Its a pretty interesting reflection on the conservatism of clinical psychology that we have never had a study conducted in our program using discourse analysis...never.....pretty astounding when you think of all the potential it holds for deconstruction of our practices and all the power plays requiring such......it demonstrates how easy it is to set up a research silo, a product partly of our poor engagement with other disciplines.......
Here is a really great article on it, particularly Foulcault influenced discourse analysis, by Linda Graham from Queensland University of Technology...she quotes Stephen Ball (1995: 267) t “the point about theory is not
that it is simply critical” ..its purpose is “to engage in struggle, to reveal and undermine what is most invisible and insidious in prevailing practices.”
Her work relates to ADHD and includes critque of the DSM...here.......pretty impressed by her work!!!
Graham, Linda (2006) The Politics of ADHD. In Australian Association for Research in Education (AARE) Annual Conference, 26th-30th November, Adelaide.
This essay offers a critical review of the problem we call “ADHD‿. In the first part of the discussion, the author presents an analysis of the literature surrounding Attention Deficit Hyperactivity Disorder. Adopting a lens informed by the work of Foucault, she teases out the medical and psychological models to show the interdependency between these otherwise competing knowledge-domains. She argues that as it currently stands the construct serves political ends and questions whether a diagnosis of ADHD is helpful - and if so, for whom? In the second part, the author considers what role schooling practices might play in the pathologisation of children and interrogates the ADHD phenomenon as a symptom of the pathologies of schooling. Graham concludes by suggesting how we might arrest the rising rate of diagnosis by thinking
Today we held a great collaborative coding session where a project was presented with focus groups held at three time points..we split the group in three, allocated transcripts from each time point and then came together after discussion in each group to compare notes as across the whole project...
This got me thinking about the best procedure to run such team reflections and how it can draw directly from Post-Milan Systemic Family Therapy reflecting teams
A 5 step reflecting process for collaborative coding....
1. Step 1...each group reads transcripts 2. Each team discusses meaning 3. Each team shares their analysis with each other while the researcher remains silent -This discussion should start with affirmations directed to the researcher before constructive comments -This discussion should always be tentative "Iwas wondering....." 4. The researcher is then asked what interested her the most about the process 5. The group is asked how this relates to their own projects
The allocation of discussion groups ca be made in many ways: analyse using different theories/look at transcripts from those with specific attributes/compare data from different data collection methods...ie: supports triangulation...
Im learning the hard way at the moment about how to write results after a thrashing by a journal for a study titled Exploring How Trainees Manage Their Own Distress In-Session: An Interpersonal Process Recall Study
The review was very constructive, pushing me to write better, particularly suggesting that I integrate theory from the literature in my results rather than saving it all for the discussion..I confess to finding this quite difficult but after about 8 hours of mental struggle Ive found my results have really come to life in a much better way that before.before they were descriptive...now they kick arse? well..they are better but it's still a work in progress...here they are, completely unproofed and informatted..they are obviously out of context without the intro and method but I thought some of you writing at the moment might find it useful..
Results
The
Discrepancy Between Planned Content and In-Session Process
Watzlawick, Bavelas and Jackson (1967) differentiate
between content and process in therapy. The former is seen as the digital or
rational where messages are unequivocal and can be analysed easily. The latter
is analogue or emotional and messages as more subtle and hard to interpret. In
this study we saw the overwhelming majority of trainees become distressed when
faced with unexpected processes in the therapy room.
They described feeling as “lost”, “confused”, “unsure”, “floundering”, having a “mental blank” or unsettled.
Trainees recalled preparing well for
their sessions, including ‘reading books
and notes’, ‘revisiting the formulation’ and ‘making a number of session plans’ but felt that this preparation
did not necessarily equip them for what was occurring that moment in the room.
In-Session Interpersonal Difficulties
Many of the unexpected processes
involved interpersonal difficulties between trainee and client, including
clients who are seen as resistant, disengageing, attempting to assert control
or seeking direct advice.
Here a clients is seen as being
resistant to cognitive restructuring.
What
was I meant to say to that? In all the cognitive therapy books the person says,
“Wow! Now that you put it like that, I completely agree.”
Here a trainee becomes confused when a
client disengaged, despite a previously strong therapeutic relationship.
