Joining

In MFT, the process of joining is foundational to the way therapists connect with client systems. First introduced by Salvador Minuchin in his development of Structural Family Therapy, joining is now ubiquitous in systemic therapies regardless of theory and model of therapy. However, as ever-present as the idea of joining is, the process of joining is not always easy to articulate. Sometimes it is mistaken for other ways of engaging a client system. This post will address four mistakes emerging therapists (and some more seasoned therapists) often make when conceptualizing joining a client system. 

Mistake  #1: Joining is the same as building rapport

Building rapport with a client is essential at the outset of therapy and continues to carry substantial weight as therapy moves form beginning to middle and toward termination. Rapport, however, is not joining. Building rapport with the client system is making a connection and developing a familiarity and a liking or respect. Rapport is a sense that initial knowing and being known. It is not deep knowing and it is not participation in a social system. Rapport may open the door to multi-directional partiality, but it is not joining a client system. 

Mistake #2: Joining is the same as multi-directional partiality

Multi-directional partiality is rapport building in every direction. In systemic therapy it is common to have multiple people in the room or to give voice to people not in the room. Linear thinkers may have anxiety about whose side they will feel compelled to be on, but systemic thinkers intentionally seek to hold in tension the equal allegiance to all members of the system and to the client system itself for the sake of the health of the system. when the therapist is actively partial in favor of each person and the whole client system, the connection between each person and the therapist can move from rapport to trust, but multi-directional partiality is not joining. 

Mistake #3: Joining is the same as building trust

Trusting building is deeper than rapport and is essential as the therapeutic relationship develops. Trust is more than a familiarity and a liking or respect. Trust involves a level of vulnerability that is not part of rapport. Trust creates psychological and interpersonal space for sensitive disclosures to be made without fear the information will be used inappropriately. Trust also is a client's demonstration of their assessment of the therapist's competence where rapport is not a measure of competence. Trust may open the door to a strong therapeutic alliance, but it is not the same as joining. 

Mistake #4: Joining is the same as therapeutic alliance

Building a therapeutic alliance is essential for client care and Lambert says could count for as much as 30% of the improvement when clients are successful in therapy. Therapeutic alliance is the strong trusting relationship between the therapist and the client wherein the client believes that the therapist is competent to do good work and committed to the process. It is the sense that there is a team comprised of the client system and the therapist and together they will do whatever it takes to accomplish the goals the team has created for itself. Therapeutic alliance is essential for client success, but it is not joining. 

Ok, so what in the world is joining if it is not building rapport, practicing multi-directional partiality, developing trust, of building a therapeutic alliance?

Join is becoming a member of the client system. Yes, all of these four things above a part of what can make joining possible or perhaps can be a by-product of joining, but they are not joining. When you as a therapist join a client system, you are being sponsored into that small social system. The boundaries of the social system that you were previously on the outside of have become permeable and you have been allowed inside of them. 

In joining, you change status from outsider to insider. You are privy to more and more information about the client system, but more than that, you are given power in that system. In a sense, joining is the most powerful intervention as it perturbs the system. No social system can simply add an entire person to it and succeed at being unchanged. The family is already restructuring and often times they are not aware at the outset to what extent of a change they have made. 

While the therapist joins the system (I would argue that in therapy the therapist cannot not join), it is critical that rapport building, multi-directional partiality, trust building, and alliance building are always actively up and running. The client system has taken a big risk letting you be a member, and sometimes your membership is probationary. When you join the family, the clock starts ticking on whether their boundaries will lose their permeability. If boundaries become rigid, the system may spit you out and then hurry back to reconstruct its homeostasis. 

When a client system lets you join their system, they have given the first fruits of honor toward you. You tell them what a wise choice they made when you build strong rapport that deepens with everyone and the therapeutic relationship becomes goal seeking team. 

Joining is an essential intervention in therapy. It should not be confused with other aspects of relating to client systems. When therapists conceptualize themselves as members of the client system, it can heighten their sense of place in client system and move their understanding from an outsider applying techniques to an independent client system and more toward seeing their work as an inside job. 

