In the following essay, I have chosen to speak about the concept of engagement as I feel it is a very important aspect of family therapy if it is to be a success. In my work as a nurse in the self-harm team, looking after young people between the ages of 12-18 who are experiencing self-harm, suicidal ideation, and/or suicide attempts, I am often meeting with families in a crisis situation. This calls for a rapid engagement with the young person and their families in order to manage the crisis quickly and effectively. Such rapid engagement, often with very little information at referral poses as a challenge, with numerous barriers to developing a therapeutic relationship, especially with the young person where containment and safety is the main focus in the initial stages as opposed to trying to find ‘the problem’.
I will first consider the strengths and weaknesses of the concept of engagement and then go on to consider how this concept may have been useful when working with the family I will present, and the barriers I face that make the concept of engagement often a difficult one due to the nature of the crisis intervention work that I do.
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''Engagement is a complex, reciprocal process concerning the relationship between the therapist and family. It refers to the specific adjustments the therapist makes to him/herself over time to accommodate to the particular family'' (Jackson and Chable, 1985:65).
According to Flaskas (1997), this definition continued to be worth repeating due to its emphasis on engagement as a continual relational process and because it explicitly prioritizes the therapist's use of self (268). The therapist's use of self in family therapy has been seen as ‘the most powerful tool in the process of changing families’ (Minuchin and Fishman, 1951, Chapter 3:32).
During the early years in the development of family therapy, weaknesses of engagement theory were that there was very little emphasis on the therapeutic relationship and more on technique. For example, Sim Roy Chowdhury (2006) claimed that, during the first forty years in the development of systemic family therapy, the therapeutic relationship has not been seen as a central concern to writers (153). Early structural and strategic family therapy theory traditionally placed an emphasis on the application of technique by a therapist and a strong theoretical rationale for the development of a good therapeutic relationship was not an advanced one (154). This was further reinforced by The Milan Group who proposed that the therapist should strive for a position of neutrality (Palazoli et al.,1980 in Roy-Choudhary 2006). Such privileging of technical expertise over the therapeutic relationship led Treacher (1992) to remark that 'major schools of family therapy are predominately scientistic and anti-humanist (26) and have failed 'to explore how clients feel about being in family therapy(27).
During the 1980s and 1990s neutrality was reframed as a ‘state of activity, whereby the therapist's curiosity was to maintain a respectful engagement and allow for the possibility of new types of conversations (Chechin, 1987, 1992, in Roy Choudhury, 2006:154). At this time attention was increasingly turning to the therapist and the position they may take in relation to the family.
In the earlier years, in his work on ‘joining’, Minuchin claimed that ‘the therapist must, from the beginning take some sort of leadership role’ (Minuchin and Fishman, 1951, Chapter 3:28). Alternatively, Anderson and Goolishan (1988) encouraged therapists to adopt a non-expert, ‘not knowing attitude to therapy to enable the therapist to have a respectful curiosity that would allow for new possibilities to develop in these type of therapeutic conversations. Reflexivity in the therapist began to be encouraged ( Roy-Choudhury, 2006:154).
Flaskas (1997) looked at the process of engagement as a way of exploring the therapeutic relationship, arguing for the need for a radical extension of the idea of engagement in systemic therapy and speaking of the 'historical failure of systemic therapy to theorize engagement as a relational process and advocated for the need for the development of a much broader understanding of engagement (264).
In more recent times, Tuerk et al (2012) stated that a fundamental assumption of the new generation of evidenced-based family therapy approaches is that family engagement and collaboration are essential for therapeutic progress (168). In the 21st Century, there is less emphasis on techniques and more on the process of family therapy as a series of collaborative conversations (Dallos and Draper, 2010:245). “Collaborative relationship” refers to how we orient ourselves to be, act and respond so the other person shares the engagement and “joint action” (Shotter, 1984, in Anderson, 2012:14).
