Human speech is like a cracked kettle in which we tap crude rhythms for bears to dance to, while (really) we long to make music that will melt the stars.
Yearning to make sense of stuff, to relieve suffering, to feel we’ve understood what matters to others, to succeed in conveying our understanding to them of experiences that sometimes go beyond words.
That wider view of a therapeutic encounter was summed up many years ago by Truax and Karkoff, who defined its three essential elements as accurate empathy, genuineness and warmth. These still constitute vital non-specific aspects of any effective therapy.
Compassion but not pity
A person’s life consists of a collection of events, the last of which could also change the meaning of the whole, not because it counts more than the previous ones, because once they are included in a life, events are arranged in an order that is not chronological, but rather, corresponds to an inner architecture.
Being moved is not enough: a salient understanding of the difficulties which prompted the referral is required – compassion but not pity. Graham Greene envisaged an attitude of pity as “disastrous”, responsible for the moral crisis of the main character in his novel The Heart of the Matter.
Writing at the same time, Martin Buber addressed the issue from a psychoanalytic position. Writing about “empathic accuracy”, he emphasised the importance of it taking place in a non-hierarchical encounter (the advantage of a “me and you” relationship, rather than the formal ‘Moi [= authority] et Vouz’ [the subject of it] or ‘Ich and Zie’).
In other words, to relate to one another at a human level during therapy, remaining authentic, even “boldly swinging into the consciousness of another”, where therapist and patient are unafraid to take the other off guard, thus allowing a far greater possibility of discovery.
The position Buber was arguing for involves the therapist working boldly but selflessly – at the service of the patient, free of pity or exhibitionism. In doing so, they have reconciled a paradox that the “monstrous pride” of Graham Greene’s character had not: expertly informed but in their expression of it working in a ‘non-expert way’.
Complexity is one of the main challenges trainees face as they enter family-based work. This is not just due to the number of people in the consultation room but also because expert systemic work must be broadly based. This ranges from knowledge of the individual within a social ecology, influenced by culture, adversity and organisational functioning, to familiarity with individual development and how unfavourable early experiences impact upon the developing brain as well as its interplay with family experience, including an awareness of heritability.
So getting to the heart of the more difficult cases they encounter can be overwhelming. Falling back on compassion and relating at a human level is important but insufficient. There often is a considerable intellectual task; taking sufficient time out for reflection is essential.
Over the history of family therapy training, methods such as ‘live’ supervision to develop reflective practice have been central. In every case this extends the time that needs to be allotted to an initial family session, vital irrespective of whether a therapist is working solo, by co-therapy, or supported by a team. The collaborative approach advocated on this website also requires additional time, but this tends to be amply paid off by the completion of an assessment within the time finally allotted for it.
Facing a therapist working under pressure, perhaps due to a combination of manifest self-confidence and insufficient reflection, puts a family in a difficult position. For example, it would take considerable confidence on the part of a family member to interrupt a therapist to ensure they did not conclude a family consultation before the fact of a mother’s past stroke, and present over-burdened responsibility for her drug-using brother’s early Huntington’s chorea, had definitely “swung” into the therapist’s consciousness.
Psychoanalysts propose that sensing what during a consultation is of the ‘greatest emotional urgency’ may be an innate quality of a therapist. Therapists’ findings, however, should not just be significant. The findings should be both reliable (so another experienced therapist would find similarly) and valid (where another experienced therapist would be likely to think about it similarly). So the ‘heart of the matter’ lies in what is to be finally understood in the family, for which there is no substitute for well-supervised extensive experience of families. Without this any innate quality of a trainee therapist may remain largely dormant.
How to think about the confidence in understanding what lies at the heart of a case
Getting to the heart of the matter involves an understanding of three concepts that are far more often talked about in quantitative research than in therapy: validity, reliability, and significance. These will be reviewed in the reverse order, as more appropriate for post-modernist work.
Significance: in quantitative research this involves an estimate of proportion, but in systemic work it concerns the amplitude of a finding to account for the difficulties of an individual or family, rather than the mathematical probability of it being a chance finding in a study population.
In short, that something fundamental is now understood sums up a considerable proportion of the clinical presentation, a key finding albeit perhaps only one of several present in the final formulation. In Graham Greene’s view, the single issue of the main character’s “monstrous pride” lay at the heart of his apocryphal novel. In Death of a Salesman, there was an intersection of at least four or five main issues.
We explore this further in the text on Formulation.
Validity: does a finding or observation make sense? Is the language used to describe it salient? Are the concepts underlying it clear, logical and beyond reasonable dispute, with any complexities unpacked? We should be able to conclude that there is no other very different way of thinking about them, or a contradictory explanation for them and that something fundamental is being understood (although not necessarily applying beyond a particular family, group, or population).
Reliability: is the finding or observation reliably found? Once the concepts underlying it are agreed and the language used to describe it, would other people find the same thing, would another conversation shortly after or before have led to similar findings, where difficulties had been understood and talked in similar ways?
Whatever the internal validity of psychoanalytic constructs, the untested repeat reliability of findings from a psychoanalytical experience has been a frequently raised objection by its critics. Consider again, from a different perspective than in the Safe Uncertainty chapter, the following summary of one author’s work to portray their systemic approach:
“My starting point for working therapeutically with men is the conviction that the traditional patriarchal masculinity is a product of the socially sanctioned, systematic, emotional and often physical abuse of male children … [I] endeavour to find the means to interrupt this vicious cycle, and to engage men in a different kind of narrative about themselves and their masculinity.”
Some confirmatory bias there perhaps?! We might question whether we can predict what to expect before we meet someone. An example of how reliability lies with how the author works, rather with the range of experiences encountered.
Elsewhere we explore unsafe certainty. Under Formulation, we use a case-example of a boy with ADHD to demonstrate the importance of keeping an open mind. It provides a compelling example of addressing what is brought into the session rather than preconceived ideas: the safe certainty of the boy’s parents (which had prompted his referral and been reinforced by previous medical diagnoses) was overtaken by family members’ contested accounts during the session. Understanding these became the main focus of the consultation: the ‘heart of the matter’ included much more than ADHD.