Protecting Privilege and Feeling Innocent: How Privilege Maintains Its Position

What is important to one group is not all that important to another. For example, short people spend little or no time solving for hitting their heads while walking through doors, regardless of the height of the door. People who are taller have to consider doorways and at times make adjustments in order to avoid hitting their heads. Short people are oblivious to the threat of low doorways because it is not a threat to them. It is an innocent obliviousness, but at the same time not an obliviousness that is necessary. It costs short people nothing to be oblivious about doorways while it would be a hazard for tall people to think the same way.

Most people are not tall enough to consider the height of doorways. Therefore, most people are blind to the concern. When the concern is raised by tall people, short people may not think it is that big of a deal since most people do not have to worry about this issue. If tall people pushed the issue further, short people might feel attacked and feel like it is for no good reason. If pushed further, short people might attack tall people as a way to defend themselves – all the while perpetuating the risk. Tall people are resisted at every step along the way.

This is short privilege rearing its ugly head. The dominance of shortness in this world leaves tall people out.

Ok, being tall also has its advantages as well, strong advantages. Positive assumptions are made about tall people that may mitigate, sometimes in large measure, the negatives. Taller people are more likely to be leaders, make more money, and be considered credible. Pretty good advantages. But let’s replace tallness and shortness with skin color. People with lighter skin being the most numerous and having a history of making this nation according to their specifications, have more privilege. People with darker skin being fewer in number and having a history of being owned, segregated, resisted, and assumed to be hostile, have less privilege.

The same process occurs with skin color and the history associated with the skin color as happens with the height example. There are predictable phases of non-change in dominant culture in the presence of non-dominant culture. These phases are: missed, dismissed, critiqued, and attacked. What follows are brief descriptions of these phases. Included in each phase is how the dominant group marginalizes the non-dominant group while at the same time maintains its innocence.

Phase 1: Miss

The first phase in this social process of protecting privilege while maintaining claims of innocence is called “miss.” The dominant group is completely or mostly oblivious to the concerns of the non-dominant group. People with lighter skin are unlikely to be aware of the concerns of the people with darker skin. The dominant group is always solving its own problems, but behaves as though their problems are the only problems. And for them, they are the only problems. However, the non-dominant group has a set of problems too that only partially overlaps the problems of the dominant group. Therefore, only a portion of their main concerns are ever addressed. The dominant group maintains its innocence because they simply do not see the problems they have no impetus to solve. It costs them nothing to be oblivious. In most cases, it is not malicious obliviousness, but rather it is more myopic obliviousness.

Phase 2: Dismiss

The second phased in this social process of protecting privilege while maintaining claims of innocence is called “dismiss.” Since the dominant group was oblivious to the concerns of the non-dominant group, the full and complete responsibility to address these concerns rests upon the initiative of the non-dominant group. This may be a challenging task and may require a bit of courage because the onramps to expressing this need are geared to the convenience of the dominant group and may provide a barrier to the non-dominant group. So, when the non-dominant group rallies the courage to assert its concerns, it has to find out how the dominant group listens to concerns and then access that onramp. When the non-dominant group does express its concerns, since they are unfamiliar to the dominant group and may not even make sense to the dominant group, these concerns are often dismissed as less important or inconsequential. This assessment is generally true if passed through all of the assumptions of the dominant group with the assumptions of the non-dominant group either not known or not legitimatized. It is a case of “it’s-not-that-big-a-deal-ism.” In short, since the dominant group cannot understand the value of the concern, it is considered to be not worth the effort to address the issue. Addressing the issue would be too disruptive and likely be too costly in time and money to address. There is also the emerging sense that legitimizing the issue or concern might disrupt the foundational assumptions of the dominant group. The innocence is maintained because only legitimate and consequential issues deserve consideration and the concerns of the non-dominant group do not rise to this level (scrutinized through the lens of dominant assumptions).

