pathologizing, labels, dichotomies, existentialism and acceptance

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Quick summary: I am offering a discussion concerning the drive to label and how labeling impacts suffering. There is a heated debate in the field of psychotherapy as to whether psychiatric (DSM) labels help or hurt the client’s recovery. I am commenting on what encourages our emotional reactions and behavior related to the topic.

What questions might arise from such dichotomies concerning to label or not to label?  Should psychotherapy be governed by modernist or post-modernist principles? There is the dialectic “and” that might surface here… this helps me to identify a label that could describe my own ego related to this subject (as my ego has a rather rigid view on the subject of labels). I hold my own dichotomous beliefs in awareness and attempt to grow from them… this subject finds me humbled… I strive to be open-minded as opposed to being dogmatic… and now I arrive at another false dichotomy and fool myself into believing that open-mindedness is simply the opposite of being dogmatic… do I strive for open-mindedness to a degree that I find myself dogmatically in favor of open-mindedness… dogmatically against dogma? Can I strive and still be truly open?

Existentialism would help this debate to arrive at a point of universality… what fear or anxiety drives us to such emotionally reactive views related to labels and the resulting intervention strategy? If we cannot find consistency must we live in chaos? Without stable labels can life avoid meaninglessness? Without having an indisputable knowledge and protocol, can we in this field still consider ourselves adequate or competent? The dialectic answer is a coexisting yes/no… And for the voice of yes let me propose an irony… isn’t it our ability to offer empathy from a place of acceptance which nurtures the therapeutic relationship, which is the most important variable in relation to outcomes? To be truly accepting do we need to accept that we don’t know… or to know that our labels are relative, transient, and infinitely tied to our own subjectivity? How do labels help us to know that we don’t know? Who are the labels for… the client or perhaps our own existential anxiety? Both?

When a human’s desire to label and quantify the environment leads them to act against their own best interest or the best interest of others, do they then have a personality disorder related to a lack of control surrounding judgments and projections? I say this in complete seriousness… if the subject is suffering, do we label hypo-control more than we label hyper-control? If control was put on a bell curve would we see equal amounts of suffering on both ends? Are labels a symptom of being overly concerned with controlling existence? Is life controllable or predictable? If life is neither controllable nor predictable than is our drive to label (ironically) pathological?

 Is labeling a symptom of our existential anxiety? Is labeling a behavior of avoidance? If we have failed for centuries to find a universal truth and yet we persist in our search using primarily the same methods, what label could be used to describe this search for absolute?

I believe that therapists have the good intentioned goal of reducing suffering and I struggle with the realization that labeling might be our way of avoiding or resisting the suffering which arises from our own relationship with meaninglessness… which arises when we attempt to quantify the unexplainable…. when we attempt to know and do not allow ourselves to simply be. Perhaps there is both hope and nurturance within the presence of acceptance… perhaps the felt sensation of healing arrives in this space.

William Hambleton Bishop is a practicing therapist in Steamboat Springs Colorado.

Narrative therapy summary

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Narrative therapy summary

Quick summary: My intention is to tell you what techniques can be used in narrative therapy, and why you would use them.

Narrative therapy was developed by Michael White and David Epston.

Narrative therapy is based on post modernism which essentially says that there is no set objectivity… we create reality based on agreed upon beliefs that we transmit through language.

  • Language enables us to have a degree of conformity in what we perceive… we agree to structure chaos to look like the reality that we live within.
  • If everyone claims that the world is flat then that is the agreed upon reality until a new idea is communicated and accepted.

Narrative therapy is not telling people, “If you perceived your life different you would not suffer… your suffering is do to you collaborating with or choosing to believe in a negative storyline!”

Narrative therapy is telling people, “Suffering and Bliss both enter into our lived experience… I would like to help you to live a life in which multiple story-lines can be used to narrate your life. I would like to help you to see that opposites can exist at the same time… you can hold love and hate for a person… a vacation can bring both fantastic and awful feelings… let us promote the positive story-lines so that you can choose to live within a positive constructed reality while seeking appropriate nurturance for the suffering which sometimes comes to visit.”

Sample Scenarios in family therapy: following the explanations of techniques, try and visualize how you might handle the following situations differently.

* Two parents walk into your therapy office with their 15 year old and tell you that their son is a pot head and a mess-up at school.

* a couple walks into your office and states that the problem is that one of them is stubborn and the other one in controlling.

* a man and wife come asking for your services saying that their marriage is falling apart as the male is an alcoholic.

*a family comes into your office and informs you that the children are all ADHD at home but not at school.

* A woman comes into your office and says that she will file for a divorce if her husband doesn’t start making her feel important.

Techniques – Narrative therapy helps clients to:

Externalize the problem – the client will see that the problem can be separated from their identity or sense of self (ego) and therefore can be removed or changed.

