The Negotiation of Blame in Family Therapy with Families Affected by Psychosis

301 Pages·2014·1.74 MB·English

by  Sarah Amoss

The Negotiation of Blame
in Family Therapy with
Families Affected by
Psychosis

Professional Doctorate in

Systemic Psychotherapy

Sarah Amoss

Tavistock Clinic

October 2014

Abstract

Despite wide agreement in the systemic field that therapists should take a
non-blaming stance, historically there has been little exploration of how this
stance is achieved in practice. The difficulty in knowing how to put ‘non-
blaming’ into practice is further heightened by competing models of
intervention with families affected by psychosis. This study contributes to a
body of literature that is concerned with how complex issues of morality
are achieved dialogically by considering how family therapists manage
the tension of intervening to promote change whilst maintaining a multi-
partial, non-blaming stance.

Two therapies carried out with families affected by psychosis are analysed
using the methods of Conversation Analysis (CA) and Membership
Categorization Analysis (MCA). In both therapies the sequences examined
are drawn from the second session of therapy where explicit blaming
events occur. By examining blaming events chronologically through the
course of a session the study shows how the rules about the way blame is
talked about are achieved interactionally.

The analysis demonstrates that systemic theory’s emphasis on the
importance of being non-blaming is grounded in a sophisticated
understanding of the threat blame poses to co-operation and agreement.
In both therapies, the delicacy and ambiguity with which blame is treated
serves to enable the conversation to continue without withdrawal.
However the cost of ambiguity is a possible misunderstanding of the intent
of the speaker. The resulting misalignment, where it continues over several
turns and sequences, leads to explicit blame becoming relevant as a
solution to a redundant pattern of interaction.

The findings indicate that the management of blame requires both the
exploration of blame and its interruption when emotions and conflict run
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high. The former enables understanding and movement towards
therapeutic goals while the latter is necessary to promote therapeutic and
family alliances. An unintended consequence of the injunction to be non-
blaming might be the premature closing down of topics, militating against
problem resolution.

The study concludes that CA and MCA offer a wealth of knowledge about
mundane conversational practices that can be applied fruitfully to
systemic therapy process research, teaching and supervision.
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Acknowledgements

My thanks go firstly to the therapists and families involved in the research,
without whose help the research could not have taken place.

I was extremely fortunate in my supervisor Dr Bernadette Wren, whose very
sharp mind is tempered by seemingly endless patience and great
generosity of spirit. I am also grateful to my second supervisor, Dr Georgia
Lepper, who not only supported me with the technical aspects of the study
but who helped to keep me focussed on the data and stop slipping off to
the library to read another book. One of the costs of finishing the thesis is
missing the great conversations I had with Bernadette and Georgia.

I would also like to thank the research community at the Tavistock Centre,
both teachers and students, for their questions, comments and
contributions along the way. Yvonne Ayo, Louise Anthias and Sue Hickman
were there from start to finish with ideas and encouragement.

I am most indebted to Ian Johnson, as always, who has been a stalwart
support throughout.