Phase 3: Critique

The third phase in this social process of protecting privilege while maintaining claims of innocence is called “critique.” When the dominant group dismisses the concerns of the non-dominant group, the non-dominant group has to decide whether it will accept being rejected or persist. If the group persists, they conclude that their first initiative did not accomplish to desired outcome and so another, “louder,” initiative is required. In order to get the concern on the radar, they need to be more assertive in their communication. When the non-dominant group turns up the volume in expressing their concerns, the dominant group hears it, but also interprets it as inappropriately loud. So, rather than the dominant group dismissing the concern of the non-dominant group did before, they may elect to critique the way in which the non-dominant group has decided to express itself. Again, the actual concern is not attended to, but rather the what is attended to is the method of communication. Now the dominant group is defending itself by critiquing the non-dominant group. Because the volume of the communication of the non-dominant group is so uncomfortable or inconvenient to the dominant group, the dominant group organizes not to address the issue brought up by the non-dominant group, but the issue of the discomfort or inconvenience that the method of communication used by the non-dominant group used to get raise their concern to the level of action. The claim of innocence is maintained here by the dominant group because it feels to them that the problem has only now just begun and that it was thrust upon them through no fault of their own. The problem, as perceived by the dominant group, is the discomfort and inconvenience imposed upon them unnecessarily rather than the content of the concern raised in the first place. In the perception of the dominant group, they were innocently going about their fair and just business and then the non-dominant group decided to make life difficult for no good reason.

Phase 4: Attack

The fourth phase in this social process of protecting privilege while maintaining claims of innocence is called “attack.” When the third phase of critique is reached, the non-dominant group recognizes rapidly that what was heard was not their concern, but their method of making their concern known. There is likely substantial frustration at how the first three phases have produced three unique ways of not being honored for their request for their concern to be addressed. The non-dominant group must decide what to do. They can give up on the effort of raising their concern or try yet another way to communicate their concern. Often the non-dominant group increases the volume further but in some other way that is impossible to ignore. The dominant group responds in the same way as they did in phase three, but with increased intensity, often with the goal of ending this interaction once and for all. They feel attacked unnecessarily and blamed for things they did not intentionally do, thus maintaining their claim to innocence. The escalation moves beyond critique to leveraging their power in a move for closure on the matter. The matter at hand, however, is not the content of the concern reiterated by the non-dominant group, but instead the now unavoidable discomfort and inconvenience posed by the non-dominant group. The dominant group feels attacked and does not know why while the non-dominant group has moved from feeling ignored at the outset of this social process to oppressed as they now have to defend themselves not only against their original concern being repeatedly ignored, but also against efforts by the dominant group to get them to quick making mention of it.

Miss to Dismiss to Critique to Ignore.

This social process holds on with an iron grip to homeostasis which perpetuates the status quo until something larger than it can intervene. And yet, it does not have to be that way. This process can be interrupted at any phase, but the interruption needs to come from the dominant group thinking more widely than itself, with good visionary leadership that is culturally curious and creative. It also takes some evaluation for the non-dominant group to make decisions about what it does and does not need the dominant group to know and not know about. Some concerns may best be dealt with “in-house.”

Regardless, knowing that this four phase social process is the easiest and most common way privilege keeps it power while holding to claims of innocence might help to inspire the creation of other ways to handle social change and embracing the wider diversity that comprises culture.

Circles of Clinical Fluency

As a therapist, each time I get a new client, there is both excitement for a new opportunity and challenge while there is also some trepidation about whether I am up to the task. One thing I hope for with each new client is a good therapist-client fit. Of course there are some inevitable mismatches that will happen from time to time, but my goal is to increase the chances of a good fit.

I imagine an entire book could be written on the creation of good therapist-client fit, what the therapist can and cannot control, what variables are at stake, the use of self, and so forth. Here I want to focus on something that is well within the control of the therapist.

Here I present Circles of Clinical Fluency. This concept was developed for therapists in training and beginning therapists, but might also be useful for mid and later career therapists as well. In masters training in Marriage and Family Therapy students are exposed to so many theories and models of therapy it can be difficult to know one way of doing therapy before it is time to learn the next one. It can be tempting to believe one has to know every single model of therapy perfectly, which is, of course, completely unrealistic. Circles of Clinical Fluency is one way of prioritizing and organizing theories and models of therapy which aims to broaden a therapists’ clinical fluency while preserving the therapists’ core sense of clinical identity and resulting in better therapist-client fit.

