To Do No Harm

Johnella Bird

Keynote Address : Inaugural Pan Pacific Family Therapy Congress

Melbourne, 4-7th September, 2001

I have been told in the past that I am not theoretical enough. I’ve been told in the past that I’m too theoretical. Today I will attempt to walk the line, where I speak to the spirit of the work while standing alone on this stage. I’ll attempt to represent the practacilities of our work while presenting the key theoretical ideas that are foundational to my work.

I’ll remind myself that the stage has already been warmed by Barbara Wingard.

I’ll remind myself of the love that was extended to me by my family and friends before I left Auckland, New Zealand.

I feel passionate about the work and I hope this passion is apparent as I speak with you all. The culture I will be speaking of today is the culture of therapy.

The title I have chosen for this plenary, is”To Do No Harm”, which represents to me a striving or an intention. It does not represent a therapeutic model, a rule or a statement of fact. I have chosen this topic because I believe the intention or striving ‘to do no harm’ needs to be at the forefront of the development of ways of working with people together with the subsequent critique of these ways of working. When this intention or striving is absent, we risk becoming agents of social control. When we become agents of social control we contribute (either wittingly or unwittingly) to the further marginalisation of those who are disenfranchised by the dominant group. My membership of the dominant cultural group supports me to speak directly to us about the challenges I have found and the strategies I have put in place to minimize my participation in the practices and ideas that injure and marginalise others.

I was attracted to Family Therapy in the late 70s because it promised:

ways of working that limited therapists involvement with and in people’s lives.
it had a focus on what could be changed versus what was damaged.
and it had an inherent optimism about both people’s capabilities and their desire for change.

I believe that throughout the 80s and 90s Family Therapists in New Zealand were at the forefront of challenging the neutrality of therapy or counselling in respect to gender and culture. We encountered exciting and painful times as we discovered individually and collectively that ‘good intentions’ did not protect our colleagues from the experience of injury through our neglect and ignorant assumptions.

This comment is not derogatory of either myself or of my colleagues. It is simply the way it is and was. These experiences continue to drive the passion I have for both teaching and engaging in the clinical work. It is incredibly challenging to create the conditions where we remain alert to that which we don’t know. It is incredibly challenging to remain alert to our collusion in an imposition of meaning that acts to marginalise others.

I have metaphorically described my attempt to meet these challenges by reflecting that within the therapeutic work I try to stand on the edge of what I know and what I don’t know. As I stand in this place I carry all the knowledge I have with me. As I turn toward other people’s unique lived experience I ready myself to and for discovery, supported by what it is that I know while being ready and willing to have this knowing changed, added to or confirmed. This intention is moved into a living practice through an engagement with a linguistic strategy which I call relational externalising.

Through this practice I generate a relational paradigm that supports me to explore what is conventionally unexploreable because it is linguistically constructed as an absolute.

Relational externalising evolved as a consequence of the clinical work I focussed on from 1988 to 1999. Through this time I found myself addressing the effects of sexual, physical and emotional abuse with people. Many of you will be familiar with externalisation. In 1989 I began this work supported by the clinical knowledges and skills I had collected, which included the technique of externalising the problem. I discovered that the concept of identifying the problem became problematic when the identity or self was regarded or known as the problem, i.e. I’m bad, mad, dirty, wrong, responsible for the abuse, crazy, ungrateful, weak, sick, deserving of punishment, seductive, etc.

Consequently I evolved a practice which had an emphasis on a deconstructive exploration of the everyday language we use, which both describes and shapes lived experience. The following represents the distinctions I’ve drawn between externalising and relational externalising.

Relational externalising and externalising difference

This method of languaging supports me to begin an enquiry process using the descriptions people give me of lived experience. For many people (including children), words are and have been meagre representations of their experience. When we privilege the language of the everyday through a relational externalising enquiry, therapists and clients are provided with an opportunity to negotiate and re-negotiate the language that more closely represents lived experience. When we relate to and with the descriptions that are shaping of our lives, we have an opportunity to reinvent these descriptions while exposing the benefits of one description over another for the self, others, or institutions. e.g. Trust overhead 2 Thus creating multiple linguistic possibilities versus the binary or middle way.