  • The belief is that when your label yourself as literally being the problem it becomes extraordinarily difficult to encourage change.
  • If you believe that you live with a problem which is separate from your sense of self, it is significantly easier to initiate the change process.
  • Example: if you say that you are a stubborn person then you have to change who you are in order to not be stubborn. If you say that you are a person who engages in stubborn behavior then you can simply change the behavior without needing to change your fundamental sense of self.
  • Michael White spoke out against diagnostic labels as he saw them as counter productive. He suggested that labels encourage people to over identify with their diagnosis thereby hindering the change process.
  • It can be very empowering for a client to see that they are separate from, and have a degree of control over, the “problem”.

 

Externalization technique – encourage clients to add a preposition to the characteristic or behavior that they would like to change.

  • Example: instead of “I am depressed,” the person would be encouraged to say, “I am currently living with depression. The therapist will then ask a question such as, “when did you notice that depression first entered into your life?”
  • The therapist will then continue to speak about the externalized concern as a separate entity with statements such as, “what have you already done to encourage depression to leave?” or “tell me about a time when depression was not allowed to influence you?”
  • The therapist will use externalization as a means of fostering a collaborative effort. Once the ‘problem’ is separated from the individual the whole family can collaborate in the solution.
  • in my opinion, Externalization is one of the most effective means of eliminating defensiveness and resistance in MFT.

 

Deconstruct the problem – It is difficult to solve problems when those problems are over generalized… this method is used to make the issue specific and manageable.

  • Example: If a person were to say, “My wife is messy and I’m pissed,” there is no clear solution nor is it clear what emotion needs empathy. The therapist would help the client to be more specific, “when my wife doesn’t put her dishes away I feel unimportant and as it is really important to me to have the kitchen clean… I have a difficult time with my stress and her putting the dishes away would really help me to feel like she understands the stress I am carrying.” the therapist could then say something like, “ so you are looking for your wife to empathize with the stress you are carrying so that stress might give you a break?”

 

Deconstruction technique – help us to understand what the problem means to you.

  • “Tell me what you see… what is going on when the problem is present. Tell us what we will see when the problem has gone away. Tell us what emotions you tend to experience when you think about these examples of the problem. If your family members where able to understand how this all affects you, what would they understand?”

Unique outcomes – Changing the dominant negative storyline. The therapist will help clients to focus on life stories which are contrary to the problem-saturated narrative.

  • This is where the whole postmodernism bit becomes relevant. Narrative therapy would suggest that you create a negative reality by focusing your attention and perceptions on story-lines which substantiate your self-created negative reality… (Neurological studies concerning brain function and structure as related to mindfulness seem to substantiate this).
  • This means that story-lines which are contrary to the dominant negative storyline are not perceived (though they are available) or they are not given attention.
  • ‘rewrite self defeating narratives’… which means that clients will begin to allow positive story-lines into their life (the premise is that if you have a negative story about your life you unconsciously will ‘look for’ negatives to substantiate the ‘truth’ of the dominant story about your life that you tell yourself… by doing so you unintentionally miss many of the positive stories that are ‘contrary’ to the dominant story.)
  • This can sound blaming so let me clarify… our brain project our beliefs onto our perceptions. This means we unintentionally see things the way that we have been educated to see them. We take information from our senses and try to make sense of that information with what we already believe to be true… narrative therapy allows people to apply new positive narratives to their perceptions… this is different than CBT in that you are free to create your own ‘truth’ as ‘truth’ doesn’t actually exist (cognitive therapy can involve disputing irrational beliefs… ration is a modernist principle. Narrative therapy allows you to focus your attention on alternate beliefs… their is no truth according to postmodernism and therefor nothing would ever need to be disputed.

 

Unique outcomes technique – encourage people to talk about storylines that are different or contrary to the dominant negative storyline. Because the therapist believes in this alternate storyline… the new storyline… the new reality is validated and can be integrated.

  • Example: “tell me about when the problem was not able to influence your relationship.” “I would like to hear about how you fell in love… tell me what you love so much about your partner.”

The Family narrates a new story for the the system to live within – Once the above techniques are used it is important that the  family collaboratively creates a new positive story line. “We are aware of how the ‘problem’ impacted our system and we will use the following ‘solutions’ as we move forward. Solution Focused and Narrative therapy are both postmodern theories and they compliment each other perfectly (I personally use the two in conjunction.)

Existentialism – I very commonly use existential interventions in conjunction with narrative therapy. Existentialism is concerned with meaning and narrative therapy allows for that meaning to be entirely subjective. I will ask questions such as, “what was the positive reason that alcohol chose to enter into your life.” or “What are some of the good reasons that your allow yourself to be taken over by stubbornness?” or “what is the meaning that that you give for this suffering that were are talking about?”

 

Letter, support groups, definitional ceremonies, reflection team… encourage the system and people in the larger community system to validate the new positive story line.

  • Family members, the therapist, people in a support group, therapist colleagues and supervisors etc will listen to the new story and will talk openly to the clients about how they can see this new narrative alive and well in the client’s life.

