A colleague recently described to me in supervision her client’s vehement and hostile rejection of a diagnosis of BPD given to her in a medical mental health facility. My social work (SW) colleague works in private practice and has a lot of flexibility to work with the client on her interpretation of the malaise that brought her to therapy. Most SWers I think would concur that psychiatric classifications can be of great assistance, especially where the use of medications is critical, but can also be extremely damaging. The SW profession has generally been shy of, if not sometimes hostile towards, what could be labelled loosely as the mental health medical model. I recall reading some of the anti-psychiatry books that sat around the edges of core social work subjects. It was no surprise to me that, when narrative therapy arose in my home state of South Australia in the 1980s, it was strongly embraced by SWers. When I began studying social work in the early 90’s I was already earning a living as a relationship counsellor, having received strong orientation to counselling through a liberal theology and ministry course (LTh). I went on to acquire accreditation with the (then) Marriage Guidance Council of Tasmania. By the time I commenced social work training in Tasmania, I had already studied a number of theories in the humanist and psychoanalytical traditions, my weakest knowledge field being CBT. By this time I was able to sense political contexts of theory and practice. Although I could have attained some credits towards a BSW I decided to do a full 4 years undergrad degree so that I could do other humanities subjects in the first two years. It seemed to me in that first two years 1990-91 that the narrative therapy model became, for a while, the favored counselling theory in the undergrad degree, until the course gravitated back to solution-focused (evidence-based) approaches. By the time I started the mandated interpersonal skills component in my third year, the solution-focused approach was in its rightful position. However, we all knew that narrative theory had a natural and fluid approach that followed the client’s interpretations, through “landscapes of behavior and meaning”. (I still have some of Michael White’s original notes from my time in South Australia!). The narrative modality remains strong in Australia and elsewhere. In the battles of the models we might say that personal narratives and “self-authorship of one’s story” competed with the diagnosticians. (CBT was just muscle-ing its way up from the 80’s and becoming authoritative as a competing paradigm.)
The PTMF has so much crossover with narrative therapy. PTMF will be very enticing to those whose preference is to avoid the pitfalls of medicalisation of psychic disturbances. I can see that PTMF has the capacity to shake up psychology like the humanist-narrative streams did for SW in the 1980’s. The model is INTENDED to be a paradigm shift. We SWs recognise ideas like – “ the construction of non-diagnostic stories; re-integrating reactions to mental suffering into universal human experience”. Tellingly – according to material I have gleaned especially from clinical psych professor Paul Salkovskis – the anchored focus will be the rejection of both the diagnostic approach and the scientific paradigm in favor of: 1. personal narratives; 2. primary focus on power issues. (I would say that SWers have been doing this sort of narrative and power thing for aeons.) The general claim in PTMF is that trauma and adversity are nearly always the result of power imbalance, abuse and its consequences.
The seven provisional patterns (not diagnoses, but the difference to me is unclear) are built around the idea of survival from trauma; trauma generated by rejection, entrapment, invalidation, attachment disruption, separation, identity confusion, defeat, loss, social exclusion, shame, single threats, and (the flavor of the year) coercive power. All these seem to be quite familiar to SWers in the field. What this framework will tend to do is bring politics and excessive critical theory into the therapeutic space. The framework certainly discourages hardline diagnostic practice, but the impetus might well tend to roll into a recruitment exercise – recruiting the client into a political project towards the utopian goal of eliminating all forms of discrimination and power abuse. I, for one, am very in favor of alerting clients to power dynamics and abuse, but I am really concerned about WHO gets to define which “power” is on the nose and which isn’t; who the perpetrator is and who the victim is. Differences between legitimate/authorised power and abusive power are not always so clear cut. Years of family and couples counselling has shown me just how fluid power arrangements can be, not to mention how off-target a client’s interpretation of another person’s motives can be. Families – for instance – are full to the brim with power realignments when a crisis emerges and familial preferences change. Personally, I am still in favor of therapeutic skepticism – taking client stories as probabilities and possibilities of things that may be the “truth”. I am reminded of the basics of memory. Psychology research professor Jesse Rissman writes about episodic memory, that memory retrieval involves our best attempt to reconstruct a plausible account of what happened at a specific time and place – given the fragments we’re able to recall.
In any case, I like the direction of PTMF, but feel annoyed that a framework like this, which by the way is still not yet near validation as a model, did not emerge in SW academic research. (Just being petty, I know.) Or maybe it did, in some fashion or other? I am not an academic and have tended to earn my living from doing the work and sleeping at night -repeat-repeat-etc.
Is psychology being – how social workers like to put it – “colonised”? Colonised by the SJ warriors?
By David Hunnerup
David is an accredited mental health social worker in Tasmania, Australia. He has been a professional counsellor in one form or another from 1980. The last 24 years of counselling practice has been in a social work framework. He is now semi-retired but still quite active as a counselling social worker and supervisor/consultant. He has used the last 2 years to read and reflect on many things he never had time to ponder. Many pet theories in social work education are now in his spotlight.