The process of discovery I have embarked on over the last twelve years has been guided by an emphasis on the ethics of therapeutic practice (i.e. the desire ‘to do no harm’.) This emphasis promotes a relating to clinical models (which includes theoretical ideas and practices) rather than an adherence to a clinical model (e.g. I am a narrative therapist and I’m not). Devotion to a clinical model is tempting as it provides the shelter of collectivity or a sense of belonging. To resist adherence to a model does not however mean that I endorse the notion of the eclectic. The eclectic therapeutic practice is unaccountable and potentially dangerous unless the practitioner can articulate the ethics that underpin this eclectic practice. The ethics are then available for review, reflection, challenge and change. We cannot stand in a multiplicity of places at the same time. I stand in one place while making that place available for reflection and review from time to time (e.g. reflect on how I have engaged in the movement from psychodynamic ideas to Milan systemic family therapy ideas – to including a sampling of strategic ideas to M. White’s ideas, to the evolution of the ideas I’ve developed.

Here is another example of the Relational Externalising language use:

‘I want to push away feelings.’

We could research using a relational externalising process:

The Wanting (e.g. – what brings the wanting to push away to the forefront.)
If you put words to the wanting, what would they be?

We could research:

The push away (e.g -What do you use to engage with the push away?)
What do you notice about yourself as you begin to engage with the push?
If you were too put words to the desire to push away, what would they be?
How does a sense of exhaustion impact on the desire to push away?
Have you ever felt this desire to push coming and instead you have done something different?

I also want you to use the imagination to feel the effect of relational externalising.

An everyday example – think about a time that you experienced a sense that you have been misunderstood in a relationship.

i.e. I feel misunderstood by ……..

Answer these questions as I ask them.

When did you notice that this understanding was getting lost?
When you noticed this understanding getting lost, what did you do?
How do you think the other person would have made sense of this?
If a renewed sense of understanding had been achieved in the relationship, how would you have known this? What would have changed?
What would the other person now know about you or the relationship if this sense of understanding had been achieved?

Come back to this conversation.

The understanding we are constructing is neither generated by me or by you.

It is generated by a relationship to the relationship (which carries a history, expectations, hopes and dreams).

It is generated by a relationship to the meanings constructed by the words used to facilitate understanding and it is generated by a relationship to the meanings made of body language/body posture and the emotional reading between the word lines.

By utilising relational externalising we move beyond the absolutes generated by the conventional use of the English language. Language where you either understand or you misunderstand or you are either understood or you are misunderstood.

Every psychological, social, anthropological and political text which is constructed with and by the English language adheres to grammatical rules that act to generate binaries and thus absolutes. These absolutes tend to create polarities that obscure the fractional, intimate and contradictory experiences of our lives. Meaning is constructed through this thereby generating the realities that we all live within. However those who are marginalised and disenfranchised suffer from these constructions.

We know that the spectre of the professional gaze is discriminatory as it falls on the marginalised, the “other/than” the dominant cultural group. The gaze translates to language and inevitably the language of assessment, categorization and evaluation.

The power of these binaries is confirmed through the use of the pronoun you, your, my or mine. When we use the pronoun in this way we generate the conditions where definitive internal states are created. These definitive internal states are the dominant feature of self and other descriptions, i.e. ‘I’m a confident, determined person,’ ‘She’s got really high self-esteem,’ ‘He’s a nervous man,’ ‘I’m depressed,’ ‘She’s resistant to her therapy’, etc. When we employ a relational externalising process we create a relationship to these qualities, ideas and practices. The linguistic relationship we create has real effects, e.g. There is a significant difference between believing I am a confident person and discovering that I have relationship with the ideas and practices that are generative of this sense of confidence. This linguistic relationship allows us to re-search the implications of gender, culture, family of origin, etc., on the development and maintenance of the experience of confidence. Relational externalising supports us to identify and deconstruct the significant language that is used to reflect and generate lived experience including the taken-for-granted ‘personality traits’. This languaging strategy is the principal support for an enquiry that makes the real effects of privilege apparent or visible to people.

Most of us would agree with the principle of treating the people we work with, with respect. We would expect ourselves to be trustworthy. Some of us (myself included) would hope to collaborate with people. Thinking this, hoping this, speaking of this, writing about this does not generate this within the therapeutic relationship. When we construct trust, collaboration and respect through the conventions of the English language we construct absolutes.

