The human being is an exponentially complex being, with the complexity being extremely pronounced when looked at from a psychological perspective. This psychological complexity becomes augmented when two distinct individuals come together in a relationship (Anderson, 2007). This is because they not only bring together their combined complexities but also establish novel complexities based on the relationship they build. When secondary factors such as careers, extended family, and most importantly children, are introduced into the scenario, the chances of a healthy relationship degenerating and resulting in mental problems becomes extremely probable. In many instances, individuals will abuse substances as an ill-advised coping mechanism. The ways and means of assisting patients in such a scenario have, therefore, been the subject of intensive study and professional discourse. Out of the most plausible solutions that have come out of the research and discourse aforesaid is the conceptual framework of collaborative therapy (Anderson, 2012). In the most concise and practical meaning of the word, collaborative therapy entails the therapist teaming up with the patient to establish a treatment framework for the patient. The patient is elevated into a quasi-therapist while the therapist has to play the part of a semi-layperson. Together they seek ways of assisting the patient from a perspective of therapy and lifestyle changes, so as to achieve the desired goals for the therapeutic process (Lester, 2006). For the complexities that come with scenarios involving marriage and secondary factors, collaborative therapy has been found to be more feasible, hence effective.
Overview of the Patient’s Particulars
Jimmy (not his real name) is 43 years old and is the subject patient for the instant essay. He is Caucasian and very proud of his Irish heritage, comes from a strict Catholic family and at some point in his life, even considered priesthood to the great but brief satisfaction of his parents. Towards, early adulthood, however, Jimmy realized that his inordinate failure in romantic liaisons was caused by the fact that his sexual attraction was towards men. However, because of his cultural background, Jimmy believed that homosexuality was both a sin and a mental health problem. He, therefore, struggled to hide it from all, including himself and redoubled his efforts at establishing a healthy romantic relationship with a woman. His efforts only led to frustration and failure. This caused Jimmy to begin taking alcohol, albeit moderately in an effort to dull the pain. Over the years, however, his drinking problem got gradually worse albeit at no time did it get out of order. At the age of 34, Jimmy met Paul (not his real name). Paul is 38 years old and of mixed descent but considered himself as an African American. He comes from a very liberal background and acknowledged his sexual affiliation at a very young age. Indeed, during his teenage, he would add the prefix ‘Miss’ to his name in informal communication and was extremely flamboyant about his sexuality. Jimmy and Paul got along very well and were clearly in love. Paul enabled Jimmy to get over his fears and be open about his sexual affiliations. Jimmy made the bold move and openly dated Paul. The result was a great peace of mind for Jimmy but at the cost of being denounced by his family. Within a year, Jimmy and Paul were married and within the course of 8 years had adopted two beautiful children, an African American girl, and a Vietnamese girl. Within the last fourteen months, however, Jimmy and Paul have been having differences, which caused Jimmy to go back to his drinking ways. The drinking problem got progressively worse, a fact that also interfered with his relationship with Paul. A week ago, the situation aggravated when Jimmy drove home from a private party dead drunk with both kids in the car. Paul is now threatening to leave and carry the children with him and Jimmy has no doubt that he cannot live without them and has hinted on suicide. It is at this point that the couple decided that Jimmy needs help, hence approaching my practice for intervention.
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Overview of Collaborative Therapy
According to Lester and Gask (2006), it is important to first consider the hypothesis of mental problems in general from the perspective of whether or not it is a chronic disorder so as to understand collaborative therapy. For the purpose of this analysis, the understanding of mental health can be divided into three major parts. The first, which shall be dubbed the ancient approach, factors mental illness as a societal anathema thus leading to harsh treatment of the mentally ill. The second, which shall be dubbed the traditional approach considers mental illness as a chronic condition. While this approach is empathetic to the patient, it is also geared towards the control of the symptoms and manifestations of mental illness (Lester, 2006). This is mainly the approach taken in lunatic asylums where patients are drugged so as to be docile and harmless. Further, under this approach, mental illness is considered as a manifest disability. The final approach, which shall be dubbed as the collaborative therapy approach does not consider mental illness as a chronic illness to be dealt with but rather as a condition that can be managed. Therefore, if handled correctly, a mental health patient can live a fruitful and comfortable life in spite of the illness. This approach qualifies the patient to be a reasonable and lucid person who can be able to give credible and worthy contributions towards the management of the situation, more so using therapy (Castle & Gilbert, 2006). Under this approach, several fundamental elements come into play as hereunder.