The names of the family I will discuss have been changed for reasons of confidentiality. I was asked to attend the Children’s ward to carry out an urgent risk assessment on Anna, an 11-year-old girl who had been admitted the previous evening due to suicidal ideation that her mother Jenny, had been struggling to manage. Her mum had been witnessing a significant decline in Anna’s mood for the past 12 months but in particular the past few weeks. Anna had reached a crisis point where she was having constant thoughts of not only hurting herself but other people as well. This was causing her extreme distress and she had arrived at a point where she no longer felt safe, even with her mum who was very supportive and loving. She was scared of her own thoughts, felt out of control, and needed to go to a place of safety.
Anna is an only child who lives with her mum. She had chosen to cease contact with her dad 1 year ago due to his alcoholism. She described him as ‘a rubbish dad’. She felt let down and disappointed by him and the ceasing of contact coincided with the decline of her mood.
My attendance at the ward was to establish whether Anna would be deemed mentally fit to be discharged. Having received the referral only 1 hour before, I had very limited information. Name and reason for admission, and that mum was with Anna was all I had to go by. With a routine referral I would have more information, and time to prepare, a letter would have been sent to the family and they would also have time to prepare. Attending to an urgent referral does not allow for this.
Arriving at the ward I am met with a very unhappy, sad-looking young girl who has had no sleep. Mum is clearly worried about her daughter. On reflection, I realize they have expectations of me before I have arrived. They have been told Anna cannot go home unless I say so. Does Anna want to go home and does mum want her home? Does Anna have the expectation that I will help her feel better? My agenda is one of containment and safety, and I have to build an instant rapport with them both to complete the assessment. This inevitably means that no matter what the ‘problem’ is, it will not get addressed in this appointment and this often leaves the young person feeling unheard. From the moment I arrived, it was clear that Anna did not want to go home. She was distressed and agitated but she did not warrant admission to a psychiatric unit and this would have been no benefit to her. She was telling me she was very scared of her thoughts and worried she would hurt her mum. Despite this, she was mentally fit to go home.
I remember thinking that Anna was telling me her story, and how she felt, and I could feel her level of distress, but I was the one making the decision to send her home. She did not feel listened to and told me that herself. I was engaging with Anna from what felt like a position of authority, a leadership position like Munichin (1951) suggested was necessary from the beginning (28). I felt uncomfortable with this. Immediately Anna does not trust me, I imagine she must feel her voice isn’t heard and I can understand why. I cannot admit her to a psychiatric unit, my hands are tied, and the relationship between me and Anna is already broken.
Mum, on the other hand, is coming from a position where she desperately wants her daughter home. She knows her daughter is safe with her and she is getting what she wants. I can imagine that she feels heard. Despite both mine and Jenny’s attempts to get Anna to believe that she will be safe at home, her distress is stopping her from doing so. I wondered whether she felt ‘ganged up on by us. I was in a position where I was agreeing with her mum and disagreeing with Anna’s wishes.
I was able to build a rapport with mum only. The position of neutrality was not an option and usually never is under these circumstances. I found myself thinking about the endless barriers to building a therapeutic relationship with young people in these circumstances and whether it was even possible when that person’s problems are seeming to be disregarded in place of safety and containment.
An even bigger barrier to engaging Anna and having any therapeutic relationship develop is the safety plan I discuss with mum. Constant supervision, removal of phone, bedroom door being left open, no privacy. I wonder if Anna feels I am punishing her for feeling suicidal? Again Anna was distressed by this, not only was I sending her home, I was placing sanctions on her for her safety. I remember feeling how task orientated the nature of my job is. I wondered whether there could be another way of working to help young people in this situation have more of a voice and therefore allow for a better engagement when they come to see me in a clinic for their follow-up appointments.