Thus we are either trustworthy or not, respectful or disrespectful, collaborative or imposing. These binary positions construct an environment where any challenges to the constructions we hold are experienced as a challenge to our integrity. Consequently we are tempted to argue back directly or indirectly (in our heads). When the challenge comes from a member of a marginalised group and the person being challenge belongs to a dominant group then the arguing back carries the weight of our membership within the dominant group and thus acts to exclude and/or silence the other. This challenge rarely occurs within therapeutic relationships because of the inherent power relationship that exists within this relationship. Note – J.B. to speak to this, (i.e. refer narrative literature and other literature where notions of respect are an integral part of the work versus we orientate ourselves to de-construct the relationship we have with ideas and practices that are representative of respect, i.e. as a cultural practice).

Thus

respect is not intrinsic
respect is constituted through cultural practices
and we relate to respectful ideas and practices.

Some therapies obscure the power relationship within therapeutic relationships with ideas such as “you (the client) know and we (the therapist) don’t.” In these therapies people (clients) can be silenced by the good intentions of the therapist. Other therapies argue for the therapist to use an imposition of meaning (and thus an imposition of the power relationship) for the benefit of people (clients), ie. we know and you don’t. In this environment it is difficult for people who are marginalised to believe that the ‘professionals’ judgment is wrong or culturally or gender biased.

The ‘we know, you don’t’ position constructs the neutral objective observer/therapist who assesses and intervenes in people’s lives. This position is supported and guided by the adherence to the psychological truths which have been constructed through either so called neutral and objective scientific methodology or so-called neutral and objective observations, (ie. mother/infant observations). These psychological truths in turn direct therapeutic conversations and the meaning made of these conversations, i.e. (this behaviour or this interaction means the following). When we take up this position we do not consider the observer/therapist as a central determiner of meaning. We don’t consider that she/he makes distinctions, carries bias or interacts actively with the information she/he receives. The information received and sought by therapists from within this environment is subsequently fitted into professional and personal known truths. Various Family therapy and psychodynamic therapeutic approaches have and do adhere to this tradition. (e.g. it takes two years to grieve adequately for the end of a relationship).

The ambiguous and the contradictory moments which fill people’s lives are nullified by the power of these grand theories.The ‘we know you don’t know’ position which uses the therapeutic power relationship to confirm and impose meaning disregards and invisibilises the effects of privilege through gender, culture, class on people’s psychological and physical well-being. In other words this position does harm by confirming universal psychological truths which relegate those people on the margins to both professional constructions of inadequacy – sickness, badness and madness together with subsequent self constructions of inadequacy, sickness, badness and madness.

In reaction to the ‘we know, you don’t know’ position many therapists have taken up the position of ‘we don’t know – you know’, (Note ‘I do know something’). Many therapists who use the narrative metaphor to guide their work have attempted to address the power relation by the following:-

focussing on people’s competencies and strengths
self disclosure, i.e. “I also have struggled with this”.
reflecting back to people how they have contributed to the therapist’s learning or life.

These attempts to “even up the relationship” have acted to disguise the inevitable power relation that exists in the therapeutic relationship, supervisory relationship, consultation relationship or teaching relationship while at the same time moving the therapist, supervisor, consultant, teacher into a subject position. From this position it is very difficult for the other (client, supervisee, student) to speak to a sense of discomfort or difference or an experience of the power relation. To speak in this environment is to challenge the good intentions of the other. When people experience receiving good intentions by a member of the professional classes (this includes the dominant cultural group and other classes of domination) this can create either a sense of gratefulness (i.e. “this person is really trying to understand, no-one else has ever wanted to know”) or a sense of care taking (i.e. “This person is really trying, they’ve got it wrong but if I tell them they’ll be really hurt”). When people (clients) occupy either of these positions they are forced to defer to the good intentions we hold even if these intentions act against them.

Those people who have the courage to expose the effects of the power relation in this climate of good intentions, are exposed to the risk of being labelled both by members of the professional classes and the peer group they belong to. The operation of the power relation within this climate of good intentions is thus insidious, dangerous and does harm. It risks further marginalisation of the marginalised and alienation of people from their environment of belonging.

