Post-modern Therapy? Balancing Between Appreciation and Critique

I have a respected friend who calls himself a “postmodern therapist.” When I first heard this term, I was intrigued and disturbed (okay, I was more disturbed than intrigued). As you can imagine, everdaythomist is no fan of postmodernism in general, for very Thomistic reasons, but in terms of therapeutic professions (medicine, psychology), it seemed even more of a stretch to label oneself a post-modernist. “Don’t post-modernists reject the existence of a knowable external reality?” I asked him. “How does that philosophical assumption allow you to help a person who clearly has anorexia, for example, or who thinks your coffee table is a monster? Or what about a person who is actually hurting herself, through, say, cutting. Don’t you think a cutter would disagree about this whole non-knowable external reality?” Everydaythomist must also admit that in her head she was also shouting, “Clearly you are wrong! Admit you are a realist, preferably with an Aristotelian-Thomistic bend, and let’s move onto more interesting matters!

Turns out, my friend calls himself a post-modern therapist, at least in part, to help him avoid doing in a therapeutic setting precisely what everydaythomist did in our conversation: declare himself right, declare the patient wrong, and then proceed to define reality for the patient according to a rigid line of truth reasoning. In a therapeutic setting, this narrow perception of “truth” may both assume more about the patient than may be justified, and may actually do the patient harm therapeutically by talking past her. To understand where he comes from in his therapeutic approach, my friend recommended I read Harlene Anderson’s Conversation, Language and Possibilities: A Postmodern Approach to Therapy. I dutifully did so, and I humbly offer my rather naive reflections in response to my friend. Why not just respond in person, you might ask? Because I am taking Anderson’s post-modern approach and recognizing that our debate does not exist in a vacuum, thus I am expanding the concentric circles of our dialogue to include other “voices” that may be at play (that’s you readers. I encourage you post-modern readers especially to jump in and tell me where I may have erred).

Harlene Anderson offers this book as a response to the many bad ways therapy can be and has been done, and she offers an introductory story of a Swedish family with two anorexic daughters to illustrate her point. The daughters both suffered at the hands of their therapists because they were not listened to, they were not cooperative, they were not flexible. In reaction to such hierarchical and over-confident therapists, Anderson offers her own approach as a “collaborative approach” which she conceptualizes as “a language system and a linguistic event in which people are engaged in a collaborative relationship and conversation—a mutual endeavor toward possibility.”

Anderson may be a therapist and may have written a book to help other therapists, but her therapeutic methods are solidly grounded in post-modern philosophical claims which she pretty thoroughly buys into. Post-modern, to Anderson, means embracing social construction, hermeneutics, and narrative. It means recognizing human systems as “language and meaning-generating systems,” reality as language, meaning as something created through language, and truth . . . well, truth is just the meaning one ascribes to an experience and believes (206) (the index does not include an entry for “truth”). Words do not have essential meanings, but meaning is generated through the use of words. She summarizes near the beginning,

Postmodern thought moves toward knowledge as a discursive practice, toward a plurality of narratives that are more local, contextual, and fluid; it moves toward a multiplicity of approaches to the analysis of subjects such as knowledge, truth, language, history, self, and power. It emphasizes the relational nature of knowledge and the generative nature of language. Postmodernism views knowledge as socially constructed, knowledge and the knower as interdependent-presupposing the interrelationship of context, culture, language, experience, and understanding. We cannot have direct knowledge of the world; we can only know it through our experiences. We continually interpret our experiences and interpret our interpretations.

Anderson buys into the post-modern critique of natural and scientific explanations of human systems. As such, she is also an advocate of social construction theories that reject any claim that knowledge reflects an ontological reality but is rather a construction. Anderson does distinguish between social constructivism and constructionism in that the former regards reality as a construction of the individual mind, emphasizing both autonomy and individualism. Anderson aligns better with the latter which de-emphasizes autonomy in favor of “the interactional and communal context of the meaning maker” (44).