This got me thinking about the difficulty in this situation of working collaboratively with all members of the family. Tuerk et al (2012) looked at engagement and collaboration strategies that have empirical support in helping young people and their families experiencing serious behavioral problems. They identified a number of successful strategies including reflective listening, empathy, hope and reinforcement, authenticity, and flexibility. When reflecting on my engagement with Anna and Jenny, I realized that it would look as though I had been working collaboratively with mum and the ward staff, but not necessarily Anna. For example, reflective listening requires the therapist to be able to summarize both the content and meaning of the conversation in a way that feels supportive to the client (Tuerk et al, 2012:170). In this case, I was listening to Anna, reflecting back to her that I understood her reasons for being in the ward, but I wondered whether she would view this as me being supportive in any way. Mum on the other hand, I felt I was working with, rather than against, as Anna may have seen it. How could Anna possibly see me as working with her, having a collaborative conversation, when I was unable to grant her wish of not wanting to go home?
Rogers (1959) wrote of the importance of empathy cutting across schools of psychotherapy and that to maintain an empathic viewpoint therapists need to demonstrate an ‘intimate understanding of the clients perspective, as though they themselves were experiencing the client's thoughts and feelings (in Tuerk et al 2012:170). On reflection, I wondered whether Jenny had felt I was being empathic towards her. I was able to offer her reassurance that she was acting in the best interests of Anna, able to console her when she was upset. As a mother myself, I could see things from her perspective and relate to her in terms of her wishes for her daughter. But again I imagined that Anna would not feel any empathy from me even though I believe I was offering it to her. Her young age would mean she could not understand that I was doing what was best for her and not admitting her to a psychiatric unit which I knew would only cause her more distress.
The situation meant I had to be authentic. Being authentic means striving to communicate in ways that are honest and consistent (Tuerk et al, 2012:172). Dallos and Draper (2010) state that for both the therapist and the family, thinking and formulation are more productive, free, and creative when there is a sense of trust and a mutually secure base or sense of safety. They argue that there is no magic recipe for doing this and that an attempt to be honest and authentic is important (158). My engagement with Anna and Jenny I believe was an honest one but on reflection, I wondered whether Anna could appreciate my honesty in any way. She appeared not to trust me, she was telling me she didn’t feel safe, both crucial to an effective therapeutic relationship. I was giving Anna the message that if she was not discharged that day from the Children’s ward, where I knew she felt safe, she would be unable to stay on there and she would be admitted to a psychiatric ward. I was honest with her about what this experience may be like for her and that I felt she would feel less safe there and much safer at home with mum. While I was being honest, I felt as though Anna must be thinking I was not telling the truth and merely saying this in order to discharge her. I had the sense that mum was appreciating me being honest with Anna about what a psychiatric ward may be like and that my authenticity was helping her with what she wanted for her daughter.
Rober & De Haene (2017) looked at Derrida’s concept of hospitality. This concept has been proposed by some authors as an interesting tool to enable reflection on the therapeutic relationship as an ethical relationship whereby the therapist develops a welcoming openness to the client. (378).
Anderson (2012) spoke of mutual inquiry, Mutual inquiry involves ‘an in-there-together process in which two or more people put their heads together to address the reason for the conversation’. In order to set the stage for mutual inquiry, a therapist should be both hospitable and open to learning. The therapist, therefore, becomes both hospitable host and guest at the same time. The ‘host–guest’ metaphor emphasizes the notion that a client is like a foreigner coming to a strange land and the importance of being courteous, sensitive to their uneasiness, and careful to not intrude. Said simply, it is about being mannerly and creating a companionship-like relationship (15-16).
When thinking of about coming from a position of hospitality like this I reflected on how both Anna and Jenny may have perceived me coming to the ward to meet them, and how I viewed myself. Unlike in my clinic, where I view myself as being the host, welcoming families I have had time to prepare for into my office, I very much viewed myself as being the guest in this situation. I had arrived in Anna’s ‘home’ for the night, the hospital bay, where she was feeling safe.