In order to limited the possibility of harm as the result of the power relation in the therapeutic relationship, we need to be able to acknowledge, expose and negotiate the operation of power within the therapeutic relationship (e.g. permission getting – note taking, gender)

Exposure of the power relation is possible when we utilise the relational externalising process. In the exposure we are constructing a relational entity through language, we can re-search the effect of, i.e. the silence, the difficulty, the deferring to, the sense of being overwhelmed, challenging the panic that comes with expectations, the critical ideas that act to silence, etc. This relational entity allows us to explore contextually the experience of the relational self. In this exploration the limitations and strengths of good intentions is exposed and explored.

In the therapeutic relationship I’m suggesting that the therapist positions her/himself relationally. This relational position is maintained through a relational form of consciousness. In turn the relational form of consciousness is created and maintained by a particular way of engaging in and with language, i.e. relational externalising.

Within the therapeutic relationship we are attempting to expose, negotiate and relate to the power relation that exists within the everyday, e.g. equality in couple work.

Our experience with the power-relations of everyday life doesn’t readily follow any prescribed direction. We are confronted by ambiguity, contradictions, and opposing representations of the self and others. We witness moments of profound change where individuals find the strength to oppose institutionally supported ideas and values by setting a different life course. Moment by moment in the therapeutic conversation we engage with the ethics of the everyday. This engagement demonstrates a willingness to continually negotiate meanings, including identifying and negotiating the effects of the ethics that guide our lives. There is no longer the offer of rest within certainty. It is no longer possible to rest within the terms of reference for justice and equality that we individually believe in. Anna Yeatman (40) refers to this by talking about “the multiple interests in emancipation” (page 228) and drawing attention to the position of insiders and outsiders.

“Each reforming achievement which transforms policy in the name of equality, establishes a new regime of governance. All governance works in terms of a bounded community, a community of identity and thus establishes insiders and outsiders.”

(Page 229)

Engaging with the power relations of the everyday requires us to acknowledge the comfort we receive from our insider position. Acknowledgement can then support us to make ourselves ethically available to the voices of those on the outside. Being available to those who are on ‘the outside’ provides us with both powerful moments of realization of what we have taken-for-granted together with the experience of responsibility for others’ pain and exclusion.

(Bird- page 278-279)

For example:

Many years ago I was a participant in a workshop facilitated by a male presenter. An integral part of this presentation was an impassioned lecture on the objectification of women (including many examples from texts and everyday cultural references – magazines, films etc). The rising discomfit I felt turned to irritation and anger. I felt patronized – a man was educating me, a woman, about the effects and implication of patriarchy.

This experience has had a huge effect on the way I teach in respect to dominant cultural ideas. However recently when I was speaking to a large gathering about the politics of therapy I used an example that deeply offended at least one person in the group. I thought I had prepared the context so that this example would be received as a challenge to Pakeha therapists about working with people who belong to a cultural group other than Pakeha. However on reflection I did not adequately prepare a context for listening to the example that took into account the membership I have in the dominant group and the membership other listeners may have to a marginalised group. The challenge was painful, however these challenges are inevitable if we sit within the contradictory environment of deconstructing the power relationship while being within the power relationship.

A number of years ago I was sitting in a lecture hall listening to a clinical presentation reflecting on the consequences for women as clients of therapists’ lack of awareness of gender relations, (Note 1 ). Well known and revered Family Therapists appeared on screen demonstrating a cringe-making ignorance of gender relations. This ignorance clearly subjected women to explanations and interventions that confined them within oppressive stereotypes. I left this lecture chastened. I wondered how the practices and ideas that I engage with would be understood in the next ten or twenty years. I considered how the relationship I have within privilege was acting to exclude the knowledges and practices that more adequately reflected people’s lived experience. I explored ideas about the context that would support an ongoing engagement with ethics, and I pondered the role of therapist, counsellors, psychiatrists, psychologists, social workers in maintaining the status quo for the ongoing comfort of the dominant group.

With these examples I am attempting to illustrate several things.

One – that it is impossible to know what I don’t know and,

Two – in deconstructing the power relationship we don’t stand outside of the power relationship but in relationship to it.