Mutually Inquiring Conversational Partnership
This is one of the most important aspects of collaborative therapy and entails a two-way inquiry approach as opposed to a singular direction approach (Castle & Gilbert, 2006). In the traditional method of therapy, the therapist would take full control and ask all the questions thus controlling the sessions. For example, the therapist can ask Jimmy about his problems kindred to domestic issues, his drinking problem, and other issues. Similarly, Jimmy can also make inquiries to the therapist who is obliged to answer, even when the question does not seem very helpful. However, under collaborative therapy, the exchange becomes akin to dialogue where both parties have substantive control of the conversation (Anderson, 2007). The therapist can ask the patient questions just as the patient can ask the therapist questions. This can be a complex process and, therefore, takes great expertise from the therapist to keep the conversation objective.
Relational Expertise
This is another extremely complex element of collaborative therapy and entails the combination of the expertise by the therapist with the expertise of the patient. As aforesaid, the patient, albeit having mental problems is considered under collaborative therapy to still be functional. The therapist may have a deep and advanced expertise on psychological and psychiatric issues but there are things that the therapist’s level of expertise cannot match by that of the patient. For example, no matter how capable a therapist is, he can never understand Paul and the kids better than Jimmy. Asking Jimmy about Paul and the kids as well as interviewing them directly can bring the therapist some form of knowledge about them, but Jimmy will still remain the superior expert. Further, Jimmy has lived with himself all his life. He knows his strengths and weaknesses better than any expert can, out of interviews and research. This is the important expertise that the patient brings to the therapy table.
Not-Knowing
Not-knowing is an important albeit controversial concept that is also an integral part of collaborative therapy supported by experts such as Harlene Anderson. It entails the therapist acting humble and not pretending to act as know-it-all in the presence of the patient (Anderson, 2007). The traditional approach to therapy had the relationship based on the patient’s belief that the therapist was a great and all-knowing expert. Collaborative therapy is different since the therapist has to partner with the patient who normally will be a layman from a psychological perspective. If the patient is awed by the expertise of the therapist, then the patient’s expertise will not manifest. Therefore, like a teacher pretends to learn alongside a student, the therapist pretends not to know, then undergoes a learning journey together with the patient (Stelter, 2014).
Being Public
Being public is closely related but different from the concept of not-knowing. Being public relates to having an extremely open minded approach to the concepts of the patient, when and as they come up during conversations. Collaborative therapy introduces an expert in the name of the patient and requires the therapist to act in a manner that recognizes the patient’s expertise (Stelter, 2014). This does not practically elevate the patient into an expert that the patient will now and then act the part of a mental patient and come up with pretty weird concepts and theories. The therapist must avoid the temptation to summarily tell off the patient as well as the patient’s ideas and theories no matter how bizarre. Instead, the therapist must have the ability and patience to hear the patient out with an open mind and work through and around the theories so raised, instead of working against them.
Living with Uncertainty
Living with uncertainty is an important concept within the framework that enables the therapist to manage the consistent contingencies that keep emanating along the way. Within traditional therapy, it is possible for the therapist to chart an effective path that the therapy process will take. Albeit there are still contingencies within this traditional approach, these contingencies are both predictable and manageable. Collaborative therapy can be considered as a vehicle with two independent and differently gifted drivers. The entire process is seemingly one big contingency (Stelter, 2014). Therefore, instead of being wary of troubling eventualities, both the therapist and the patient can learn to enjoy them and work around them as and when they come. The alternative will be continuous and counterproductive worrying.
Mutually Transforming
The concept of mutually transforming within the context of the collaborative therapy framework means that the therapist and patient develop a form of the empirical learning process from each other. The actual meaning of even elementary issues must be adjusted so as to be understood comprehensively and not as they are traditionally supposed to be. This is because in collaborative therapy, the process of not rigid develops depending on the actual circumstances of the therapist-client relationship (Stelter, 2014). Like a play without the script, none of the parties should carry a presupposition on what happens next. This is because the next step is reactive and not preemptive and shall be based on the circumstances at the next level. The generally understood concepts will, therefore, develop a comprehensive meaning that will keep of adjusting based on the continued mutual growth in the therapist-patient relationship (Stelter, 2014). For example, marriage within the context of Jimmy does not just mean marriage in the general understanding of the man but specifically means marriage as understood by Jimmy, but based on the continued influence of the therapist. Marriage, therefore, takes a fluid meaning. As the patient learns and changes, the therapist also stands the chance to do the same.
