A narrative approach to strategic eclecticism.
In recent years, there has been increased literature in the field of mental health counseling regarding the merits and limitations of eclecticism (e.g., Blocher, 1989; Ginter, 1988, 1989a, 1989b, 1993, 1996; Harris, 1991; Hershenson, 1992; Hershenson, Power, & Seligman, 1989a, 1989b; Kelly, 1988, 1991; McBride & Martin, 1990; Nance & Meyers, 1991; Simon, 1991; Weinrach, 1991). A variety of eclectic models have been developed in counseling and psychotherapy, including prescriptive eclecticism (Frances, Clarkin, & Perry, 1984), radical eclecticism (Robertson, 1979), systematic eclecticism (Patterson, 1989), and technical eclecticism (Lazarus, 1989). Several authors (Colapinto, 1979, Liddle, 1982, Patterson) have suggested that the proliferation of eclectic models is reflective of a growing realization that no single clinical theory is adequate to account for all types of problems and clients. Although there is a lack of consensus regarding the meaning of the term eclecticism, many writers have discussed the importance of combining theories and techniques in a systematic manner (Fraser, 1984: Ginter: Guterman, 1991, 1992: Liddle; McBride & Martin: Simon).
Held (1984, 1991) has set forth strategic eclecticism as a basis for using theories and corresponding techniques from virtually any clinical system within the change process of another model. According to Held, strategic eclecticism allows for the systematic selection of disparate theories and techniques within a process-oriented model that emphasizes
a theory of change rather than the content to be changed. For example, Held (1984) has shown how the theories and techniques from various clinical systems can be incorporated within the change process of the interactional therapy model developed at the Mental Research Institute in Palo Alto, CA (Watzlawick, Weakland, & Fisch, 1974). Guterman (1996a) has similarly developed a solution-focused approach to strategic eclecticism. In each of these eclectic approaches, the metatheory (i.e., interactional therapy and solution-focused therapy) used to incorporate theories and techniques is stated so generally that it allows for the incorporation of virtually any content within its change process.
In this article, we propose that narrative therapy (White, 1995, 2000; White & Epston, 1990), a process-oriented model informed by postmodernism, serves as a useful framework from which to develop a strategic approach to eclecticism. In the past quarter century, postmodernism has emerged as an influential intellectual movement and has recently been considered in the mental health counseling literature (D'Andrea, 2000: Ellis, 1996, 1997a, 1997b: Ginter, 1997; Guterman, 1994, 1996b: Rigazio-DiGilio, Ivey, & Locke, 1997). Postmodernism holds that human experience is language-based and socially constructed (Derrida, 1989: Gergen, 1985; Lyotard, 1984). Various clinical models have been developed in keeping with a postmodern perspective. Although different in some respects, these postmodern models all emphasize the important role of language and a collaborative approach to working with clients (Anderson & Goolishian, 1988; de Shazer, 1991; White & Epston).
In narrative therapy, problems are conceptualized in terms of narratives that are influenced by one's culture. White and Epston (1990) have referred to these narratives as dominant stories. According to White (1995), a dominant story that has been reinforced by one's culture and thereby internalized is a habitual pattern of construing a situation or issue. The change process in narrative therapy involves helping clients to identify unique outcomes and create more preferred stories about problems and their lives (White, 1995, 2000: White & Epston). Narrative therapy is a fitting metatheory for strategic eclecticism because its dominant stories are stated so generally that it does not prescribe or proscribe what the stories shall be. Accordingly, mental health counselors can use theories and techniques from other models in a compatible way within the change process of narrative therapy.
A narrative approach to strategic eclecticism also speaks to the need for convergence between the modernist and postmodernist perspectives and, in particular, an increased understanding of other therapeutic models (Hansen, 2002; Johnson, 2001; Linares, 2001). Referring to this shift in thinking, Linares has borrowed the term ultramodernism (Marina, 2000), a view that allows for rapprochement between postmodern thinkers and those in the modernist camp. According to Linares, an ultramodern perspective "describe[s] what may be a way of moving beyond postmodernism in an integrative way" (p. 410). Indeed, the history of philosophy reveals that there has been a persistent dialectic between the endorsement of subjectivist and realist epistemologies (Linares; Russell, 1977). Strategic eclecticism addresses the need to go beyond the distinction between subjectivity and objectivity (Keeney, 1983) by allowing for the systematic and compatible use of a multitude of theories and techniques.