When
I said something that wasn’t an answer to her mind, you could tell she immediately disengaged. She stopped looking
at me and started playing with tissues. Whereas every other time she was
completely looking at me, very, very engaged.
One trainee described feeling “frozen” and “backing down” when a client was seen as overtly counteracting
explicit guidelines for homework tasks. In this case a couple were asked to
write on the same sheet, to facilitate a comparison of perceptions concerning
events. The trainee recalls the husband disagreeing.
“Can we have separate ones of these?” I went
“Oh! Okay! Yep”, agreeing to it because I was just so thrown by something that
I thought we’d really explicitly talked about.
Another trainee described feelings of
powerlessness in the face of a client who frequently requested direct advice.
It’s
an expectation of me to provide advice, it didn’t sit comfortably. I felt like
I was being trapped in a corner. She was putting me on the spot – trying to
nail me down kind of thing. I didn’t feel very comfortable [slight nervous
laugh]. I notice that I wave my hands around a lot more when I’m feeling scared.
Each of these examples suggest that
trainees had an expectation that client’s would follow therapy as described in
text books or in their own pre-session planning, as if what Bennet-Levy &
Thwaites (2007) calls declarative knowledge would be translated directly to
procedural (skills-in-action) without reflection on the interpersonal dynamics
at play in the room.
Complex or incongruous presentation
While trainees found interpersonal
interactions difficult they also had difficulty making sense of the complexity
of the client’s story.
What
I had sitting on that chair were three different session plans. What I did not
expect was for her to have all three as a presenting issue. “Ahh! Which one?!”
I got frazzled, there was a sense of urgency.
These stories were seen to “lack of
coherence and stability,”and trainess were unsure of how they related to the
presenting problem or how to integrate these experiences into their
formulations or treatment
Here a trainee is poised to intervene
with a client who has a history of social anxiety, only to discover that he is
telling the story of breaking up with his girlfriend.
I
was lost. I thought he was going to go and have coffee with this girl and
explore his feelings, so I thought we were testing predictions like, “It’ll be
awkward” and “It won’t be fun.” It became apparent that actually he was going
there to tell her he wasn’t interested. I was like like, “Riiiigggght. Now I’m
going to leave.”
Here a trainee finds it difficult to
make sense of seemingly incongruous reactions to a death in the clients life.
I’m
thinking, “What’s going on with you? This guy had died and you’re . . .
reacting with humour.’”He does impressions. He does impressions when asked
emotional questions.
The emotional reactions described by
students regarding both interpersonal processes and complex client
presentations reflect discomfort with what family therapists Anderson, H. &
Goolishian, H. (1992) call a ‘not-knowing’ position, an essential prerequisite
to curiosity (Palazzoli et al. 1980) that leads one to ask open-ended reflexive
questions of the client, rather than concern oneself with how to best
intervene. It would seem in both of these types of situations trainees are
momentarily “frozen’ or ‘baffled. Many also described feelings
of inadequacy at not knowing what to do next. ’
I
didn’t like that feeling. It felt like I was ineffective, like I’d lost
purpose, um, and I don’t see how that’s useful to the client.
One trainee described how her supervisor
helped her see that her negative judgments were related to her idea that
therapy had to be formal and technical, rather than natural and conversational.
I
was thinking “That part wasn’t special – it’s conversation” but my supervisor
today was going, “That – that’s therapy. That bit where you casually dismiss
that you re-framed that helost his job?
That’s therapy, What about the bits where I couldn’t fill in the sheets and do
the ABC and he’s like, “Yeaaahhh.”
In this example the trainee seem to have
misconstrued the collaborative nature of therapy, where meaning is contracted
through dialogue. (Overholser, 2011)
Activation
of Rudimentary Reflections
Bennett and Thwaites (xxxx) provide some
conceptual confirmation for the findings in this study, asserting that the
reflective system is activated when there is a mismatch between expectations
and reality. In their approach trainees are taught to focuss attention on the
problem at hand, develop a mental representation of it and engage in an active
cognitive proves of problem solving. However this occurs in supervision, as a form
retrospective of reflection on-action rather than in-session reflection
in-action (Schon)
While they were initially ‘taken aback’ Trainees describe how, in “what seems like a fleeting moment” or a ‘rush’
they are able to acknowledge the emotion they are feeling then struggle to engage
in a process of reflection (in my head I
was like “What the hell?”).