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TABLE OF CONTENTS
ABSTRACT .............................................................................................................................. I
ACKNOWLEDGEMENTS ................................................................................................. III
CHAPTER 1........................................................................................................................... 1
BACKGROUND TO THE STUDY .................................................................................................. 1
THE RESEARCH QUESTIONS ..................................................................................................... 3
HOW DO FAMILY THERAPISTS DO ‘NON-BLAMING’ IN THEIR ROUTINE PRACTICE? ......................... 3
HOW DO SYSTEMIC THERAPISTS MANAGE BLAME IN THE CONTEXT OF FAMILIES AFFECTED BY
PSYCHOSIS?.............................................................................................................................. 4
HOW DO THERAPISTS MANAGE THE COMPETING INSTITUTIONAL TASKS OF DECREASING BLAME
AND INCREASING AGENCY IN THEIR ROUTINE PRACTICE? ............................................................ 4
HOW DO FAMILY THERAPISTS MANAGE THE TENSIONS OF NEGOTIATING CONFLICTING VERSIONS OF
EVENTS WITHOUT ALLOCATING BLAME? .................................................................................... 5
ORGANISATION OF CHAPTERS................................................................................................. 6
CHAPTER 2 - LITERATURE REVIEW ............................................................................................ 6
CHAPTER 3 - METHODOLOGY .................................................................................................... 7
CHAPTERS 4 AND 5 - DATA ANALYSIS ........................................................................................ 7
CHAPTER 6 - DISCUSSION .......................................................................................................... 7
CODA ...................................................................................................................................... 8
CHAPTER 2........................................................................................................................... 9
INTRODUCTION ....................................................................................................................... 9
PART 1 - THEORETICAL LITERATURE ........................................................................... 9
BLAME .................................................................................................................................... 9
WHAT IS THE FUNCTION OF BLAME? ........................................................................................ 10
THE NEGATIVE IMPACT OF BLAME ........................................................................................... 11
BLAME IN THE CONTEXT OF FAMILIES EXPERIENCING PSYCHOSIS. ........................................ 12
THE DOUBLE BIND .................................................................................................................. 12
HIGH EXPRESSED EMOTION ..................................................................................................... 13
FAMILY MANAGEMENT SOLUTIONS TO BLAME...................................................................... 14
CRITIQUE OF THE ‘CAUSE OR EFFECT’ DEBATE.......................................................................... 15
SUMMARY ............................................................................................................................. 16
NEUTRALITY, CURIOSITY AND MULTI-PARTIALITY – SYSTEMIC SOLUTIONS FOR BLAME. ..... 17
INTRODUCTION....................................................................................................................... 17
FIRST ORDER THEORIES - NEUTRALITY .................................................................................... 18
SECOND ORDER THEORIES - IRREVERENCE AND CURIOSITY ....................................................... 20
THIRD WAVE THEORIES - NOT KNOWING AND MULTI-PARTIALITY.............................................. 22
FROM CURIOSITY TO NOT KNOWING........................................................................................ 23
THE CONSTRUCTION OF PERSONAL AGENCY ............................................................................. 26
THE NARRATIVE SELF ............................................................................................................. 27
THERAPY AS A SITE OF MORAL NEGOTIATION ........................................................................... 30
SUMMARY ............................................................................................................................. 31
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PART TWO - THE RESEARCH LITERATURE ................................................................ 33
INTRODUCTION ..................................................................................................................... 33
ATTRIBUTION RESEARCH ........................................................................................................ 33
EXPRESSED EMOTION RESEARCH ............................................................................................. 33
EE AND SYSTEMIC FAMILY THERAPY ....................................................................................... 34
THE EFFECTS OF BLAME IN FAMILY THERAPY ........................................................................... 35
BLAME AS AN INTERACTIONAL PHENOMENON .......................................................................... 35
AGENCY RESEARCH ................................................................................................................ 39
SUMMARY ............................................................................................................................. 40
CHAPTER 3......................................................................................................................... 43
INTRODUCTION ..................................................................................................................... 43
THE AIMS OF THE STUDY - WHAT KIND OF TALKING IS ACCEPTABLE HERE? .......................... 43
PART 1- EPISTEMOLOGICAL AND METHODOLOGICAL ISSUES.............................. 44
INTRODUCTION ..................................................................................................................... 44
PSYCHOTHERAPY OUTCOME AND PROCESS RESEARCH IN A MODERNIST FRAME. ......................... 44
PSYCHOTHERAPY PROCESS RESEARCH IN A POST-MODERN FRAME ............................................. 45
DISCOURSE RESEARCH ............................................................................................................ 45
DISCOURSE ANALYSIS............................................................................................................. 46
CONVERSATION ANALYSIS .................................................................................................... 47
THE ORIGINS OF CA ................................................................................................................ 47
THE FOUNDATION OF CA AS A DISCIPLINE................................................................................ 48
WHAT IS CA? ......................................................................................................................... 49
TWO DOMAINS OF CA ............................................................................................................. 50
THE BUILDING BLOCKS OF CA ................................................................................................. 51
TURN TAKING......................................................................................................................... 51
SEQUENCE ORGANISATION ...................................................................................................... 52
THE ADJACENCY PAIR ............................................................................................................. 53
PREFERENCE ORGANISATION................................................................................................... 53
REPAIR ORGANISATION ........................................................................................................... 54
THE ORGANISATION OF TURN DESIGN ...................................................................................... 54
