue is the ability and willingness to listen. Listening is one of the key features in dialogue that “go-out-of-the-window” way too fast. I would like to emphasize that listening is more than just sitting still while the other one is talking. Listening is an activity: You do not just shut your own mouth, but you attempt to really understand what the other person is trying to express and convey through words, gestures and body posture.
One way of listening is mirroring the other person i.e. repeating what the other person is saying, either directly or in your own words: “You feel that I am not always really listening to you? Can you tell me more about that!” Through mirroring you force yourself to listen to that other person. In doing so you much more likely hear what that other person is saying instead of what you think that person is saying (Andersen, 2013; Andersen & Seikkula, 2005). If you don’t listen, you won’t be able to repeat what the other person has said.
By mirroring you place your own talent of “speech” in parenthesis, something that makes it more likely that the other person will listen to you as well. We invite thus to dialogue by practicing the principles of dialogue ourselves. The best way to do that is by starting to listen. When you are in a position of authority, it might be wise not to initiate the dialogue with the attempt to promote your point of view, since this easily can be perceived as authoritative directing. All participants in the conversation have shared responsibility for dialogue, but difference in authority-relations gives a special responsibility to those who holds most authority.
Trust is more likely obtained, when we initiate the dialogue by listening to those that hold a different view than ourselves. We all know how wonderful it feel’s when we are listened to; when we can lower our shoulders, and talk together in civilized manner. Disagreeing in dialogue doesn’t have to be a problem; it is not what happens but how we handle what happens that makes the difference and determines the outcome.
Reflecting conversation – Being together in a way that makes a “difference”
When people experiencing difficulties and challenges in life, it is of great importance that the professional is curios and aware enough, so he can anticipate the possible invitations to change and expanding processes. The sprout of change and expansion is embedded in a dialogical conversation. However, we often don’t get our eyes on an individual’s potential for change and expansion due to dichotomous thinking; black or white; true or false; right or wrong etc. (Hertz, 2013).
The ability to discover the “undreamed” possibilities are not found in dichotomous thinking and approach, since it is devoid for curiosity. We can get our eyes on he “undreamed” possibilities when we are curious, explorative, inquisitive and meticulous in listening. The undreamed possibilities for change and expansion are found within the confines of “neither-nor” and “both-and”. It is when we as professionals listen to what a person really is saying that we can develop a fruitful process wherein we ca get our eyes on the undreamed possibilities that surpass the limiting dichotomous thinking (ibid).
I conscientiously apply the concept of invite/invitation since there are many people that have had no undivided positive experiences with professionals, and for that matter, professional institutions. Due to a lack of positive experience with professionals, many people understandably take a more reserved and quite position in their attempt to limit more of the same experience. Being reserved and quite can thus become an effective protective-function and must not be confused with, misunderstood and misinterpreted as a psychiatric and diagnostic category.
The new DSM-V, possess the potential to execute such error. This means that we as professionals in our meeting and congregating with people must ask the question as to how we can “lure forward” the desire to get involved in processes of change. To lure-forward this desire for change we as professionals must apply curiosity and a curios anthropological approach, so that we together can get our eyes on the creative possibilities a dialogue offers. We must not approach that other person as an object that we can define! We rather must find ways in which we can be together in helpful ways! Too, I often think that it is due to the professional’s lack of creativity that obstructs the emerging and creation of a co-creative and useful story. In our sincerity to be helpful for people, we can become so subject-driven that the interpersonal perspective drowns in the sea of “fancy” terminology, theoretic models and expressions. We rather must acknowledge that our identity is closely knitted to the stories we tell to or about ourselves.
To be together with people in a way that it makes a difference is in a high degree dependent on a focus on context. We cannot understand people isolated from context, since context gives colors to meaning that develops between the professional and the person while interacting, reflecting, and dialoging together concerning the different issues the person wishes to discuss. Many professionals make the mistake in forcing a person to talk about, and answer questions on issues that the person is not ready for to answer. It is of pivotal importance for the development of helpful processes to respect the person’s reluctance to talk about, and answer questions concerning certain issues in their lives. Forcing someone to talk or answer will in most cases lead to the imploding and destruction of the conversation (Andersen, 2013; Andersen & Seikkula, 2005).
The challenges and topics that arise in conversation and dialogue are contextual and can thus never be perceived and treated as separate entities. When we chose to consider and perceive a person’s challenges in life without considering and including context, we easily can be in danger of experiencing confusion and misunderstandings. This, to me this is common sense. Yet, in meeting the other person we often fail to stick to this important feature and approach in conversation and dialogue. Harold Goolishian (Anderson, 1997) once said something that I think is worth reflecting over; you must listen to what is said and not to what you think is said! The voice of a professional can easily suppress and silence the other person. Often, professionals draw to fast conclusions and fall in love with their hypothesis.