This article is organized as follows: First, the theory and practice of narrative therapy are described. Next, principles and guidelines for employing a narrative approach to strategic eclecticism are explicated. In that section, the process/content distinction (Held, 1984, 1986, 1991, 1992; Prochaska & DiClemente, 1982) is used as a lens from which to contrast divergent theories and techniques and, also, to make sense of their application within a strategic approach to eclecticism. A case example then is provided to illustrate the application of strategic eclecticism within a narrative therapy approach. Finally, directions for future research and theory building are considered.
In recent years, an increasing number of clinical models have emphasized a narrative approach to conceptualizing problems and change. The pioneering narrative model was developed at the Dulwich Therapy Center in Australia (White, 1995, 2000; White & Epston, 1990). For purposes of this article, narrative therapy hereafter refers to the model developed at this center. Narrative therapy is informed by various postmodernist theories, including the social constructionist position that people's views of so-called reality are intersubjective and language-based (Gergen, 1985). Put simply, people create notions of truth and knowledge through the conversations they have with one another (Hoffman, 1990). Narrative therapy is also unique by way of its application of Foucault's (1987) analysis of knowledge and power. According to Foucault, oppressive ideas develop in social, cultural, and political contexts and, thereby, impact individuals. In narrative therapy, clinical problems thus are understood as the result of restraining narratives that are influenced by one's culture. White (1995) has referred to these problems as dominant stories. One of the main goals of narrative therapy is to help clients create more preferred stories about their lives. Narrative therapy usually involves the following four phases: (a) mapping the influence of the problem; (b) identifying unique outcomes; (c) "restorying"; and (d) formulating tasks, interventions, and the frequent use of letter writing and other narrative exercises.
Mapping the influence of the problem refers to the assessment process in narrative therapy. During this phase, a line of questioning is presented to help the client understand how the problem has influenced his or her life. This process serves to increase opportunities for identifying unique outcomes (described below) and, also, to externalize the problem by helping clients view themselves as separate from their problems. When mapping the influence of the problem, mental health counselors ask how the problem has affected various aspects of the client's life, including relationships, work, and daily functioning.
After mapping the influence of the problem, counselors help clients to identify unique outcomes. In narrative therapy, unique outcomes refer to those behaviors, thoughts, and feelings that contradict the dominant story (White & Epston, 1990). The purpose of this phase of narrative therapy is to encourage clients to acknowledge exceptions to their problems that might not have otherwise been considered significant and, in so doing, to assist them with creating a sense of agency. Questions aimed at identifying unique outcomes include, "When has there been a time when you did not experience this problem?" or "When have you been able to overcome the problem?"
After identifying unique outcomes, the client is helped, through various lines of questioning, to amplify and ascribe meaning to those instances. This process, referred to as restorying, is designed to empower clients with a sense of self-efficacy. Restorying questions include, "What does this (i.e., the unique outcome) say about you and your ability to deal with the problem?" and "What are the possibilities?"
Then narrative therapy involves formulating tasks and interventions designed to identify unique outcomes and enhance the restorying process. In keeping with a narrative focus, this phase often employs writing exercises to help clients work toward the goals of treatment. Often clients are encouraged to put a name to their problem during the externalizing process of narrative therapy (e.g., a client's anger might be named the "angry monster"). This client might then be instructed to write a letter to the angry monster. The letter might take the form of the client's expression of determination and commitment to not permit the problem to become overpowering.
Strategic eclecticism allows for the systematic, compatible, and effective application of diverse theories and technique within a metamodel (Duncan, Parks, & Rusk, 1990; Guterman, 1996a; Held, 1984, 1991). The term strategic is used here to refer to an effort on the part of the mental health counselor to tailor conceptualizations and interventions to account for the uniqueness of each client and problem and, thereby, to facilitate the change process in an effective manner. Duncan, Parks, and Rusk have proposed a rationale for strategic eclecticism as follows:
Should [a client's worldview] appear congruent with a particular theoretical orientation, the therapist may utilize that content to structure the intervention. Presenting the concern in the language of a particular approach (e.g., framing client complaints of depression, malaise, and meaninglessness from an existential perspective) may enable a reorganization of the meaning system which supports the problem process. (p. 572)
Hence, if the theories and techniques from another model fit with a client's worldview or if the client initiates presentation of such content, it may be used within the change process of narrative therapy.
Held (1984, 1986, 1991, 1992, 1995) has used the process/content distinction as a lens from which to describe strategic eclecticism. In this article, the process/content distinction is similarly used to contrast divergent theories and techniques and, also, to clarify the use of strategic eclecticism within narrative therapy. Several authors (Held: Prochaska & DiClemente, 1982) recently have drawn a distinction between the process and content aspects of counseling. The terms process and content address two fundamental questions that pertain to all models: (a) What is and is not a problem? and (b) How do mental health counselors go about helping clients to change? Process refers to what is done to bring about change (i.e., interventions, methods, and techniques). Content refers to the object of change in any given clinical theory.
