We share our personal and professional journeys through different identity discourses that have shaped our practice as clinical psychologists and systemic psychotherapists working with children, adults and older people within public physical and mental health services. Through examples of our work with children affected by illness and disability, we track the development of our understandings of identity from ‘internal states of self’ to understandings that are relational, distributed, performed, and fluid. Integrating the practical theory of Coordinated Management of Meaning (CMM), Michael White’s Narrative approach, in particular the reauthoring map and Outsider Witnessing with a systemic constructionist approach to identity, we offer a therapeutic approach, the We-dentity Daisy Method, to provide an antidote to some of the more individualised and potentially pathologizing ways of describing young people’s experiences.
This project explored the relational context between parents and their autistic children in middle childhood. Familial, parental and child factors may significantly impact outcomes for autistic children, and represent a vital area for research. Specifically, the influence of the caregiver representations, child attachment patterns and parent–child interactions upon each other were investigated. All three constructs were separately assessed in 11 parent–child dyads (22 participants), with children aged 6–11 years who had received a diagnosis of autism. The study employed a multiple case-study methodology utilising Miles and Huberman’s abductive method of data reduction, display and conclusion development, to explore the complexity and connections in the data. The project highlighted high levels of adversity in the backgrounds of parents of the autistic children; an elevated level of unbalanced caregiving representations amongst the parents; and evidence of high-risk attachment patterns identified in the autistic children. Looking at the interaction of these factors, the study showed: 1. The relational nature of the behaviour of the autistic children; 2. mutual difficulties with emotional engagement, intimacy and co-regulation of affect; 3. the irreducibly unique nature of the relationships between autistic children and their parents, suggesting a need for bespoke, idiographic understanding of them rather than one size fits all explanations; and 4. that security and sensitivity can co-exist with an autism diagnosis, highlighting the limits of attachment theory to explain all difficulties experienced by these families. We suggest that a systemic attachment framework may broaden clinical and research enquiry, revealing the multiple challenges these families are facing, and the significant strengths and resources possessed, offering new avenues of support.
This paper is based on my experiences of becoming a systemic family therapist, reflecting on how my identity and Greek cultural narratives have shaped my practice. A historical overview of first-, second-, and third-order approaches illustrates the evolution of the self of the therapist in systemic therapy through self-reflexivity. Reflecting on my experiences in a multicultural context, I explore the significance of curiosity in understanding how my cultural narratives influence my practice. I examine how my identity is formed and re-formed based on context. To achieve this, I provide practice examples where I attended to my internal dialogues, used supervision, and applied reflective tools such as the cultural genogram. Expanding on these reflections, I propose the Culturally Permissioned Reflexivity Map (CPRM) framework, which integrates insights from the Location, Dislocation, and Relocation (LDR) framework (Draper, Marcellino & Thomson 2023), reflexive mapping approaches, including the Social Identity Map (Jacobson & Mustafa, 2019), the cultural genogram (Laszloffy & Hardy, 1995), and conceptual work on mapping emotional reflexivity (MacKian, 2004). The CPRM framework aims to deepen further our understanding as to how cultural contexts shape which emotions and professional positions feel permitted, silenced or tolerated within the therapeutic and supervisory relationships. The core argument of this paper is that, in therapeutic relationships, therapists should integrate all aspects of their selves to establish meaningful connections with clients. This integration is central to the therapeutic process and facilitates change.
Background: This paper locates the meaning and naming of Systemic Therapy within evidence-based practice. Part of this situated knowledge is informed by our clinical experience within an NHS Trust in North West London. Aims: The paper investigates the evidence base for Systemic Therapy as represented within National Institute for Health and Care Excellence (NICE) guidelines. It also considers the need for competency-based training and examines the implications for how the discipline is described and understood within NHS structures. Methods: The methodology involves a literature review of NICE guidelines and the NHS Long Term Plan. This review addresses five key questions about the status and application of Systemic Therapy within the UK’s NHS context. Results: Findings highlight ongoing confusion about what constitutes Systemic Therapy and the range of models and methods it includes. This lack of clarity presents a barrier to effective implementation and may impede progress toward the aims outlined in the NHS Long Term Plan. Conclusions: We argue for investment in a clinical doctorate in Systemic Therapy, bursaried by the NHS, to support development of a skilled workforce. Clarifying the relationship between NICE frameworks and systemic practice offers an opportunity to improve evidence and healthcare outcomes.