The task of a professional is to contribute to the co-creation of reflective space, wherein the other person feels himself acknowledged, heart, taken seriously, and by that inviting to attractive co-creative processes wherein the other person gets in touch with his development resources -and managing repertoire. A person’s perception concerning “self”, is constructed through language that is braided together with valuable events and characteristics, thus becoming an account and history of self.
Making a difference
Often people look for help when daily live stalls and negative histories gain a too domineering place in life that it obstructs their potential for personal development and expression. In an earlier article (Westerhof & Knutsen, 2016) me and my colleague emphasize that change, when too small, is in danger of not being noticed when we are in conversation and dialogue.
Too small changes hold thus the risk of not opening for hope in respect to obtaining more fruitful progressive processes, something that is a prerequisite for developing alternative and more useful stories concerning the “lived life.” We must dare to let go off our own convictions, and become more curios and interested in the other person’s ideas and world, in order that we can contribute to an introduction of unexplored possibilities. How we meet that other person (Wifstad, 1994) unfolds in togetherness, and becomes essential for how that other person develops his life. We become an important context for each other that either promotes or inhibits.
Tom Andersen in (Anderson & Gehart, 2007, p. 90) expresses the idea that different opinions concerning a particular issue can create problems, and points to Harold Goolishian who coined the term “the problem-created system”. Inspired by Gregory Bateson (Bateson, 1972) Goolishian meant that a problematic situation easily can attract people to develop an opinion as to how the problem should be understood, tackled and solved. Yet, repetition can easily occur when these people hold the same opinion, and thus become little of use in the development of new and more productive ideas and understandings. Yet, if there exists among these people a difference as to how to perceive, understand, tackle, and solve the problem, they will be potential useful for each other, developing newer emerging helpful meanings and stories. If contrasts become too different, nothing will happen that occurs as useful and meaningful for that other person. This issue of differences must become more visible in our therapeutic practice.
The individual, society and diagnosis
Diagnosis represents certain knowledge and we must dare to ask, what kind of knowledge? How we separate mental health from sickness; normality from anomaly, has consequences for the person, his network, economy, social life and society overall. In recent years themes concerning diagnosis have initiated different debates related to how beneficial they are and their applicability. It was these debates that lead to the delay in publishing DSM-V, which was planned to be published in 2010. Instead it wasn’t published before 2013 (Frances, 2013). Psychiatrist and chair of taskforce DSM-IV, Alan Frances distances himself strongly from most parts of the DSM-V. He is strongly convinced that the DSM-V has led to the disturbing expansion in medicalization too, that it promotes false epidemics like ADHD, Autism, and Bipolar-disorder in children (Frances, 2013).
As professionals we should not disallow the place of diagnosis in psychiatry. There is a difference between diagnosis related to intrapsychic suffering and innate anomalies that are labeled as diagnosis, e.g. FAS – Foetal Alcohol Syndrome. As professionals we must be extremely cautious in applying diagnosis too quick. Diagnosis should be an alternative, not a first choice (Frances, 2013; Gøtzsche, Smith, & Rennie; Hertz; Hertz & Glomnes, 2011). The problem with applying diagnosis is that the professional stands in danger of just focusing on parts of context. This can lead to serious error in treatment and the collaborative and co-creative process, because professionals often don’t put the parts back in their context(s). In doing so, diagnoses are applied on a too thin basis – it lacks reference to context(s). With that professionals are in danger of applying diagnosis in relation to what is observed as behavior but not in relation to an individual’s different context(s) in which he has become and thus is related to.
A diagnosis creates identity (Hertz, 2013)and my clinical experience is that there are many people striving with getting rid of the many different identities, that they involuntarily have become a part of due to unrestrained diagnosing activity. Alan Frances (Frances, 2013) writes that there has occurred an inflation in diagnosing due to its overuse. Diagnosing that too often is exercised at wrong times in a person’s life. E.g. a diagnosis should not be even in the equation when a person’s life is in disarray. Yet many practitioners don’t stick to that rule; after my experience many violate the principle. The main principle is that one doesn’t place a diagnosis concerning a persistent condition when a person finds himself in existential chaos.