Anderson sees broad implications for this philosophical basis in a therapeutic setting. First, the therapist is removed from the pedestal as the “knower” and is instead placed in collaborative dialogue/conversation with the patient (henceforth called “client” since “patient” assumes the person is sick or needs to be treated, which Anderson does not assume). The therapist, rather than diagnosing, is called to take a perspective of “not-knowing,” to suspend all pre-knowledge and judgment in order to properly hear what the client is saying. Attention is given to the client as a story-teller, and the therapist is called to be fully engrossed in the individual before them and the unique narrative they offer (no note-taking, but lots of questions). The therapeutic session is “public” in the sense that the therapist is frank about her own thoughts, prejudices, and biases, and is also willing to share information about herself. Moreover, to the extent that other voices need to be brought into the conversation, they are invited (family, friends). Finally, therapists are called to honor a client’s story, to take them seriously, and to validate them. She tells the story of Lars, a Norwegian seaman who thought he had a chronic disease and was infecting others. The therapist, Harry asks him

How long have you had this disease? . . . As Harry showed interest in Lars’s dilemma and let him tell his story the way he wanted to, Lars began visibly to relax, even to become somewhat animated, and he began to share in Harry’s curiosity. Harry’s intent was not to challenge Lars’s reality or story, or to talk or manipulate him out of his delusion. Harry wanted to learn about it, be sensitive to it, to maintain coherence with it. Colleagues observing the interview were critical of Harry’s question ‘How long have you had this disease?’ They feared the question reinforced the man’s ‘’hypochondriacal delusion.’ A safer, more neutral question, they suggested, would have been ‘How long have you thought you’ve had this disease?’ The not-knowing position, however, precluded the stance that Lars’s story was delusional (138).

Six months later, Lars’s life is back on track and weather he was infected or not was no longer an issue.

This compelling story reveals both the strengths and the weaknesses of Anderson’s approach. Methodologically, it is good to take patients seriously, at least in practice, to give them a chance to speak, to hear their stories, and to be attentive to the particularities of their needs. It is also good to be humble in psychiatric diagnosis. I am reminded of a Mad Men episode from the first season where Betty, Don Draper’s wife, has been seeing a psychoanalyst for some time who says virtually nothing during their sessions until one day he announces “you have a problem with your mother.” In the episode, Betty is upset, and rightfully so. It may be that the doctor is right, but his answer is not only imprudent in its delivery, it is also likely reductionistic. Betty’s problems are much deeper than her mother, and the therapist need only listen to hear that.

But why do we need a post-modern philosophical foundation to encourage prudence in the therapeutic environment? Why must we deny the existence of an objective, identifiable reality independent of human representations? Anderson is not even completely consistent in her application of her post-modern principle. Lars, she thinks, is delusional. He does not have a disease, and his delusion is disrupting his life. She recommends prudence (though she does not use this word) in dealing with a person like Lars, but if he were to jump out of the chair and start assaulting her, claiming that he heard voices in his head telling him to infect her with the disease, I suspect she would not be so enthusiastic about entering into a stance of “non-knowing for the pursuit of collaborative dialogue.” Moreover, Anderson is convinced that her therapeutic stance towards Lars is right, and his previous therapists were wrong. Sounds like a truth claim to me.

The reality and the truth is that Lars really is delusional and his delusions are hurting the people around him. He needs help, and the therapist is the one to provide that help. I can buy that the most effective help a therapist can give is humble and prudent, but I cannot buy the claim that meaning and truth is just a linguistic construct. Surely, there must be a middle ground.

Realism, and the more recent critical realism, tries to forge this middle ground by recognizing that as human beings, we need truth, we have access to reality, and that language indeed communicates meaning but also points to things that really exist (when I say “ow” and point to the paper cut I got from reading the Summa, I am pointing to something that really exists and that I know, namely, my bloody finger). As a result, statements can be true or false depending on the degree to which they correspond with reality, and reality limits the relative meaning that statements can have. As such, we have a criteria for judging the merit of statements and formulating an appropriate response.

I suspect that Anderson’s post-modern therapy is also a reaction to realism, which has been taken to an extreme in our contemporary world by reducing everything to matter, or to biology. Thus, all psychiatric problems have a biological (or a genetic) origin, leaving little room for the dynamic way in which human behavior is shaped in non-material (i.e. linguistic) ways (this relates to an earlier blog post I wrote on metaphysical naturalism. Anderson would critique such naturalism from the opposite perspective in which I have done). But in her reaction, Anderson throws out the proverbial baby with the bathwater (both of which I am still positing exist, as I bet Anderson does to) and lapses into a metaphysical relativism which is just as problematic as metaphysical realism.

