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How to be together in Therapy in a meaningful way that makes sense and a possible difference?

A Collaborative approach in working with people striving with substance abuse and addiction

Luuk L. Westerhof, MSc


This article attempts to share some light on how we, as professionals can be together with people striving with substance abuse in a way that it makes sense and a possible difference. I will pause for a moment by the question as to how can we be together with people striving with substance abuse in a manner that our practice has relevance for them in their everyday lives? We are living in a fastchanging 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. I think it is much more fruitful when we take a humbler position in working with people, realizing that 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 everything 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 options influence treatments I like to continue a little on 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 socialscience 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 in 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 researches 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 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 in 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. 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. (Anderson & Jensen, 2007). Within the post-modern paradigm (Andersen, 1987; Anderson & Goolishian, 1992; Anderson, 1997) there are two major orientations: the postmodern 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 (1988, 1992) 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 (Gergen, 1991). 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 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 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 measureable 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 postmodern perspective is adhering to the notion of a socially constructed self (Gergen, 1991).

Conversation, Collaboration, Listening and Dialogue

In working with people battling with substance abuse, I often wonder how my 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; beingtogether-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 (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 & D. Gehart, 2007; Anderson & Jensen, 2007; Anderson, Jensen, Jahr, & Reichelt, 2008; Maturana, Lettvin, McCulloch, & Pitts, 1960; 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, loosing 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, 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 him self 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 him self 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 multipl