Many people are striving with “erroneous identities” due to the violation of this principle. As professional’s we rather should look for opportunities to develop expanding dialogues with that other person: dialogues who can lead to the unveiling of behind lying issues that the person is experiencing in his daily life. Problems that develop symptoms like behavioral issues, concentration deficiency, substance-abuse, criminal behavior, substance-dependency, or to put it in other words: Normal responses to abnormal challenges in childhood and adolescence. Instead of focusing on diagnosis as a first choice I argue that we as professionals rather must develop and emphasize on the development of dynamic creative dialogues with people, and where we can get our eyes on the interference that occurs within the context(s) of social disorder (Hertz, 2013).
It is these contexts of social disorder that have contributed to the development of behavioral issues (ibid). This ecological context focused approach (Arnesen, Ogden, & Sørlie, 2006; Klefbeck & Ogden, 1995a, 1995b, 2003, 2013; Ogden, 2001) offers after my estimation a better alternative in our attempt to understand people, rather than drawing too fast conclusions. Allen Frances (Frances, 2013b) writes in his book “saving Normal” that there has occurred a diagnostic inflation due to the uncritical usage of diagnosis.
It can be useful to ask the question; “what clinical profit do we experience from diagnosis in psychiatry – and what is the alternative?” A fundamental premise in discussing this issue must be that there is no universality in diagnosis, and that they at least must be practical applicable for the individual and professional. Professor in psychology and researcher Peter Kinderman argues for quitting all together with diagnosing psychiatric disorders, and instead starting diagnosing the problem(s) (Kinderman, 2014).
And what, if the social discourses in high degree create and contribute to the suffering of a person? Or even worse, what if these social discourses reflect the discourses prevailing within psychology? We live in an increasingly digital world where the relational aspect is more and more dimmed due to the need of increased effectiveness. In Norway we witness more and more that the RGP functions as a buffer in their encounter with psychiatric disorders, with too many patients on their list and the lack of competence to alternative thinking, and where the prescription book has become the avenue to quick solutions.
Professionals often don’t get their eyes on a person’s potential for change which can emerge in dialogue between himself and that other person since he is too busy with individualizing the problem. I firmly believe that individualizing the problem, its origin, and too its potential for change is ascribed to pathological characteristics. Too much attention and focus on individual-based explanatory models will obstruct and displace the emerging of more preferred stories.
It is when diagnosis and the role of being sick is experienced as attractive, that it is inevitable that we develop a respect for this perspective (Hertz, 2013). People can become too comfortable with their diagnosis or role of being sick because they know that it releases incentives within the public support system. This can be experienced as great and comfortable, but people are in danger of becoming learned helpless (Seligman, 1972, 1978).
A person’s experience of being valuable can be eroded when diagnosis takes its place. We must remember too, that even diagnosis can be helpful and valuable, diagnosis ought to be considered as a temporary picture of ways of being and communicative forms. Diagnosis should thus be considered as a contribution to creative dialogical processes (Hertz, 2013).
From this perspective, the professional should focus more on inviting people in participating in expansive and reflexive processes, that surpass the negative domineering imaginations on assumingly established truth’s. Assumingly truths often emerge when life is on its way to get locked. As professionals we must not underestimate people, doing so is equal to sapping the life out of them.
Reflexive processes is about “learning to learn anew” , something Bateson coined as ‘Deutero learning’ (Bateson, 1972). Our task as professionals is not to explain certain phenomena’s, but rather assist people in describing their own life. For a person to do so, the professional needs to be aware of two things: (1) he needs to put great emphasis on how he connects with people. Often professionals talk about persons being treatment-resistant. Yet, a person’s feelings of displeasure, unease and uncomfortability are relational.
In general, people oppose to being defined by professionals in who they are, what they are and what they are not. Yet they are often more open to the idea that they can describe their life while remaining the main-author. In rewriting parts of their life-stories they might invite the professional inn as co-author. Yet this depends totally on how the professional can connect with that person. (2) Acceptance: as a professional you might have many titles to your name, being specialist in psychology, psychiatry etc. but, if the person you attempt to help doesn’t accept you, nothing will happen: we cannot force change – it can only come voluntarily. This means that in working with people the professional must place emphasis on how he in collaboration with that person can lure-forward the desire for change.
For illustration sake, I once accompanied a person (a client) to a psychologist. The context was that the person was in treatment in an inpatient rehab facility. The duty of the psychologist was to assess the person’s mental health with the help of tests. The person I accompanied was in treatment due to some drug use over a period of one year. She told me that she used soft-drugs because life had treated her cruel and she wasn’t able at the time to fight the effects of certain events that had occurred in her life. Yet, while her life was in disarray and disorder, the rule of not placing a diagnosis was violated causing her to be winding up with several diagnoses. She was determined to get rid of these diagnoses since she couldn’t relate to them, nor recognize them as being valid. When she told the psychologist that she wanted a re-assessment of her mental state, she was refused and told that she did not understand the severity of her disorders. The woman exploded and stood up out of her chair pointing her finger to the psychologist saying, “you will never get another chance to speak to me: you are the most unusable psychologist I have ever met.” From that moment on my client never talked to that psychologist again. I was not only able to connect with her, but too, I gained her trust and her acceptance.