SUMMARY ............................................................................................................................. 55
CRITIQUES OF CA ................................................................................................................. 56
SUMMARY ............................................................................................................................. 58
APPLIED CA.......................................................................................................................... 58
STOCKS OF INTERACTIONAL KNOWLEDGE ................................................................................ 61
SUMMARY ............................................................................................................................. 62
MEMBERSHIP CATEGORISATION ANALYSIS .......................................................................... 62
MEMBERSHIP CATEGORISATION DEVICE................................................................................... 63
STANDARD RELATIONAL PAIR (SRP)........................................................................................ 63
CATEGORY BOUND ACTIVITIES (CBA). .................................................................................... 64
CATEGORY BOUND PREDICATES. (CBP) ................................................................................... 64
DUPLICATIVE ORGANISATION.................................................................................................. 65
THE ECONOMY RULE............................................................................................................... 65
THE CONSISTENCY RULE ......................................................................................................... 66
HEARER’S MAXIMS. ................................................................................................................ 66
SUMMARY ............................................................................................................................. 67
CRITIQUE OF MCA ............................................................................................................... 67
SUMMARY ............................................................................................................................. 70
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PART 2 – THE DESIGN OF THE STUDY .......................................................................... 71
INTRODUCTION ..................................................................................................................... 71
THE RESEARCH SITE AND PARTICIPANTS .................................................................................. 71
THERAPISTS ........................................................................................................................... 71
FAMILIES ............................................................................................................................... 72
THERAPY 1............................................................................................................................. 72
THERAPY 2............................................................................................................................. 72
ETHICAL ISSUES ..................................................................................................................... 73
INFORMED CONSENT ............................................................................................................... 74
ETHICAL APPROVAL................................................................................................................ 74
DATA COLLECTION AND ANALYSIS .......................................................................................... 75
REFLEXIVITY AND SELF-REFLEXIVITY...................................................................................... 77
SUMMARY OF THE AIMS AND DESIGN OF THE STUDY. ................................................................ 77
THE DATA ANALYSIS............................................................................................................... 79
CHAPTER 4......................................................................................................................... 80
INTRODUCTION ..................................................................................................................... 80
THE THERAPY CONTEXT....................................................................................................... 81
THE FAMILY ........................................................................................................................... 81
THE THERAPISTS..................................................................................................................... 81
THE CONTEXT OF THE DATA SELECTED. ................................................................................... 81
PART 1................................................................................................................................. 82
THE CONSTRUCTION OF AN INTERACTIONAL PROBLEM ......................................................... 82
ACCOUNTING FOR ‘NOT GOING BACK’...................................................................................... 82
MEMBERSHIP CATEGORY DEVICES- WHAT KIND OF PERSON DOESN’T GO BACK? ........................ 83
THICKENING THE STORY OR JUSTIFYING THE ACTION? .............................................................. 85
MARKING TROUBLE -WHAT CONSTITUTES A REASONABLE ACCOUNT? ....................................... 85
PURSUING ALTERNATIVE REASONS .......................................................................................... 87
MISALIGNMENT - TROUBLES TELLING OR HELP SEEKING? ......................................................... 89
UNHAPPY INCIDENT REPORTS .................................................................................................. 90
EXPLAINING OR EXPLAINING YOURSELF. .................................................................................. 91
ATTEMPTING A REPAIR ........................................................................................................... 93
DOING NEUTRALITY ............................................................................................................... 94
CONFLICT .............................................................................................................................. 94
ARGUMENT OR CONFLICT........................................................................................................ 95
EMPIRICAL EVIDENCE FOR SYSTEMIC THEORY AND PRACTICE ................................................... 96
REPAIR .................................................................................................................................. 97
DISCUSSION........................................................................................................................... 98
THE THERAPISTS’ INTERACTIONAL PROJECT ............................................................................. 98
JANET’S INTERACTIONAL PROJECT........................................................................................... 99
STEVEN’S INTERACTIONAL PROJECT .......................................................................................100
CONSTRUCTING A NON-BLAMING THERAPY .............................................................................100
PART 2............................................................................................................................... 102
INTRODUCTION ................................................................................................................... 102
THE CONTEXT .......................................................................................................................102
RECYCLING THE ARGUMENT ..................................................................................................102
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THE COSTS AND BENEFITS OF AMBIGUITY................................................................................104
MAKING THE IMPLICIT EXPLICIT .............................................................................................105
TWO DOMAINS OF ACCOUNTABILITY.......................................................................................106
BLAME AS AN INVITATION TO TAKE RESPONSIBILITY ...............................................................106