To grasp this way of organizing theory and therapy, imagine three concentric circles that look like a target with a center bullseye. The center bullseye is the therapist clinical heart language, the theories and models that resonate most with how the therapist is bent. The second circle is populated by theories and models wherein the therapist is clinically fluent and can pivot to seamlessly if needed. The outer circle is comprised of theories and models of therapy and other popular clinically related information that may be familiar to clients in which the therapist is conversant. When a therapist has a solid core, a strong middle circle, and an expansive outer circle, I hypothesize there is an increased chance of therapist-client fit.

Clinical Heart Language

Each therapist should have 1 to 3 models of therapy or perhaps an integrated model of therapy wherein they live their lives. This model of therapy is so similar to how the therapist thinks, feels, behaves, interacts, and engages the world that it hardly makes sense to limit its assumptions to therapy. It’s just how life works. It is how the therapist understands the world. This is the model of therapy that made so much sense in the training program. This is the model of therapy the therapist comes back to time and time and again. It is the model of therapy that when the therapist first met the model, there was an intense familiarity and maybe even some relief. It just made sense. Some therapists find that when they discover this model of therapy they learn more about themselves than any other model or perhaps anything else in their entire lives. The model has served to reveal something already true about the therapist.

This is the clinical heart language. Therapists find it easiest to do therapy while speaking their clinical heart language. It is easiest to be very genuine and authentic in therapy and it feels less like work and more like a meaningful and helpful conversation.

In order for there to be good therapist-client fit, the therapist must come to therapy and be fully present and full alive in session. It is often easiest to accomplish this task while doing therapy in the therapists’ clinical hearth language.

Clinically Fluent

Each therapist should be clinically fluent in 5-7 varied models of therapy. Clinically fluent means that even though it is not the therapists’ first clinical language, the therapist is competent to do therapy using that model.

When considering therapist-client fit, sometimes the client is simply not all that responsive to the therapist’s clinical heart language. Because of client factors, it may not matter how genuine and skilled the therapist is at CBT. If the client makes sense of the world in a narrative way, the CBT approach may feel too mechanical, too formulaic, and too constricting. It could be true the other way was well. If the client is responsive to the logical and straight forward approach of CBT, but is met with the therapist doing a master job at storying and re-storying, therapy might not get too far.

The point is that the therapist can work their model as much as they want, and most of the time that will suffice, but when it does not, it is incumbent upon the therapist to pivot to another model that may be better for the client and leave their cherished model behind.

In the common factors research, we understand that it is at least as important (and possibly more important) to be an empirically-validated therapist as it is to use empirically validated treatment models. When a therapist is able to pivot seamlessly from their heart language to another clinical language in which they are fluent, it increases the chancres of good therapist-client fit.

Clinically Conversant

Each therapist should be clinically conversant in as many models of therapy as possible as well other clinically related concepts that are in the zeitgeist of the general population. For example, although the MBTI (Meyers Brigg Type Indicator) is not a model of therapy, there are millions of people who are able to tell their letters (e.g., “I am an INFP”). Whether the therapist believes there is any clinical utility to knowing their type, clients often make major life decisions based on their beliefs about their type or the types of the people around them. Another example of being clinically conversant is with a personality typing system called the Enneagram. Again, it is not a model of therapy and it is not clinically validated, but it is emerging in popularity. Knowing that there are 9 types and being conversant in them might help to widen that outer circle and empower the therapist to increase the chances of strong therapist-client fit.

This third circle is sort of the ‘liberal arts’ of psychological and systemic consciousness. Being able to discuss anything can help pave the way to excellent client care.

We all strive to give clients the very best care we can. There are hundreds of models of therapy out there and there is no way to know them all. Circles of Clinical Fluency is a way to prioritize them with an aim toward therapist-client fit.

Developing Your Voice

it can be tempting for early career therapists to believe that the right model of therapy, the right theory, or the next empirically validated technique will be the thing that makes them a great therapist. In their best efforts to provide the very best care for clients, and perhaps to ease their anxiety about doing good work, early career therapists may reach for something "proven," "validated" or even "magical" in order to be worth the fees they charge. 