We walked for about a year together on a basis of equality, collaborating and co-constructing new and more expedient stories. Two years after I met this woman in her hometown: she was doing great, succeeded greatly in raising her baby, and was enrolled in a bachelor program at a university nearby.
Tom Andersen once said at a conference in 2005 (PP-services, Kristiansand) that we must quit prescribing of what he called frozen diagnoses and more apply living descriptions. We can’t just dissect parts of a system and study it isolated: the information we as professionals attempt to elicit from people in treatment, are found deep embedded within the contexts(s) an individual has been, or still is related to. A professional who wants to understand human behavior must therefore study living systems. He must study language, relationships, and the patterns that connect living systems together, “The patterns that connect” as Bateson (1972) puts it in his classic ‘Steps to an ecology of Mind.’
Here, the professional faces a challenge. He no longer can think that descriptions and explanations concerning certain phenomena are determined by the phenomena in itself “ding an sich” (a thing as it is, not mediated through perception by the senses or conceptualization, and therefore unknowable) (Lock & Strong, 2010, 2012). Pivotal is that the dialogue between the professional and the other person invites to more creative and co-creative processes. In doing so a professional becomes liberated in keeping up a mirror allegedly portraying “the world as it is” (Lock & Strong, 2010). Instead, the professional is challenged in developing new thoughts and ideas.
There are certain professionals that tend to believe that human beings can be deadlocked behavioral- and thought patterns, and that it is their duty to find methods that can dissolve this deadlock. Yet, a human being as a living learning system is never deadlocked in the sense that he never can change, therefore there is no such thing as being deadlocked. It is much more expedient to embrace the idea that a human being is a perpetual living and learning system, and while he is learning within the context of collaborative dialogue, that which is experienced as being deadlocked, evaporates in language.
At a rehab facility where I used to work as a therapist, I was leading a weekly talk group for men. In one of those sessions my co-workers had rolled up sleeves exposing his veins. One participant told the group that he was triggered in seeing the veins and developed thoughts and desire to relapse and get stoned again. But, while the group members were talking and exchanging thoughts, feelings i.e., this person said that while he and the others were talking the desire to relapse and get stoned evaporated. He said that the experience was surreal yet very real, and that he had learned something. When he was asked what he had learned he said; “Its need to know that troublesome and addictive thoughts can evaporate in language.”
The week after when he came to my office for his weekly consultation, he talked like never. The problem evolves around the person; it does not necessarily dwell within him. This is a more circular and holistic approach to challenges that people face in ordinary life. It is therefore that we must put emphasize on reflecting processes and contextual relational processes of change.
We are living in a very complex world with people facing daily complex challenges in life. As professionals we must never be trapped by the temptation to approach these challenges by linear thought and understanding. We must remember that each change within a human being as a living system is related to the conscious experience of meaning with existence.
The professional’s responsibility is not solemnly to get his eyes on what exists in the here and now, but too contributing to developmental and reflexive processes that are found in relational practice, and that possesses the potential to lure forward new understandings. The purpose of these new understandings is to prevent the professional in getting stuck with one version of “truth”, but rather that he can fetch his eyes on a plurality of alternative realities. It boils pretty much down to a person’s ability to move himself from universe to multiverse: from linearity to circularity; from the problem within to the problem revolving around… It’s when we invalidate the existence of parallel alternative processes that people are bound to collide with one another:
“Worlds collide when prejudice and biases are in the driver’s seat. It is not what actually happens, but what one insists on happens, that causes worlds to collide”
- Luuk L. Westerhof
When a professional fall in love with his biases, opinions, prejudice, hypothesis and conclusion’s, he is in danger of losing the person he is set to help, in the process (Cecchin, Lane, Ray, & Wendel A.. 1994). When a professional fall in love with e.g. hypothesis, he tends to become more occupied by getting answers that confirm the hypothesis rather than hearing what an individual really is saying.
The professional thus loses easily his contact with the co-creative process since he is too busy getting his “prophecy” fulfilled. Expedient expansion in processes between a professional and another person start to occur, when he instead of talking about a person as someone with innate deficiencies, focuses on a plurality of possibilities. The professional can avoid deadlock- and breakdown in communication, in focusing on how to promote thoughts of diversity and plural versions of “reality and truth”. At all times we must be careful not to become like that man who thought he knew it all, and it was just that he knew. As professionals we must be interested in the epistemological question why do I think the way I think? This epistemological approach is difficult to stick to for many professionals, since it challenges the roots of his basic thinking which directly unveils what he is motivated and directed by.