In short, I think my friend is a methodological post-modern therapist, not a philosophical one. Everydaythomist is in no position to tell therapists what to do, but she is in a relative position to judge therapeutic philosophies and ethics. I think my friend likes the idea of listening to clients’ narratives, to deconstructing, at least in part, the extreme therapeutic hierarchy, and to recognizing the individuality and particularity of his clients. But I would encourage my friend to also recognize philosophically and ethically that the client in front of him is real, with real problems and real needs, and the therapeutic task (indeed, the human task in general), is dealing with the real. Just as a person is real, so too can a problem be. Anderson tacitly recognizes the former (hence her emphasis on conversation and collaboration), but not the latter. I see the two as more interconnected.

Part of dealing with the “real,” everydaythomist would also encourage, is recognizing the need for at least some degree of teleology, which even Anderson makes room for in some of her anecdotal accounts. This means recognizing that real things have real purposes (teloi) and that the therapist can be more or less helpful in helping a client achieve these purposes. At one point, Anderson asks a client, “what does it mean to you to be a good mother?” In asking this, she is asking a teleological question, pointing a client to her telos, her end or purpose qua mother. Now, asking the question in itself is teleological—it points the client towards the telos that exists by virtue of the nature of the thing, in this case, the mother. If there are mothers, a teleological position posits, there are good ones and bad ones, and we know the difference by nature if something is not hindering us from this knowledge (like disease). Not that there are not different ways of being a good mother, but there are also clearly bad ways of being a bad mother as well. In many cases, the question itself will suffice for the teleological task (as it does in Anderson’s example, for reasons I would suggest pertain to natural law, but that is a tangent we don’t have time for in this post). But at times, it may require the therapist to softly redirect, as when a client answers something like “It means killing my children that I don’t think are good enough.” A therapist can try and find a prudent response, but prudence demands that the client be pushed a little towards a true telos (or at least restrained for straying too far from her telos).

In conclusion, everydaythomist is still a realist but hopefully has gained a more sensitive appreciation for the way in which post-modern philosophical critiques have contributed both to metaphysical theory and social and ethical praxis. I know that Anderson’s book has at least committed me to the importance of listening and the critical need for conversational humility. And to my friend, I am grateful for these lessons.


6 comments so far

  1. Jeremiah on

    Thanks for reading the book and commenting about it. I would agree with quite a few of your assertions.

    Again, terminology has a lot to do with the disagreement that spurned this blog post. Apparently I am more of a methodological therapist than philosophical, although I do believe in quite a few of the philosophical constructs (i.e. social construction theory).

    Any philosophy taken to its fullest extreme can have negative ramifications, and that includes postmodernism. A true postmodern therapist would let the client talk for an hour without any sort of direction or purpose. In some ways, the act of catharsis is a therapeutic intervention itself, but I imagine a research study on true postmodern posting poor results. As stated, the primary function of postmodern therapy for me has to do with my stance of power and attempting to empower my clients as much as possible by removing my agenda for change and allowing the client to define change.

    Now, I do have some basic assumptions for how I practice everything. For example, I believe that truth is by-and-large socially constructed. Yes, there is God, an absolute truth who has distinguishable features, but my definition of God is different from your understanding of God. And my definition of God was defined through individualized experiences and interpretation of individual/communal experiences. So I have a goal of learning about the client’s life story. I believe that we are involved in systems of some sort (family, sociological), and that every system has a goal of maintaining homeostasis. I believe that most, if not all behaviors are in response to that system–either to enhance, modify, or break away from it. So the questions that I start with stem from that understanding of life.

    Ludwig von Bertalanffy, one of the designers of systems theory, created a term called “equifinality” to define the concept that even though there is one goal, there are many ways to get there. My therapy humbly invites the client to define that path for him/herself, and the postmodern umbrella does a lot better job of explaining how to provide that stance than the modern umbrella (and many other umbrellas) do. Is it a perfect system? No. But what system is?