Orienting towards Everyday Ordinary Life
As a concept, orienting towards ordinary life is more of a practical than theoretical aspect of collaborative therapy. According to Anderson (2012), it is better for a therapist to operate on the assumption that each and every one is resilient and desirous of positive relationships. Therefore, instead of having a formal and structured therapy sessions, collaborative therapy entails an informal setting, akin to a conversation in the real world. When two people seat to talk informally, each has an equal opportunity to take substantive control of the conversation. The instant concept advocates for the same approach to therapy on the understanding that whichever path the patient takes, it is meant for good and will, therefore, lead to good (Anderson, 2012). This takes a sharp contrast to the traditional form of therapy that was rigid, carefully controlled and leading to a defined direction. Instead, the therapist will apply faith that by euphemistically loosening the leash, the patient will still help steer the therapy into the right path due to the primal presence of positive intent.
Analysis of the Patient’s Situation
Differentiation
Among the major problems facing Jimmy relates to differentiation. Differentiation from psychological perspective relates to the ability to compartmentalize and separate between different issues. There are different kinds of differentiation kindred to the scenario of the instant patient’s case. The first is spousal differentiation. This refers to the ability of each of the spouses to maintain a reasonable and healthy virtual distance between one another. In spite of the fact that couples are in a committed relationship, they remain two distinct human beings with their individual lives, preferences, and priorities (Titelman, 2014). Each of them should, therefore, have a reasonable personal space for the maintenance of a healthy relationship. However, it is possible for a member of a couple, more so one that is undergoing some challenges to try and cling too close to the other spouse. This is to the detriment of the party’s psychological well-being as well to the health of the relationship. The second kind of differentiation is the differentiation of the self (Titelman, 2014). This entails the inability to separate thoughts from emotions, a concept that is colloquially termed as thinking with the heart. The mind is rational and bases its thought processes on facts while emotions are more often than not rational. Poor differentiation of the self will almost always lead to misinterpretation of issues, more so in a marital setting thus leading to conflict.
From the perspective of the patient, Jimmy believes that Paul no longer loves him because they do not spend time together. They both have careers but that occupy their time for most working days. Albeit Jimmy has no problem with this, he wants all their time away from work to be spent together. He intends to be involved in each and every endeavor that Paul is in and is also determined to have Paul tag along in each and every activity that he undertakes. On the aforementioned night when Jimmy got drunk while out with the kids, he had anticipated that Paul would join them. He got offended when Paul did not and ended up drunk, thus endangering the kids. Further, Jimmy believes that the only reason why Paul needs time away from him, while not at work is that he is having an affair. Jimmy believes that he even knows the possible culprit in the affair.
A second problem that is facing Jimmy as aforesaid is alcohol abuse. Albeit alcohol abuse is acting as a source of exacerbation for the problem, it is not really the cause of it. Instead, based on a careful analysis of the situation, the primary problem lies in Jimmy’s background. This patient was brought up in the belief that who he is as a gay man is wrong and against the will of God. It is worthy of notice that the will of God was extremely important to Jimmy as at some point he even fathomed priesthood. Secondly, Jimmy also sacrificed the love of his entire family who also believed that homosexuality was sinful and, therefore, shunned him. Finally, within the relationship are two children, whom albeit adopted, Jimmy loves desperately. The first two aspects aforementioned can be considered as the opportunity cost for Jimmy to be in the marriage with Paul. He feels that he made major relationship sacrifices so as to be in the relationship with Paul. Jimmy does not regret what he left because he treasures what he gained in return. However, he places the value of the relationship with Paul all the value of the relationships that he lost. This makes the instant marital relationship more valuable to Jimmy than it can ever be for Paul. Finally, the issue of the children also becomes a bearing factor in the relationship. Jimmy loves the children desperately and they are the only family he has. As it is through his marriage that he got the children, their value is also added to the aforesaid relationship.
Marital Skew and Schism
Another issue facing the marriage between Jimmy and Paul that is also closely kindred to the differentiation issue takes the form of a marital skew. A marital skew can be legally considered as a form of marital abuse, albeit it is, in essence, a psychological issue. It relates to the scenario where one of the spouses overvalues the relationship and is willing to do anything to retain it (Anderson, 2007). This creates a scenario of high susceptibility for abuse by the other spouse since the spouse who over treasures the relationship is willing to do whatever it takes to retain it. In the instant scenario, the marriage means everything to the patient and he would rather die than lose it. This creates a situation where having an understanding of his situation, Paul can actively or passively take advantage of the ready acquiescence of Jimmy in each and everything. The risk of marital abuse upon Jimmy is, therefore, very high.