Dissociative shutdown states occur when the individual encounters inescapable stress or trauma – or memories of inescapable stress or trauma. In the therapeutic space – occupational therapy, psychotherapy, or family therapy – working with shutdown states poses a clinical challenge. The individual’s loss of full awareness of what they are doing, or their loss of capacity to feel their body, to think, or to move or act, can bring the therapeutic process to a halt. Over the last half-century, body-oriented therapists working with the felt sense of the body, therapists working with patients presenting with complex trauma, and therapists working with patients with functional/dissociative seizures have introduced the use of grounding strategies to help patients maintain their connection with the body, self, close others, and the environment. This article explores the use of pickle juice (and other pungent foods) as a useful grounding strategy for managing dissociative shutdown states. Clinical examples are provided via vignettes. Also provided are a hypothesis and neurobiological model – the homeostatic sensory-reset hypothesis – as to why pickle juice and other pungent foods, which activate special sensory receptors in the gastrointestinal tract called transient receptor potential channels, help to disrupt and alleviate dissociation shutdown states.
When children display disruptive behaviour problems at school or at home, their relationships with others are affected. Taking a systems perspective into account, where all parts of a system mutually influence each other, and considering the reciprocal nature of interactions which imply that children are influenced by and influence their close surroundings, the present study seeks to examine differences in parents’ self-reported psychological distress and self-efficacy, and associations with teachers’ and parents’ reports of children’s disruptive behaviour problems. Data from an earlier randomised controlled study were used to compare a systemic school-based intervention – Marte Meo and Coordination Meetings – with services as usual. Results showing a decrease in parental psychological distress, as well as an increase in parental self-efficacy. Associations with reports on disruptive behaviour problems home and in school are presented and discussed.
This article explores a variety of chemosensory strategies – pungent foods, ammonia salts, and essential oils – as potentially useful interventions for clinical states of dissociative shutdown (including functional/dissociative seizures); re-experiencing symptoms of posttraumatic stress disorder; and other states involving changes in arousal and a loss of balance in the neural pathways or networks crucial for the processing and integration of somatic, or body-based, sensations, as a result of stress-system dysregulation or trauma-related experiences. All of these states are common in clinical practice. Patients find them distressing as they interfere with normal daily function, quality of life, and capacity to manage the daily challenges of life. Based on the current literature we, the authors, provide an update pertaining to the current knowledge base about the neurobiology that underlies the therapeutic effects and clinical utility of these chemosensory substances. Whilst the use of chemosensory substances goes back into antiquity, our understanding of underlying neurobiological mechanisms is just beginning to emerge.
Background: This study aims to summarize the existing literature on factors associated with post-traumatic stress disorder (PTSD) among parents of children with a neurodevelopmental disability. Methods: A systematic search of three databases was conducted using predefined criteria. Studies were screened for eligibility by title/abstract, followed by full-text review. Data was extracted to capture key information including study characteristics, participant demographics, and factors associated with PTSD. A narrative thematic analysis was employed to identify and categorize findings. Heterogeneity across studies precluded a meta-analysis, thus a narrative review was conducted. Results: From a pool of 15,852 studies, six articles published between 2002 and 2023 were included. Among the factors studied, lower levels of social support, increased caregiving demands, and parent’s history of depression were most frequently associated with elevated PTSD scores. Conclusion: This study offers insights into the factors associated with caregiver PTSD, highlighting the need for future research.
We live in an increasingly polarised world. This paper draws on CMM’s LUUUTT model to explore how polarisation is co-constructed in the process of communication. While humans have always engaged in in-group ‘Othering’ of outsiders as a means of asserting identity and belonging, the digital revolution brought about a radical shift in the way these Othering stories are told. Social media platforms have removed physical, temporal and psychological barriers to engaging directly with the ‘Other’ in extended episodes of ‘moral conflict’. Devoting a greater portion of one’s life to ‘doing’ conflict has profound implications for an individual’s self-concept and perception of the world around them. The tragedy is that the polarisation and division played out over social media rarely delivers the yearned for sense of belonging: The ‘us’ that people seek online remains ultimately chimeric, as acceptability and affiliation is achieved at the expense of authenticity and genuine connection.
There is a noticeable dearth of studies directly analysing the narratives of well-functioning couples. Consequently, this research explores the content of narratives from individuals in relationships deemed to be well functioning. To identify such couples, a triple criterion was employed: (1) participants’ self-declaration of their relationship as well-functioning, (2) evaluation of relationship satisfaction using the Dyadic Adjustment Scale, and (3) alignment with Olson’s Circumplex Model. From this criterion, 20 couples were selected and participated in separate face-to-face narrative interviews. Thematic analysis revealed seven dominant themes: 1. Feelings and mutual attitudes; 2. Us together; 3. Relationship changes and development; 4. Our history; 5. Dialogue; 6. Relationship problems; 7. Children. Such narrations from well-functioning couples, emphasize mutual sentiments, collective memories, dialogue and a pronounced we perspective.