Held (1991, 1992) also has defined two levels of content: formal content and informal content. Formal content refers to the clinician's assumptions about the causes of problems--that is, "explanatory concepts that must be addressed across cases to solve problems" (Held, 1992, p. 27). Informal content refers to the client's more subjective assumptions about the causes of problems (Held, 1991, 1992). All models necessarily take a position regarding formal content. For example, in Freud's psychoanalysis and Skinner's behavior therapy, formal content is defined as repressed complexes and environmental contingencies, respectively. Furthermore, all models tend to fit informal content within their formal content during the change process. Thus, in both psychoanalysis and behavior therapy, and in virtually all models for that matter, the client's understanding of the problem (i.e., informal content) is reframed in terms of the clinician's theoretical lens (i.e., formal content).
The formal content in narrative therapy is dominant stories. Similar to other process models, the formal content in narrative therapy is stated generally; that is, the specifics of the dominant stories are not elaborated and, instead, the client's informal content is the principal metaphor used in treatment. Because the formal content in narrative therapy is so general, it allows for the conceptualization of formal contents of other clinical systems as informal contents (i.e., as metaphors rather than as objective depictions of the domain of problem formation and change) that are, in turn, incorporated at narrative therapy's formal content level. The use of formal contents from other schools as informal contents within narrative therapy need not be restricted to instances when clients initiate such ascriptions. Mental health counselors not only become influenced during the change process by learning and incorporating the client's worldview, but also teach clients when appropriate (Guterman, 1994, 1996a). Thus, if consistent with the client's problem and worldview, mental health counselors may introduce clients to theories and/or techniques from other clinical systems at the informal level, in hopes of then using these at narrative therapy's formal level during the change process. A case example is provided to illustrate the use of strategic eclecticism in narrative therapy.
A 42-year-old woman defined her problem as being depressed for the past 5 months following a divorce from her husband of 12 years. She stated that since the divorce she had felt that she needed her ex-husband in order to be happy and that she was a failure because her marriage had ended. The client acknowledged that these perceptions were probably unrealistic and that they were contributing to her depression. On the basis of the client's insight and, in particular, her understanding of how thinking influences feelings, the mental health counselor decided to incorporate rational emotive behavior therapy (REBT) (Ellis, 1995) theories and techniques within the narrative change process. In REBT, clinical problems are viewed as largely the result of irrational beliefs that consist of demands that humans place on themselves, others, and life conditions (Ellis). The formal content in REBT is conceptualized as irrational beliefs. The change process in REBT involves helping clients to replace irrational beliefs with rational beliefs. Various techniques are used in REBT, including cognitive disputing of irrational beliefs, behavioral tasks, and imagery exercises.
Toward the end of the first session, the mental health counselor initiated an educative phase of treatment, including presenting to the client the basic principles of REBT. In addition, the client was asked to obtain and begin reading an REBT self-help book before the second session. During the second session, the client reported that she had started to read an REBT self-book (Ellis, 2001) and had found it helpful. The mental health counselor and the client reached a consensus that the client's depression was largely the result of the irrational belief, "I must be loved by my husband and have a successful marriage in order to consider myself a worthwhile person" (Ellis, 1995). Although irrational beliefs are traditionally conceptualized as formal content from an REBT perspective, in this case the client's irrational belief served as informal content insofar as it was subsequently reconceptualized by the mental health counselor as the formal content of narrative therapy. Hence, the client's irrational belief can be understood in terms of formal content-as-informal content used at the formal content level of narrative therapy.
In this case, the irrational belief, "I must be loved by my husband and have a successful marriage in order to consider myself a worthwhile person," served as the dominant story. In keeping with the change process in narrative therapy, the mental health counselor encouraged the client to map the influence of the irrational belief in relation to various aspects of her life. The mental health counselor then helped the client to identify unique outcomes by asking, "When has there been a time in the past 5 months that you did not place on yourself this demand to be loved by your ex-husband or to have succeeded in your marriage?" The client reported that at various times during the past week there were instances when she experienced a major difference in her thinking. For example, the client noted that on one evening she convinced herself that the divorce was not indicative of her worth as a human being but, rather, was merely the result of discord in the marital relationship. The client also identified times when she thought to herself that she would find happiness in life without the love of her husband.