Jenny was very welcoming to me, relieved to see me, and I imagined she would be seeing me both as guest and host. This led to a good engagement with her from the start. Alternatively I was curious as to whether Anna viewed me as an unwelcome guest. This may not have been her immediate perception of me but I imagined that once she had realised I was sending her home she may have seen me as the ‘intruder’, coming into her space, a now uninvited guest. The nature of this kind of assessment makes it hard for me to be the host. Often families can be hostile towards me on my arrival to the ward as they have been waiting for a long time, often feeling distressed about the events that have led them to be there. I imagine for a lot of families I am seen as an unwelcome but necessary guest who they have no option but to engage with. This does not always make for the foundation of a good therapeutic relationship.
Rober and De Haene (2017) argued that the concept of hospitality invites therapists to accept the complexity of therapeutic responsibility in being a supportive presence that necessarily and simultaneously involves the ‘violence’ of appropriation and power difference (380). Derrida used the term ‘violence’ in the therapeutic relationship to mean something that is subtle and unintended and an inevitable part of the encounter between the therapist and client (in Rober and De Haene, 2017:380). When thinking about my own engagement in particular with Anna, the ‘violence’ in the relationship may be seen as me coming from a position of power.
This may have looked intentional to Anna when it is not intentional on my part through choice, my job was to engage her as best I could in the time I had and ensure her safety and containment in the days ahead. As much as I do not want to in these circumstances I have no choice but to use my ‘power’ to discharge patients like Anna.
This has led me to reflect recently on this being a part of my job I feel powerless to change. I would like to be able to give Anna and other patients what they feel they need to help them when they are feeling very distressed but currently I am unable to do so. As a result this often impacts on the relationship I have with them when they come to see me in the clinic the following week for review.
In conclusion, good engagement is fundamental to the therapeutic relationship. Early engagement theories focused on technique and the therapist taking various positions such as one of the leaders or one of neutrality. Engagement theory in more recent times increasingly emphasizes the therapeutic relationship as being central to good engagement with families in order for therapy to be successful. This focuses on a collaborative approach, with all members of the family being involved and heard, and the therapist coming from a position of hospitality where they are open, welcoming, empathic, and most of all authentic.
My reflections on my first encounter with Anna and Jenny have enabled me to think about how difficult it can be in my role to establish a therapeutic relationship with all involved, during a time of crisis and whether a good engagement with the young person in these situations can ever really be achieved and what measures could be put in place, if any, to change this and be able to work in a different way. I am still considering the answers, if there are any, to this question.
References:
- Anderson, H. (2012) Collaborative Relationships and Dialogic Conversations: Ideas for a Relationally Responsive Practice. Family Process. 51(1): 8-24.
- Choudary, S.R (2006) How is The Therapeutic Relationship Talked into Being? Journal of Family Therapy, 28: 153-174.
- Dallos R; Draper, R (2010) An Introduction To Family Therapy 3rd Edition. Berkshire, OU Press.
- Flaskas, C. (1997) Engagement and The Therapeutic Relationship in Systemic Therapy. Journal of Family Therapy, 19:263-282.
- Jackson, S; Chable, D.G (1985) Engagement:a Critical Aspect of Family Therapy Practice. Australian and New Zealand Journal of Family Therapy, 6:65-69.
- Minuchin, S; & Fishman, C.H (1981) Family Therapy Techniques. Harvard University Press, 1981. Cited at ProQuest Ebook Central, https://ebookcentral.proquest.com/lib/nhsscotland-ebooks/detail.action?docID=3300755.
- Rober, P; De Haene, L. (2017) Hopsitality in Family Therapy Practice: A Further Engagement with Jacques Derrida. Australian and New Zealand Journal of Family Therapy, 38:378-390.
- Treacher, A (1992) Family Therapy-Developing a User Friendly Approach. Clinical Psychology Forum,48:26-30.
- Tuerk, E.H; McCart, M.R; Henggeler,S,W (2012) Collaboration in Family Therapy. Journal of Clinical Psychology,68(2):168-178.
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