Attachment theory offers a profound conceptual shift in moving beyond individualised explanations to relational ones. With its battery of assessments based on understanding parent-child interaction and relational narratives, the field has built a considerable evidence base for understanding problems as residing between people rather than in people. In this paper, however, we suggest that this very success has led to such understanding ossifying at a dyadic level – a child’s relationship with a specific parent, neglecting the impact of co-parenting relationships on child attachment. For this reason, we sought a means of moving attachment assessment to a triadic level, exploring a child’s attachment to his parents’ relationship not just his parents as individuals. The essential dyadic nature of current attachment interviews such as the Adult Attachment interview (AAI) and the Parent Development Interview (PDI) we argue, means that key aspects of potential attachment self-protective organisation may be missing. For this reason, we developed out of these interviews, a Family Attachment Interview (FAI), that explores both childhood attachment and current caregiving in triadic terms. We suggest analysing this interview using the methodology derived from the AAI and the Meaning of the Child Interview (MotC; a systemically aware way of making sense of caregiving discourse), as a means of understanding family relationships rather than yielding classifications. We illustrate how this could work using a case of a couple in therapy struggling with their couple relationship and parenting, who were given the FAI. The approach is novel and in development and we invite collaboration in taking these ideas forward.
Externalisation is a technique from Michael White’s narrative therapy that is commonly used in treating eating disorders. With anorexia, its use presents challenges particularly with a diagnosis where the person is so strongly identified with it. Separating the person from the problem can sometimes lead to a resistance from the patient who feels that the anorexia is part of them. Sartre’s existential approach is a form of psychotherapy that can help resolve this dilemma of accepting that the anorexia is part of who they are but also challenge how they are objectified by it. In addition, because existentialism is always relational (i.e. we are never a separate subject), these objectifications only make sense with a self-other (i.e. the family or the wider system). It helps the patient to engage in a dialogue with the socially constructed narratives that underly the anorexic presentation. The central aim of Sartre’s work is to overcome objectifications of self and other, and this approach offers an innovative method of challenging these objectifications within families. We explore exercises that may be useful in the clinic with a particular emphasis on the future as a way of tackling anorexia and has implications for other clinical presentations and not only anorexia.
Background: The psychological impact of Domestic violence and/or abuse (DVA) can continue long after the abuse. There is limited research on psychological interventions for people who have experienced DVA historically. This UK based research explores intergenerational dyads meaning making of the DVA and how they navigated its impact. Methods: This research utilised Narrative Inquiry (Riessman, 2008) to explore the stories of two mother-daughter dyads, four total participants who experienced DVA, focussing on how narratives have changed over time and the impact of the dyad’s relationship. A novel design was used in interviewing dyads together and then separately to aid in understanding the impact of the relationship. A total of two joint dyadic interviews and four individual interviews were undertaken across the research. Results: Three collective stories were identified: (1) ‘The relationship with DVA’, (2) ‘Understanding and Connection’, and (3) ‘Right support at the right time’. Within these collective stories were four sub-stories: (1) ‘Acts of resistance’, (2) ‘Mother and daughter’, (3) ‘Failure of services’ and (4) ‘Embodied lives’. These stories were heavily braided together and spoke to individuals’ resistance particularly through their relationships with each other. Conclusion: The research shows dyads who experience DVA are knowledgeable in how abuse can impact them and how they can navigate these impacts. Clinical recommendations that can be drawn from this expertise include: suggestions on vernacular, the necessity for support to be varied in approach and goal, the ability for individuals to access different support throughout their life, the importance of engaging with embodied experiences of distress, the importance of meaning making, the benefits of a more relational-collaborative approach to services management of risk and the value of therapeutic paradigms which privilege relationships, community and navigating intergenerational trauma. This research provides a direction for future research by suggesting the exploration of more heterogeneous groups.
This paper re-visits a familiar family therapy technique, ‘tracking’ which is often regarded to be part of the first phase of family therapy and associated especially with strategic approaches. We suggest that it is consistent with constructivist approaches to family therapy and can be employed in a collaborative way to co-construct and enrich relational narratives. Ideas from attachment theory and neurobiology are integrated to show that circularities are also influenced by the emotional states and physiological arousal of family members. An attachment narrative therapy (ANT) approach is employed to describe how tracking can be understood and employed to promote changes at multiple levels, including attachment relationships. Families are encouraged to adopt an ‘observer’ position on their relationships and in turn to become authors of their interactions in contemplating ways they can chose new avenues of actions. Details of the procedure of engaging in tracking with individuals and families are described with clinical examples.
