I was once told by a famous therapist that being eclectic is a mark of sloppy thinking. I respectfully disagreed. I still do. Yes, most of us go to school to learn a particular theory and practice. It’s a useful way to start. In order to work successfully with people, we do need a theoretical map to guide us. But I think our original training is a foundation, not the whole building.
As we mature as therapists, we learn from emerging research, from published papers, from experience with a wide variety of clients and from in-service opportunities that stretch our thinking and our skills. It is up to each of us to integrate what we learn into some unified whole that we can use with integrity. The result is what I call a “thoughtful eclecticism.”
My own journey as a therapist started with training at the Alfred Adler Institute in Chicago. On that I’ve layered family systems theory, numerous workshops regarding specific diagnoses and disorders, as well as training in hypnosis and a foray into behavioral psychology.
I’ve embraced some of what I’ve been taught and discarded some others. Like most therapists, I’ve thought long and hard about how each piece fits into my own very individual theory and practice in order to be of most use to my clients.
I share part of my own journey as a way to encourage early-career therapists to think about how they are adding to the scaffolding begun by their initial training. For the purpose of this article, I’ll confine the discussion to the two major threads: Adlerian Psychology and Family Systems Theory.
My goal in working with clients has always been twofold: To understand each person in their uniqueness and to then empower him or her to make manageable changes that will relieve distress and set in motion a more positive, productive and happy life.
Assessment: After hearing the presenting problem (s) or symptoms, the first move is always to ascertain to the best of my ability that there is no medical/neurological issue and medication interactions that may be at the root of the client’s distress.
In addition, I check for current abuse or neglect and/or substance abuse. Therapy may not be indicated if the issue is medical. Active abuse or neglect needs to be reported and stopped. Substance abuse may need more immediate intervention than therapy alone can provide. Once those issues are addressed, assessment then moves to a psychological orientation that, for me, combines both intra-psychic and interpersonal dimensions.
Adlerian theory starts with the individual. Although Alfred Adler was one of the first to discuss the impact of the person’s social world on development, he didn’t operationalize it well. When I was introduced to the early thinkers about family systems (Haley, Whitaker, Satir, Watzlawick, Hoffman, etc.), I thought their work added that missing piece. My assessments, then, draw from those two theoretical lines.
Adlerian psychology is intrapsychic in nature. As the child grows, the individual’s psychology is shaped by his or her creative but unconscious decisions about how to respond to experiences. Assessment therefore includes:
1) Questions that lead to an understanding of how the person sees life, other people and themselves and what they believe they need to do to survive and thrive within that understanding. In Adler language, this is called a person’s Lebensstile (“life style”). This term is not to be confused with the current idea of “lifestyle” as a material way of life but rather as the “lens” through which the person looks at the world.
2) Data is gathered from early childhood in order to help both client and therapist understand the development of this lifestyle and to begin to look at ideas and emotional responses that are now making trouble for the client.
3) Questions about early memories: Memory is not static or continual. In Adlerian theory, the way we “remember” an event is a metaphor for how we currently see the world. Memories are yet another avenue for understanding the individual’s lifestyle.
4) Dreams, if the client presents them, are seen as yet another metaphor for the client’s current thinking, hopes and fears.
5) Troublesome “shoulds” in the client’s thinking are seen as the person’s internal struggle to fit current situations into her/his life style. Even when problematic, clients often try to force fit current events into the existing internal template instead of changing the template.
From Family Systems
The central tenet of family systems work is that it is interactive, i.e, an individual is seen as part of a dynamic ecological system made up of past and present relationships among family and other key individuals in the person’s life. The person’s psychology is seen as a creative response to his/her perception of their place in that system. Assessment therefore includes:
1) Questions that help us understand the family “map” (also called a genogram). I’m interested in who is included or excluded and why, the relationships among them, who currently has influence on the client and whose influence from the past continues to have impact. Of importance is teasing out distinctions (seeing “parents” as two individual people, for example).
I’m also looking for indications of “intergenerational transmission,” patterns of behaving that are passed down from generation to generation. Examples of these include alcoholism, philandering or distrust of men on the negative side; strong positive role models, important cultural connections or adherence to principled values on the positive side.
2) Family therapists are constantly tracking many relationships at once. Questions are focused on finding patterns in relationships, especially how the beliefs and actions of various family members affect the client and how the client’s response then impacts the rest of the system. I’m looking for how that circularity keeps the client “stuck” in their distress.
3) Exploration of early history is in the service of understanding that circularity and the perhaps unconscious conclusions the person reached that are still having impact (both positive and negative). Data from early childhood to the present also helps me develop a compassionate understanding of the client’s role in the ecology, what happened whenever she/he made attempts to change and who might be an ally in supporting the client.
4) Troublesome “shoulds” in an individual’s thinking are seen as an interpersonal project that helps keep the family stable in its own (perhaps unstable) dance.
Result: I’ve come to believe that an individual’s personality and symptoms are problem-solving responses to both the internal template and the external supports and pressures (past and present; real and imagined) from important familial relationships.
The two-fold assessment helps me operationalize both. Sometimes that understanding fits a DSM diagnosis. Sometimes it results in a Z code that is distressing but not a reflection of mental illness. Regardless, interventions, then, have to address both the intrapsychic and interpersonal issues (see Part II).
I’ve had conversations where it’s been argued that the blend I’ve come up with is unnecessary; that Adlerian and Family Systems theory each already includes consideration of both the individual and family dynamics. Nonetheless, I’ve found the vocabulary and tools of the two constructs to be complementary in ways that are useful to me and helpful to my clients.
This article isn’t intended to present a detailed or complete discussion of the two theoretical lines I’ve found most influential to my work. Nor is it a call for other clinicians to adopt the same theories or to come to the same conclusion. My intent is only to demonstrate how one therapist (me) has developed a thoughtful eclecticism.
I do believe it is important for us all to take the time to think carefully about just how we are blending what we have learned over the years into an integrated whole. Having a clear set of assessment guidelines gives us a starting point for each new client and provides a unifying structure for subsequent sessions. It lends authenticity and integrity to our work.