    Just some thoughts. Thanks so much for reading my book.

    • everydaythomist on

      Thanks, Jeremiah. Out of curiosity, what is your opinion of Barbara Held? If I had more sick time on my hands, I might read her critical realist critique of post-modernism. Regardless of her philosophy, you have to love someone who uses the word “kvetch” in the title of a book!

    • Tasha Chemel on

      I would also call myself a postmodernist, but I also have serious qualms about the models I use, mostly collaborative and narrative. First, I think it is essentially dishonest for the therapist not to let one that he or she has a different viewpoint than the client. In the short term, this might be helpful but it is my belief that this dishonesty strongly affects the therapeutic relationship, even if it is not c consciously perceived. Second, I like the idea of a maethodological postmodernist, and I think the destinction between methodological and philosophical postmodernism is often overlooked, to the detriment of clients. Any one who is working in an agency is by definition a methodological postmodernist, because he or she is choosing to practice postmodernism in a setting where the hierarchy between the agency, the client, managed care companies, and the therapist will never be flattened. The pressure to document evidence of progress, to create a treatment plan means that the therapist at least to some extent is using language to shape and mold the client’s conversations. The client thinks that he or she has created a new, alternative story, but despite the therapist’s best efforts to be collaborative, the story might be more reflective of the therapist’s views than the client’s. Even the vocabulary of narrative therapy is suggestive of hierarchy. There are marginalized stories, subjugated stories and preferred story. One story is always seen as being inferior to another. Ultimately, there are two kinds of talk: talk that promotes the problem story and talk that promotes the so-called alternative story. Therapists are trained to reinforce good talk and redirect from bad talk. It’s put in prettier language, but that’s basically what’s going on. The danger is that the therapist comes to believe he or she fully embraces postmodernism, when that is not the case.

  2. Dan Scheid on

    Thanks for a great post, Beth. I too wrestle with the benefits/contributions of postmodernism. I think it’s Francisco Ayala who marks out three kinds of materialism: 1) Methodological: all that will be considered are material causes, a necessity of empirical science; 2) Epistemological: All that can be known is matter; 3) Ontological: All that exists is matter. It seems Anderson is a methodological postmodernist, and possibly #2, but not #3. One thing I think postmodernism is quite good at is power relations, and the way in which the real can be dramatically redefined and imposed by the powerful. I just showed the movie Food, Inc., to my class, and I was struck by how pervasive new definitions of food have altered how students see the innate teloi of animals and the earth. Let’s discuss more over beer at a conference soon!

    • everydaythomist on

      Thanks Dan, for reading and for commenting. My friend who recommended Anderson I think falls into #1 and *possibly* #2, but I would be tempted to say that Anderson, if pushed, would fall into #3. My friend, however, who did comment in response to the post, believes in God, and so I would hesitate to say that he would fall fully into #2 although he might behave clinically as if he did. I wonder, can you accept #2 and/or #3 and still be a Christian? #3 is definitely a stretch, but it is that tricky #2 that I wonder about. Regardless, I have a lot of work on my hands struggling to understand the diverse manifestations of post-modern theory and the way in which they challenge our field of ethics.

      I appreciate very much what you said about power, and in conversation with my friend after church yesterday, I mentioned how beneficial Anderson’s book was for me in terms of thinking of power dynamics in the classroom. However, I also like to think of Running With Scissors. At one point in the movie, the young Augusten Burroughs says something along the lines of “I just want to be told what to do. I want rules!” In other words, Augusten found the freedom granted by the challenge of authority to be no freedom at all, and as a teenager, he needed the teleological guidance of a benevolent authority who could direct him with wisdom and with prudence. Again, when it comes to power, we need a balance between appreciation and critique. Although, the power wielded by corporations, especially food corporations, may need more critique than appreciation.

      I look forward to seeing you at a conference soon, but I will be limited in how many I can attend once I move to Montana to start my new job! Do you think we could ever convince SCE to come to Helena?

    • everydaythomist on

      Also, Dan, congratulations on the new baby. What do you say? Guest post on the virtues of fatherhood? Can’t wait to meet her.

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