A significant number of children fulfil a young carer role for parents experiencing mental health difficulties. Young carer research highlights children’s experiences of responsibility and role reversal. This study investigated the retrospective experiences of female young carers for a parent with psychosis-related difficulties, which may pose unique and specific challenges. Seven adults who grew up with a parent experiencing psychosis were recruited. Semi-structured interviews were completed and analysed using Interpretative Phenomenological Analysis. Findings are reported in two parts relating firstly to the retrospective accounts of experiences during childhood; and secondly, the current journey of sense-making. Four central themes were constructed, namely: ‘ Caring was lonely and uncertain, but there were some connections ’, ‘ Learning how to be the parent while still a child ’, ‘ It felt natural, but still difficult to understand ’ and ‘ Gaining empathy and resilience, while experiencing an ongoing impact ’ . Clinical implications include the importance of family-focused interventions and an understanding that the impact of offering this support continues into adulthood.
Mental health work in Norway has undergone extensive market-based liberal shifts in recent decades, which has put time under pressure. While streamlining services is claimed to improve quality of care , researchers have expressed concern about a devaluation of face-to-face relationships. This article explores how young service users experience the role of time in mental health work and how temporal dimensions affect professional relationships. To do so, we draw on the case of young service users from two third-sector organisations that provide low-threshold mental health services in Norwegian municipalities. In total, 14 semi-structured interviews with service users were conducted and analysed through a hermeneutic phenomenological approach. Hartmut Rosa’s theory of resonance, as well as the concepts of chronos and kairos , were applied to shed light on the temporal and relational experiences of participants. The findings showed how time was experienced through presence and availability, including sharing vulnerable moments and being flexible in the use of clock time. Additionally, the findings revealed that professionals who stayed connected and supported young users over time obtained a more holistic view of the person and were able to provide stability during difficult phases. Through such continuous relationships, the young people experienced gradual inner and outer transformations where they saw themselves in a different light and explored new ways of being.
This paper is presented as a response to an invitation from the editor of Human Systems. Systemic theory and therapy have evolved over the last 70 years and each new generation of practitioners encounters the historical and contemporary literature through fresh eyes. Clinical psychology is one discipline which continues to value systemic approaches. Multiple Clinical Psychology (DclinPsy) programmes nationwide facilitate training approved by the Association for Family Therapy and Systemic Practice (AFT). The University of Plymouth is one such example. This paper offers a window into the experience of a trainee clinical psychologist attending a foundation in family therapy course, undertaken as part of their wider training on the DclinPsy. It covers a brief summary of the history of family therapy, the practitioner’s insights into how it is utilised in NHS services and its modern-day application for clinical psychology.
This study highlights metaphors as ways of articulating the nature of spiritual experiences. A secondary analysis of data from a previous study revealed that spiritual experiences were described using metaphors. A sample of six participants was selected. The study aimed to describe metaphors of inpatients’ spiritual experiences in mental health care. The study had a qualitative design. The metaphors were interpreted as individuals’ embodied meanings of spirituality. These meanings were identified through a hermeneutic phenomenological framework, informed by the approach of interpretative phenomenological analysis. The analysis identified three superordinate themes, to capture the embodied lived experiences of spirituality: the meaning of the immortal diamond, the meaning of the lion-hearted warrior and the meaning of navigating by divine compasses. By acknowledging metaphors as important sources of subjective knowledge, this study reflects on how mental health professionals can use metaphors to gain insight into inpatients’ spiritual universe to facilitate relationships of resonance within a Relational Recovery perspective.
Identity development is often viewed as co-constructed within social contexts. Much research focuses on older childhood, despite early childhood being considered critical in the formation of ‘self’. Creative methodologies (i.e., those that might utilise creative mediums and the senses such as audio-visual stimuli or play), drawing upon attachment, narrative and systemic theory, and interpretative, observational thematic analysis were utilised to explore child meaning-making in the context of autism. Participant understanding of self often related to a sense of ‘difference’ and desire for belonging and acceptance. Development of creative, sensitive, applied methods has advanced methodological approaches for working with vulnerable populations. This study demonstrates that experiences of parental perspectives and interactions are connected to children contextualising their experiences of self, other, and the world around them in some capacity. As such, it is important to provide parents with the tools, knowledge, and understanding to aid the development of positive narratives to provide the best support for their children
This paper describes the development of systemic therapies in a Specialist Perinatal Mental Health Service (SPMHS) that developed Attachment Narrative Therapy (ANT) specifically for families in the perinatal stage of the family life cycle. ANT offers a good fit in the perinatal period, integrating systemic family therapy, narrative therapy, and attachment theory. From pregnancy to the child being two is a family life cycle stage of great change and reorganisation. This involves opportunities and challenges for attachments and relationships between parents, the baby and wider family/carers. Attending to cross-generational narratives and attachments are important in ensuring the perinatal stage is navigated successfully. Peri-ANT, a semi-structured version of ANT, was developed as a manualised approach. It can be flexibly adapted to the unique circumstances of each family. The paper describes the perinatal context, service needs and priorities, and the development of Peri-ANT including construction of the manual and how it was delivered.