From my childhood in Holland I remember that in the 70thies, at a certain lake there was a high degree of mortality amongst the fish. Experts thought that the mortality was a causal effect of botulism. They treated the water in correspondence with this theory, but the mortality rate didn’t decline. The mortality in the fish population stalled when the experts left their theory and began to develop questions like:
what kind of poisons can the water possibly hold? Where do these poisons come from? Is there any connection with the rain that falls, causing a shortage of oxygen in the water? Are there any agricultural toxins blending with the water due to erosion?
It is when they left their universe of alleged truths and moved towards a multivers of ideas, possibilities, and alternatives that they found their way to effective measures of change.
In working with people fighting substance abuse and addictions, the main question must not be what is wrong with you but rather what wrong has happened to you? We must focus on questions like, how does a person create meaning in his life that can contribute to effective change? A person’s development is embedded within a person’s relationship between himself and the contexts he relates to, is affected by, and thus is a part of.
Therefore, we must never consider a person as being “addicted” in the sense that the addiction represents the person as being a fixed person. He is an addict, or he is an abuser of substances. The addiction is not necessarily found embedded within the individual, but more in the contexts an individual is a part of, is related to, or interacts with. An individual as a living and learning organism corresponds and responds always in correspondence with the environment(s) he interacts and socializes with.
This actualizes and places emphasis on the importance that a professional, always, must interact collaboratively with that other person in respect to the context(s) that individual is related to. These contexts are related and connected to one another, continuously. That’s why we need to leave the notion that people are fixed psychological and mental beings, but rather adhere the concept of a person as being an ever developing individual; nothing is everything can become! Thus, a person is like a traveler always in motion discovering new landmarks! A professional will never get his eyes on possibilities and the potential for change unless he is able to combine interaction with time. The Russian theorist Valentin Voloshinov once said:
“Meaning does not reside in the word or in the soul of the speaker or in the soul of the listener. Meaning is the effect of interaction between speaker and listener…”
This approach, without a doubt, challenges the increasingly tendency to individualization, something that we sadly as professionals have become a part of, due to the way we organize our constructions that are supported by the culture, that we are part of (Hertz, 2013).
Creativity between the professional and the individual can contribute to the development of exiting and creative processes wherein new understandings and possibilities can emerge.
Creative processes can develop when the professional increasingly and sufficiently becomes curios on the contexts, and develops a desire for co-creating movement in what apparently seems to be locked (Hertz, 2013).
Change is not found in the movement itself but in the space between the movements. Problems between a professional and the person that needs his assistance occur when the professional doesn’t develop the skill to “tune-inn” – zooming inn and out. In absence of this skill the professional will not be able to understand the person, his challenges in context(s) (Bronfenbrenner & ProQuest (Firm). 1996).
A birdwatcher cannot study birds in the distance unless he is skilled enough to change lenses from tele lens to macro. Likewise, for a professional, he will not get his eyes on the undreamed possibilities unless he is able to shift between different perspectives and approaches: in this respect, perpetual insisting curiosity is of the essence!
The late Tom Andersen (2013) a Norwegian psychiatrist pointed once out, that when the professional has his focus on just one aspect, then everything else is pushed into the background. When a professional becomes too occupied with defending his prejudice, hypothesis, biases, or alleged truth’s he then will contribute to the invisibility of the other person’s expressions. Too fast conclusions and prescribed diagnosis will easily assume the status of eternal and alleged truth’s in that, they never become the object of thorough scrutiny and reflection but rather are implemented as undisputable realities.
Yet, processes of change demand that the professional assumes a more epistemological approach. He must question his own thoughts and justifications for why he is thinking the way he thinks. It’s when assumptions turn into alleged public valid truths concerning a phenomenon that the professional’s relationship with the individual is in danger of getting deadlocked. As a professional it would be more expedient and profitable when he emphasizes more on the meaning of understanding an individual’s challenges related and connected to context(s), and that everything an individual does creates context.
Because of that, the professional’s relationship with the individual should contribute to reflexive processes that make room for different descriptions of reality. The complexity of an individual’s issues is embedded within “the condition of the moment.”
Professionals must develop curiosity on questions like, how does a person manage? Where are the possibilities and where are the limitations for an individual as a learning and living system? There is something about finding out what the limits are for a professional and an individual’s interface for learning. It’s much about stirring-up