 

Collaborating with new story Techniques:

  • A therapist will write a letter or a group will say to the client something like, “Ben, I was impressed to see how you allowed the nurturance of your partner to enter into your life to help you to combat the anxiety which sometimes arrives when you go to work. I see that you have called upon personal strength to engage in an exercise routine which greatly impacts anxieties’ ability to gain influence over you.”

 

Reflecting upon our life increases our reflective ability – With reflection we allow ourselves to observe our lived experience and we are then less likely to go through life on autopilot. In this way narrative therapy is a mindfulness tool which enables you to be free to live in the moment… and free to live within the story-lines that you reflect upon.

You are not the story you are the observer and the creator of the story… you can observe yourself in any story you wish to create.

William Hambleton Bishop is a practicing therapist in Steamboat Springs Colorado.

Postmodernism – making an ‘out there’ philosophy useful

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Quick summary – By allowing yourself to investigate how your relationships, actions and emotions are governed by your perceptions you may find that by offering yourself a freedom of perception you can change the way in which you are impacted by your reality. – By using open-mindedness and an adaptability in relation to your beliefs and ways of perceiving, you free yourself from patterns of seemingly automatic reaction. Postmodernism suggests that reality does not exist… it is a construct of your belief system… a radical postmodernist would say that if you believed that you could walk through a wall, then you could walk through a wall… perhaps this is not particularly helpful to the masses, but what if we took this down a notch… what if you allowed yourself the freedom to perceive a situation differently so as to reduce your discomfort related to the subject? What would be the benefits of letting go of some of your deterministic thinking (‘when this happens I must feel this’ ‘If I did that I would be bad’ ‘I should_______ because _______)? Sometimes we trap ourselves in suffering by rigidly holding on to what we label to be objectivity… postmodernism suggests that objectivity does not exist – there are not facts. Perhaps if we took a small piece from postmodernist thinking we could all say that “I don’t have to feel or behave in a set way… my reactions do not have to be predetermined… I have a consciousness which is evolved enough to allow me to live without being controlled by my environment… I can choose to perceive or believe my reality to be different.” Embracing your subjectivity is an emancipation from atomization. 

According to the philosophies inherent in postmodernism reality is a construct which is ever changing… reality is simply what we have chosen to believe… anything can be a fact if you believe it to be a fact… and facts become more factual when we use communication to get others to believe that those facts actually exist. According to postmodernism, if everyone believes the world to be flat… then the world is flat.

 

Through language we allow the collective to live within a reality which appears to have objectivity and continuity… a radical postmodernist would suggest that if you want a different reality you must simply believe that a different reality exists.

Now this theory might be fascinating to certain people (such as myself) but it is not particularly useful for a society which still seems reluctant to accept modernism (modernism basically states that the world is governed by logic – math and other sciences can accurately depict and explain reality… reality is quantifiable).  

Our reactions and actions are related to the beliefs which we project onto a stimuli or event etc. I view postmodernism to be useful if it is used as a means of increasing adaptability related to perceiving… this could make a person less reactive and perhaps more content with the random happenings of existence.

As a therapist there are many themes that I have seen surrounding the subject of deterministic thinking.

Here are some very common examples of rigid deterministic thinking patterns that often create unnecessary suffering in people’s lives. (Remember to be nice to yourself… I am well aware of all the below cognitive distortions and I still find myself caught up in them anyway… this is not an exercise intended for you to cast negative judgment on yourself… notice which phrases you use and explore the subject with open curiosity.)

“I have this characteristic so I should to this.”

“I am a ________ so I must ___________ .”

“Anyone who __________ is a _____________ and must __________.”

“This happened with a family member so I must do this.”

“I have to feel this way because this happened.”

“Bad things never happen if you do things the right way.”

“I can’t do it that way or else I would not be me.”

“He did this so he needs to do this.”

“When someone does this the only solution is to do this.”

“We don’t do that or we don’t emote like that or we don’t think like that in my family/culture/community/country.”

“I should _________because ________.”

“I can’t support her because she is a ________.”

“___________ is always wrong or bad.”

“If I did that then I would be a __________.”

“I am a _______ and we believe _______ should always be handled by ______.”

We all have intuition and we all have subjectivity… countless times I have witnessed people fall hopelessly into suffering because of an inability to overcome their rigid ‘shoulds’.

What would happen if you allowed more of your actions to be governed by what felt right in the moment as opposed to adhering to a rigid ideology which states objectively what you should do?

Postmodernism is then useful to every one if we use it as a tool to better understand how our lives can benefit from lessoning our grasp on deterministic thinking… lessening the degree to which we are controlled by the ‘shoulds” in our lives…lessening the degree to which we believe that we must react a certain way to certain stimuli.

This process will also likely have a nice affect on your relationships… people don’t generally like it when you force your own subjective reality onto them… people tend to get along better when they are less concerned with proving objectivity… proving that someone is right and someone else is wrong.

William Hambleton Bishop is a practicing therapist in Steamboat Springs Colorado.