When we consider this while engaging a relational consciousness through relational externalising we move beyond the constructions of right and wrong, respectful and not, collaborative and not. Instead we engage in the present moment with a relationship where respect and collaboration is an ongoing negotiation.

Hence the interest I have in exploring and working with the politics of therapy.

Counselling and therapy is always political. It is political because the therapeutic conversation can be constrained within the narrow parameters of one regime of truth (the therapist’s) thereby subjecting people’s (clients) experience to a definitive explanation. It is also political when the conversation exists within multiple truth regimes. Within multiplicity it is none the less impossible to represent all the possible truth regimes or explore the mechanisms and processes that elevates one regime of truth over another. Within multiplicity there are also preferences, demonstrated and perpetuated in the emphasis on certain questions and responses. This emphasis has the inevitable consequence of relegating some parts of people’s (clients’) description of lived experience into the background.

Weedon (32) argues that no discursive practice is outside of power/knowledge relations.

Meaning is always political. It is located in the social networks of power/knowledge relations which give society it’s current form. Not all areas of discourse are equally significant in the hierarchy of power/knowledge relations but no discursive practice is outside them. (Page 138).

However in therapeutic work and in lives, we need to locate ourselves somewhere and establish at least a temporary fixing on meaning. To not do this leaves us with a fluidity of non-position that renders us incapable of taking a stand to support people’s (clients’) suffering under the influence of oppressive and invisiblising practices and ideas. The non-position inevitably supports that which is prevalent or dominating as it offers no form of resistance.

When we consider Weedon’s statement that:

” the important point is to recognise the political implications of particular ways of fixing identity and meaning (Page 173),”

Then therapy/counselling with a focus on making sense of lived experience through a process of exposing and negotiating meaning, is inevitably political. Acknowledging the political implications of therapy enables us to both render ourselves available to ongoing critique of the certainties we hold while finding strategies to engage enthusiastically with the relationship between knowing and not knowing. (Bird, page 34-36)

Therapeutic/counselling work which has as its focus a relational externalising enquiry process creates a climate of discovery rather than imposing meanings, i.e. we ask ourselves ‘what does this mean’ versus ‘this means this’. This emphasis positioning us as re-searchers of lived experience which requires us to privilege what is said versus interpreting what is said and acting on that interpretation, e.g. looking behind what is said to confirm a psychological explanation or hypothesis.

When we know that particular discursive regimes can torment, oppress and silence people and that those discursive regimes are often carried and believed in by the same people (clients) who are oppressed by them, we can feel stuck between two positions. These positions are identified by two questions:

– Do I expose these ideas by presenting an alternative version? If I don’t will I be supporting the ongoing oppression of these people (clients)?

– If I do expose these ideas, will people (clients) experience me as another agent of control?

When knowledge is presented to people (clients) in a definitive, comprehensive logiocentric way, the following circumstances emerge:

Knowledge, including alternative knowledges are represented as static, unified truths.
There is pressure to comply to one truth over another.
The knowledge is presented as comprehensive and people (clients) may not feel entitled or able to argue against it.
The knowledge carriers including the alternative knowledge carriers, become the arbiters and gatekeepers of the one truth.
To decline the other person’s (therapist) particular regime of truth is to potentially lose the relationship. This has serious implications for the therapeutic relationship understanding.
To accept the other person’s (therapist) regime of truth is to potentially endanger other close relationships (partner, friendships, family members)
The activity of accepting a particular regime of truth offered in this way threatens to capture the person as a convert.
The activity of declining a particular regime of truth offered in this way threatens to alienate people from a member of the professional classes. The professional can then interpret the rejection as evidence of psychopathology and act on the person in accordance with this view point.