Even in the absence of a marital skew, the patient is also a perfect candidate for a marital schism. A marital schism happens when a couple or a member decides to hold on to a dysfunctional relationship because of the children (Anderson, 2007). This can be based on the fear of losing the children through a separation or hurting them. The patient herein, over and above placing a great value on the relationship also places too great a value on the children themselves. The result is a marital schism where even if everything fails, the children will still act as the glue that holds the family together. While still on the subject of the children, it would be important to address the issue of triangles, coalitions, alliances, multigenerational transmission. These are secondary relationships that arise within a couple that has children who are beginning to mature up. One or both of the parents will begin to relate to the children in a manner that is an extension of, or a reaction to issues kindred to the main relationship between the couple.
American psychiatrist and family relations expert Murray Bowen came up with the Bowen’s Theory which defines this concept (Craighead & Meyers, 2013). It looks at a family as an emotional unit held together by relationships between one another. The ideal relationship should be first between the couple itself, then jointly towards the children. If for some reasons the couple begins to become dysfunctional, parents will begin to develop independent relationships with the children, leading to triangles. Coalitions and alliances are forms of multigenerational transmissions that belong to the said category of triangles (Craighead & Meyers, 2013). A good example based on the patient’s case is the day Jimmy had gone out with the children and came home drunk. He did not really need to go out with the children, only with Paul. Carrying the children can be considered as an alliance to elicit compliance from Paul.
Cybernetics
Cybernetics from a general perspective relates to the study and understanding of all manner of systems. Within family therapy, the concept of cybernetics is applied by looking at a family as a form of system with many moving parts. Among the major contributors in the application of cybernetics in family therapy is Gregory Bateson (Titelman, 2014). The way the parts integrate and interrelate with each other is an integral part of cybernetics. A good example would be the instant patient’s scenario. The patient is an individual human being with several personal characteristics. This is one component of the system. The patient is in a relationship with a spouse who is another component, as well as two children who also make another component. Part of the system is also the nature of the relationship between the two spouses as well as the secondary relationship between them and the children (Titelman, 2014). Other fundamental aspects of cybernetics in family therapy include boundaries and feedback loops in the relationship.
Boundaries and Feedback Loops
The two main deficiencies that have caused and exacerbated the patient’s problem are ineffective boundaries and an ineffective feedback loop. Boundaries are the virtual limitations set up actively or passively between couples so as to maintain an element of differentiation. The boundaries can either be rigid or diffuse. Rigid boundaries are more active than passive and entail clearly demarcated virtual limitations that set the limits that each spouse cannot cross under any circumstances (Titelman, 2014). On the other hand, diffuse boundaries are more passive and can be varied from time to time depending on the situations. In a normal relationship, boundaries will not be either rigid or diffuse but a balanced combination of the two. The most important aspect of boundaries, however, lies in the two spouses having a similar understanding of the boundaries so as to prevent conflict or misunderstandings. (Titelman, 2014)
In the case of Jimmy, there is no common concept of the boundaries with Paul having a very rigid concept while Jimmy’s is on the extremity of diffuse. Feedback loops, on the other hand, is a term that has been borrowed from technology and been applied to many aspects of life including psychology. A feedback loop is a mechanism designed specifically for a system to share issues and outcomes within its different parts. If the feedback loop does not work, error and inefficiencies will go unnoticed and unrectified within the system. Similarly, in a relationship, there is a need for a mechanism for communicating with one another based on the assessment of each other (Titelman, 2014). This includes a mechanism for communicating compliments, dubbed as a positive feedback loop. Generally, when the positive feedback loop is used, the user expresses a hope, desire or anticipation that the same conduct would be repeated.
The mechanism for communicating complaints is dubbed the negative feedback loop and is geared towards ensuring that that particular issue desists. There is a right and wrong way of sharing a compliment or complaint respectively and the two systems vary exponentially. A well-communicated complaint can bring the relationship closer together but even a compliment, when communicated in a wrong manner, can result in conflict (Titelman, 2014). The establishment of proper mechanisms within the relationship between the patient and his spouse is an important step in solving the marital problem that he is facing.
Recommendations
All the issues facing the instant patient can be handled through therapy in general and particularly collaborative therapy. Indeed, it would be correct to say that based on the prerequisites of the instant scenario, collaborative therapy is the most if not the only suitable mode of therapy applicable. For a start, the nature of the relationships surrounding the patient is so complex that the specific expertise of the patient is necessary for the therapy sessions. Among the unique prerequisites entail the fact that this is a homosexual marriage. The institution of marriage has been the subject of sociological, anthropological, and psychological research for centuries. This has led to the development of an understanding about the same leading to the possibility of professional expertise (Craighead & Meyers, 2013). Homosexual marriages are a relatively new concept that has not existed long enough to enable the development of an understanding of the kindred trends. Secondly, this is an interracial and intercultural marriage, which also involves interracial children. The permutations of complex issues are exceedingly high and it would be impossible for a therapist, acting as the singular expert to properly decipher it. This creates the need for the patient to also play the role of an expert in his own therapy, hence the recommendation for collaborative therapy.