Yes, it's tempting. 

Don't give in. 

No one else but you can talk out of your mouth but you. Your voice, and your voice alone, will ever speak effectively in the therapy sessions wherein you are the therapist. 

The purpose of theory, models of therapy, and the myriad techniques available is not to remove the therapist from the equation, but instead they exist to shape the therapist. You are not to lose your voice in these tools of therapy, but instead you are to find your voice, refine your voice, strengthen your voice, and make a contribution to the lives of your clients that you alone can provide. 

If your goal is to become someone else with all the training, reading, and rehearsing, then the best you can do is a fair impersonation of someone else. You may be able to mimic Susan Johnson or Bill O'Hanlon, but you are obviously not them. Do not solve for how to be your mentor or clinical hero or how to "nail" the model of therapy, but instead seek to develop the part of you that your mentor, hero, or model of therapy calls to in their work and in those techniques. Becoming the vest best clinical version of yourself is the goal for early career therapists. 

And mid career therapists. 

And late career therapists. 

You can do empirically validated therapy all you want, but if you are not actively becoming an empirically validated therapist, you will never be the best you can be. Do clinical work in your voice as shaped, coached, and refined by everything you learn. 

Listening To Your Body and Heart

Listening to Your Body and Heart

Have you ever been in a session with a client and felt something in your body or had an unexpected emotion? Maybe your stomach squeezed a little or you furrowed your brow unintentionally. Or perhaps you experienced a vague and dull sense of dread. If this ever happens, listen to it. Your body is trying to tell you something.

In general, we listen with our minds to learn content and to observe nonverbal and relational process. However, we listen with more than our cognitive minds. Beyond what you can observe cognitively, you may detect something with your body or with your emotions before detecting it with your mind. Your body is listening with more than its ears.

When you do feel something with your body or something emotionally in session, it probably means something, though not necessarily. Since it could mean something, it is best not to ignore the experience. Instead, it is better to explore what your body is trying to tell you and what your emotions are trying to tell you.

Here are a few questions to help you explore what your emotions and body might be trying to tell you:

1. Whose feelings am I feeling? 
This is an important question because sometimes your efforts at empathy can result in more than just locating, observing, and articulating a client’s emotional state. You may actually begin to feel the client’s feelings. Of course it is not an exact shared experience as you are different people, but it may indicate that the emotional boundary between therapist and client is to ambiguous and may need some better clarification. There is a substantial difference between excellent empathy and emotional enmeshment. It is important to distinguish the difference and evaluate whose feelings you were feeling and explore why.

2. Am I mirroring the client?
Slightly different than feeling the client’s feelings is mirroring the client’s feelings. There are times when the therapist serves as a reflection of the client or the therapeutic relationship serves as a mirror to the way client’s interact with other people. In mirroring the client, emotions or sensations in the body may emerge. Mirroring the client may help the therapist have great insight and empathy for the client, but mirroring must be intentional and be used for building therapeutic alliance, doing assessment, or intervening (or all of these) and not merely as a uncritical response to the client.

3. Is there something wrong?
Sometimes your body can sense danger or threat that cannot be cognitively detected. Usually it is not the case that there is danger, but it is worth asking the question of your emotions and body. It could be that there is nothing wrong with the client or threat from the client, but instead, interacting with the client has in some manner uncovered something of great important or urgency in your own life. Sometimes it is an unspoken client issue. Perhaps the client has some unspoken level of desperation or fear that was not present in previous sessions, perhaps a new bout of suicidal ideation that is unspoken but expressed in almost imperceptible non-verbal nuance. Sometimes it might be worth investigating with the client.

4. Has the client shown me something I have seen before?
This question has to do more the therapist’s family of origin and non-clinical experiences. It could be an indicator of therapist past trauma, negative experiences, or persistent and unresolved family of origin issues. The interactions with the client may have touched some muscle memory or emotional memory that has nothing to do with the client at all, but instead connects to the therapist’s past.

When we listen in therapy, we must listen with all of our senses and we must listen with our body and our emotions. When we listen as a whole person, we can so much more. And when we hear more, we increase the care we are able to provide for ourselves and our clients.