However, when ideas and practices that oppress people (clients) remain unexposed then our silence is a compliance with these ideas and practices. Instead of either presenting people (clients) with other knowledges or remaining silent we can use a relational externalising enquiry that orients us (therapist and client) toward discovery. The relational externalising enquiry process I use can provide us with a technical skill that exposes the history, activity and power implications of particular discursive regimes. This exposure provides a climate for an exploration of the implication of other discursive regimes including those the therapist doesn’t have access to. The enquiry creates a climate for discovery and re-search that people (clients) can embark on both inside and outside of therapy. Weedon(32) comments that:

To speak is to assume a subject position within discourse and to become subjected to the power and regulation of the discourse. (page 119)

To speak using the relational externalising enquiry process represented in this discussion is to speak relationally. Speaking relationally assumes a subject position in relationship to a discourse. From this position people (clients) can view, experience, explore and re-search the regulatory function of the discourse. Speaking and engaging in relationship to and with discourse using an relational externalising other or self enquiry creates an environment where all discursive regimes are experienced as potentially temporary and serving a purpose that supports a particular community. This method of engaging protects us from the processes of conversion, where one comprehensive counselling/ therapy truth stands against others. When we hold counselling/therapy truths, we can find ourselves arguing for the counselling/therapy truths superior status by using theoretical constructs that ignore the ethical implications of practices. We can also be tempted to engage with ethics as fixed truth positions. Once we claim a fixed truth position we can relax into privileging our ideas, for example, the ideas we hold about justice or equality. Of necessity any fixed truth position exists outside of an engagement with both the practice of inclusion of marginalised voices and the practice of ongoingly reflecting on the practice of ethics.

The practice of relational externalising engages the self in relationship to the idea, concern, ability, etc., thus supporting us to engage in a conversational process that is generative of relational consciousness. This relational consciousness then allows us to engage with ideas and practices rather than being subsumed by ideas and practices. (Bird, page 36-38)

When I re-search the political, social and personal implications for people (clients) of certain modes of subjectivity I am hoping to: –

expose the strategies for implicating people in the practices and ideas that act to torment and oppress them;
expose the ideas of the autonomous self which suggest individuals are totally responsible for the success/failure, health/illness, poverty/wealth in their life;
expose the ideas and practices that act to marginalise one group while rewarding and supporting others;
develop other knowledges and practices that can act to support people (clients) to ongoingly resist the prevailing knowledges and practices that oppress them;
expose and critique the ethics that define what is legitimate and what is not.

(Bird, page 40)

Conclusion

It is noticeable from this overhead that I am very active in the therapeutic process. I contribute to the conversation and the people I work with contribute to the conversation. However the contribution we each make is different. Counselling and therapy is always political, it is never neutral.

It is my strongly held belief that relational consciousness and relational externalising creates an ethical platform for me to stand on, e.g. respect as a relationship. This platform allows me to ongoingly negotiate respect and collaboration within therapeutic conversations. It supports me to work beyond and within the margins of my lived experience. It creates the potential for momentous discoveries to be made within everyday lived experience. The ideas I’ve presented today represent one way of meeting these ethical obligations. I don’t expect you all to take up this way. I do however hope that if respect, collaboration and trust are central tents of the therapeutic work you do – that you take up the challenge of wondering –

What are the strategies that you use to ensure that you are not acting as agents of social control?
What and are the accountability structures that you use to reflect on what it is that you can’t know across culture, gender, class, sexuality, age ?
and, what strategies do you use to make apparent or visible the power relationship in the therapeutic relationship, supervision/consultation relationship, teaching relationship?
and, once visible how do you negotiate the experience of this power relationship with people?

In grappling with these questions you will reflect a striving or an intention ‘to do no harm’. This will not protect you from the discovery that you have unwittingly imposed ideas and practices on others. I believe that there is no definitive position on cultural relations, gender relations, class relations, however there is protection in the way you engage with these discoveries. These discoveries will take you beyond what is known to you. This can be both exciting and at times terrifying. More importantly it represents a desire to learn from our predecessors, to humble ourselves by seeing that their flaws are also ours. There is nothing admirable about the facility of hindsight. When I look to the therapists of the past – 100 years, 50 years, 20 years, 10 years ago, I see my potential future. We can do it differently, we must do it differently if the intention and striving we carry is ‘to do no harm’.

– – – – – –

References

Bird, Johnella. ‘The Heart’s Narrative’, Edge Press, PO Box 80089, Auckland, New Zealand 2000.

Weedon, Chris. ‘Feminist Practice and Post-Structuralist Theory’, Oxford, Blackwell Publishers, 1987.

Yeatman, Anna. ‘Voice and Representation’ in ‘The Politics of Difference’, edited by Sneja Guneward,

Anna Yeatman, Allen and Unwin Pty. Limited, 1993, page 228-245.