At the initial stage, the patient will need individual therapy independent of the spouse. This is because there are personal issues that have a bearing factor on the marital relationship but have little to do with the marriage itself. They are carried over baggage from the cultural, family and religious background of the patient. The bitterness, feeling of loss and personal conflict issues need to be resolved first. Further, the very important issue of alcohol abuse also needs to be addressed urgently and comprehensively. The patient also has a problem with the differentiation of the self. This caused emotions to interfere with reasoning thus causing him to arrive at unreasonable conclusions. A good example of the same is the assumption that his spouse is cheating on him. The suicidal thoughts also emanate from a poor differentiation of the self. These are interim and urgent issues that will need to be canvassed through collaborative therapy as carefully outlined hereinabove (Titelman, 2014).
The moment the patient is at peace with the self about being a homosexual and the prices paid for the same, then issues kindred to the marriage itself can be resolved in individual and where possible couple’s collaborative therapy. For a start, the issue of spousal differentiation must be canvassed. This issue will, however, not be a major problem to solve since the personal issues kindred to the patient that act as a bearing factor in the issue will already have been canvassed. It is the issue of spousal differentiation that the subject of boundaries shall be addressed. Whereas it is unnecessary to establish very rigid boundaries, it is important for the couple to have the same understanding of what boundaries will exist between them. Another important subject for collaborative therapy is how the couple relates with their children. There is need to develop a joint and united front in the approach to the children so as to eliminate triangle relationships which are an anathema to marriages.
The issues of marital skew and schism have not fully manifested but need to be touched on in the case there is an underlying element of the same. From a general perspective, the cybernetic approach and family therapy should be used in the aforementioned aspects. Within cybernetics, the most important element is the creation of feedback loops. Communication has clearly been a major problem in the relationship, more so between the spouses. One of the causes of the frustration therein lies in diminished sharing of issues and perhaps also compliments. Jimmy might want to spend time with Paul because he values his company. However, the way the same is communicated may be misconstrued as a complaint that they have not been spending enough time together. The development of proper and effective positive and negative feedback loops is fundamental to a healthy relationship (Titelman, 2014).
Conclusion
It is clear from the foregoing that the psychological aspect of man is extremely complicated. Further, the complications become exponentially augmented when the issue of relationships is introduced. If the relationship happens not to be traditional in nature, therefore, lying outside the scope of the well-researched and understood relationships, there can be no formal expertise on the subject. Yet comprehensive therapy will still be necessary. This calls for the therapist to revert to the expertise of the patient. This is the basis of the concept of collaborative therapy. It differs exponentially from the traditional form of therapy that encompasses an all-knowing therapist who is fully in control. The patient on the other hand, will be wholly in the hands of the all-knowing expert therapist. Under collaborative therapy, however, the therapist is humble and forms a team with the patient through the journey of therapy. The instant case involved a homosexual patient who was brought up in a homophobic culture. There is also the secondary issue of adopted children from different cultural affiliations. To resolve the serious issues facing the said patient, a careful application of collaborative therapy is necessary.
References
Anderson, H. (2007). Collaborative therapy relationships and conversations that make a difference . New York: Routledge.
Anderson, H. (2012). Collaborative relationships and dialogic conversations: Ideas for a relationally responsive practice. Family process , 51 (1), 8-24
Castle, D. J., & Gilbert, M. (2006). Collaborative therapy: framework for mental health. The British Journal of Psychiatry , 189 (5), 467. Doi: 10.1192/bjp.189.5.467
Craighead, W., & Meyers, A. (2013). Cognitive behavior therapy with children . New York: Springer-Verlag New York.
Lester, H., & Gask, L. (2006). Delivering medical care for patients with serious mental illness or promoting a collaborative model of recovery? The British Journal of Psychiatry, 188 (5) 401-402. doi: 10.1192/bjp.bp.105.015933
Stelter, R. (2014). Third generation coaching: Reconstructing dialogues through collaborative practice and a focus on values. International Coaching Psychology Review , 9 (1), 51-66
Titelman, P. (2014). Clinical applications of Bowen family systems theory . New York: Routledge