Three different strategies were then
described, each of which has been described here as rudimentary.
Referencing the expert
A significant number spoke about
mentally referencing a supervisor or perceived superior to help them decide how
to proceed. For one the supervisor operated as a “voice in your head going, you should do that”. For another it
served as a reminder of “what is the
right thing to do in terms of an intervention point-of-view”?
In some cases this strategy was seen as
helpful, particularly when their supervisor was trusted or open about their own
mistakes. For others comparisons with an “expert”
only exacerbated feelings of inadequacy.
He’d
have something meaningful to say, with his level of insight. Whereas I don’t
know what to do with her.
Attempts at transference
Despite the range of distressing
emotions experienced by trainees the majority described an ability to
acknowledge these emotions while they were happening in sessions. In some cases
trainees discussed how their own emotional response communicated to them the
emotional experience of their client.
“I was feeling lost, and I guess that’s
how she was feeling as well.”
“He’s probably feeling really upset and
really disappointed, too”
These reflections, while important, do
not yet mirror the complexities of transference dynamics, in terms of
recognising that interpersonal difficulties encountered with clients are
actually a potential tool for exploring complex unconscious processes (Gabbard,
2001).
Check
the therapeutic relationship
Trainees also engaged in momentary
reviews of the therapeutic relationship, either checking whether the
relationship was strong enough to handle the difficult moment, or reviewing it
so as to make a choice between trying to re-establish rapport or continue with
the skills-based intervention. Relationships reviewed as strong made it “easier to say a lot of things” and
caused some easing of distress because “I
don’t really mind making mistakes in front of her.”
Engage in Self-talk
Self-talk was also a common strategy
used to try and get the session back on track after distressing events.
Trainees described talking themselves through fleeting reviews of their
formulation and treatment plans.
Just
trying to quickly re-formulate in my head how I could quickly change th direction of therapy to be still effective.
I’m
sort of not wanting to shut that possibility down but at the same time I do
sort of have a therapy plan which I went back to. I’m trying to make sure that
we take each session somewhere and that I use the time well.
This differs significantly from the kind
of complex inner conversations described by Rober et al. (2008) in his analysis
of work by more experienced therapists. Here the therapist can make mental room
for a conversation between multiple positions, including the interaction in the
room, client’s story and planning for action. This conversation is held
internally but at a distance, a process of constructive hypothesising about how
to respond in the moment (Rober, 2002).
Retreat
to Safety of Non-Directive Counselling
For many trainees, especially those who
lacked confidence in treatment techniques the next step after reflection was to
retreat to the safety of non-directive counselling.
I’m
supposed to be using some sort of technique and I don’t know what I’m doing.
I don’t have any strategy for her, CBT
or DBT or schema stuff– I have nothing to structure her thinking.
Skills used included listening,
affirming, summarising, reflecting or asking questions. For the majority of
trainees these basic counselling skills came more “naturally”
than skills that were seen as more interventive.
I
feel like being warm and being empathic towards a client are not things I have
to fake, and not things I have to remind myself to do. I suppose things that
I’m still less comfortable with, and still getting used to, are you know,
particular questioning techniques, or, you know, more sophisticated cognitive challenging
and things like that.
Using basic counselling skills in the
moment also served as a “coping
mechanism”, “buying time,” supporting a “facade of control” and the maintenance of a “professional stance.” For many therapists “surviving” the distressing moment was the goal.
Risk
Taking
Other trainees, however, decided to push
themselves ‘outside of their comfort
zones’and focus on intervention. Some were motivated to “take these risks” by “professional growth.’ Intervention did
not necessarily flow from a reconceptualization of the case or the formulation
based on the distressing experience but was instead described as an attempt to
‘push ahead’, be more ‘directed’
See! It
works! You’ve just got to talk. Now you
can get back to what you’re doing.” I’m pleased I did something. That it
actually went okay – that when I interrupted they both seemed to settle fairly
quickly – was a good reminder to me that when I do this it doesn’t actually
damage the relationship too much.
Arguably, despite the limitations, this
type of risk taking is critical to learning (Spellman & Harper, 1996).
Trainees who took risks, however, were careful to review the therapeutic
relationship first to see if it was secure. . Those trainees who felt it was less
seemed more tentative in their decisions and less likely to respond in a way
that might “challenge” the client.