After the client identified these and other unique outcomes, the mental health counselor helped her to amplify and ascribe meaning to these instances through the restorying process. The restorying process led to the client's understanding that her worth as a human being is not contingent on whether or not she is loved by another person or is successful in her relationships. Then, various REBT techniques were used to reinforce and build on the client's progress. For instance, the mental health counselor instructed the client to use REBT's cognitive disputing and complete REBT self-forms to aid in the identification and disputing of irrational beliefs. In addition, the mental health counselor asked the client to keep a log of instances when she found that she was thinking, feeling, or acting against the irrational belief that was identified in treatment. At the start of the third session, the client identified numerous unique outcomes. For example, she stated that since the second session she had caught herself slipping back to feeling depressed on several occasions. She then quickly identified and disputed the irrational belief and, as a result, felt much better. At the end of the fourth session, the mental health counselor and the client agreed that there was sufficient progress and that further treatment was no longer needed.
It could be argued that the clinical applications in the preceding case resulted in an approach that is indiscernible from the REBT model from which these applications have been borrowed. Ellis (1977) might argue, however, that a narrative therapy model, only occasionally using REBT theories and techniques, results in an inelegant version of his approach that fails to produce a profound philosophic change in all of the client's core irrational beliefs. Hence, the defining feature of Ellis's approach, the client attaining new core rational beliefs, might not be actualized when using REBT within narrative therapy. However, such a large scope of change as sought in REBT might not be deemed necessary by the mental health counselor and the client. In such cases, the narrative approach uses REBT to accomplish different goals.
Questions arise as to what distinguishes narrative therapy from the other models, especially those informed by modernist epistemological conceptions, that are used within its strategic approach. Hansen (2002) has pointed out that in a modernistic context, counseling models seek to maintain some degree of exclusivity from other models. According to Hansen, "each approach [in a modernistic context] purports to have discovered the most important determinants of the human psychological condition and mental healing (e.g., cognitions, unconscious conflict)" (p. 317). As a result, models operating consonantly with modernism tend to posit theories that are mutually exclusive from one another. The approaches informed by postmodernism, on the other hand, are not organized by any such claims of truth about the causes of problems and change. As a result, the postmodern models are able to incorporate competing theories of counseling within the change process. Hence, narrative therapy's primary emphasis, like other postmodern approaches, is on change processes, rather than on the formal content to be changed.
The approach described in this article speaks to one of the main rationales for eclecticism, namely, the need to tailor conceptualizations and techniques to fit with the unique aspects of each client and problem. Along similar lines, Held (1984) has suggested that strategic eclecticism is desirable "because of the uniqueness of different therapy cases that require different theoretical and methodological underpinnings" (p. 237). Indeed, the process-oriented models that are informed by postmodernism--for example, solution-focused therapy (de Shazer, 1991), the collaborative models (Anderson & Goolishian, 1988), and narrative therapy (White & Epston, 1990)--provide mental health counselors with a great deal of choice as a result of their positing such general theories of problem formation at the formal content level. A strategic approach to eclecticism affords the mental health counselor with many theories and techniques that might otherwise not have been considered within a narrative model. Moreover, the formal content of narrative therapy and its corresponding theory of change serves to guide the change process. For example, in the case described, the mental health counselor instructed the client to identify unique outcomes in relation to the irrational belief and, thereby, effect a restorying process.
The preference to avoid imposing predetermined content during the change process can result in the mental health counselor feeling less than grounded during the change process. Questions remain, however, regarding precisely how mental health counselors might be guided in their selection among so many disparate theories and techniques within a narrative approach to strategic eclecticism. Colapinto (1979) has suggested that "there must be idiosyncratic, implicit models operating behind the strategic decisions of eclectic therapists" (p. 439). Future research could focus on identifying the criteria from which mental health counselors choose theories and techniques within a narrative approach to strategic eclecticism and the effectiveness of their choices.
Finally, strategic eclecticism and, in particular, the approach set forth herein speaks to various writers' (Johnson, 2001; Linares, 2001) call for convergence between the modernist and the postmodernist schools. Indeed, strategic eclecticism might hold promise for the systematic development, refinement, and expansion of numerous divergent counseling models. Mental health counselors can follow the process set forth in this article of invoking pertinent rationales for using theories and techniques from other models, and then modifying those theories and techniques as necessary to retain, while at the same time enhance, the integrity of the model of their choice. Such applications may well be enriching so long as mental health counselors recognize the necessity of clarifying, distinguishing, and respecting their chosen model's integrity.
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Jeffrey T. Guterman and James Rudes are assistant professors in the Counseling Program of the Adrian Dominican School of Education at Barry University. Miami Shores, FL. E-mail: email@example.com
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|Publication:||Journal of Mental Health Counseling|
|Date:||Jan 1, 2005|
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