DOING NEUTRALITY -THE CO-CONSTRUCTION OF POWER .........................................................108
DISCUSSION......................................................................................................................... 110
THE VARIOUS FUNCTIONS OF BLAME IN ARGUMENT. ................................................................111
THE STRUCTURE OF ARGUMENTS ............................................................................................112
WHAT KIND OF TALK IS REASONABLE HERE? ...........................................................................112
PART 3............................................................................................................................... 114
INTRODUCTION ................................................................................................................... 114
THE CONTEXT .......................................................................................................................114
THE PROBLEM OF AGREEING ON THE PROBLEM. .......................................................................114
SUMMARY AND DISCUSSION OF THERAPY 1 ......................................................................... 116
SUMMARY ............................................................................................................................117
CHAPTER 5....................................................................................................................... 119
INTRODUCTION ................................................................................................................... 119
THE THERAPY CONTEXT..................................................................................................... 119
THE FAMILY ..........................................................................................................................119
THE THERAPISTS....................................................................................................................119
THE CONTEXT OF THE DATA SELECTED. ..................................................................................119
PART 1............................................................................................................................... 120
THE CONSTRUCTION OF AN INTERACTIONAL PROBLEM ....................................................... 120
NEGOTIATING A LEGITIMATE TOPIC. .......................................................................................122
TALKING VERSUS NOT TALKING .............................................................................................122
THE EXPECTATION OF RELEVANCE..........................................................................................124
MISALIGNMENT BETWEEN THE COUPLE...................................................................................125
USE OF EMBEDDED PRESUPPOSITION TO REPAIR COUPLE MISALIGNMENT ..................................125
MISALIGNMENT BETWEEN T1 AND KEVIN ...............................................................................126
THE USE OF QUESTIONING ......................................................................................................127
GOOD TALKING AND BAD TALKING.........................................................................................128
POTENTIAL CONFLICT ............................................................................................................129
REPAIR .................................................................................................................................129
‘DOING’ COLLABORATIVE ......................................................................................................130
SELF-BLAME .........................................................................................................................131
IDENTITY CATEGORIES...........................................................................................................132
THERAPIST REPAIR OF THE COUPLE ALLIANCE .........................................................................133
DISCUSSION......................................................................................................................... 135
DOING SYSTEMIC- HOW SYSTEMIC THERAPY IS TALKED INTO BEING .........................................135
WHAT IS THE PROBLEM? ........................................................................................................135
WHO IS TO BLAME?................................................................................................................136
HOW DO WE TALK ABOUT IT? .................................................................................................137
WHAT ARE THE CONSEQUENCES? ...........................................................................................138
PART 2............................................................................................................................... 139
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INTRODUCTION ................................................................................................................... 139
THE CONTEXT OF THE DATA SELECTED. ..................................................................................139
SHAPING A SYSTEMIC EXPLANATION.......................................................................................139
THE COSTS AND BENEFITS OF AMBIGUITY................................................................................140
DOING NON-BLAMING............................................................................................................141
CONSTRUCTING RESPONSIBILITY WITHOUT BLAME. .................................................................142
UPGRADING AN AGREEMENT OR RECYCLING A COMPLAINT? ....................................................142
TROUBLE ..............................................................................................................................144
MITIGATION AS REPAIR ..........................................................................................................144
THE BENEFITS AND COSTS OF MITIGATION...............................................................................145
REPAIRING THE CONSEQUENCE OF MITIGATION .......................................................................146
CLAIMING AGENCY................................................................................................................147
THE IMPORTANCE OF CONTEXT AND SEQUENCE .......................................................................148
EXPLAINING OR EXPLAINING ONESELF ....................................................................................149
EXTREME CASE FORMULATIONS .............................................................................................150
DISCUSSION......................................................................................................................... 151
WHAT IS THE PROBLEM? ........................................................................................................151
WHO IS TO BLAME?................................................................................................................151
WHAT IS REASONABLE BLAME? ..............................................................................................152
WHAT ARE THE CONSEQUENCES OF MITIGATION? ....................................................................152
MISALIGNMENT- DIFFERENT PROBLEMS REQUIRE DIFFERENT SOLUTIONS ..................................153
REALIGNMENT- REDEFINING THE PROBLEM .............................................................................153
TEAM WORK..........................................................................................................................154
PART 3............................................................................................................................... 155
INTRODUCTION ................................................................................................................... 155
THE CONTEXT OF THE DATA SELECTED. ..................................................................................155
FROM OPPOSITION TO CONCILIATION ......................................................................................155
THE STRATEGIC USE OF QUESTIONS ........................................................................................157
UPGRADING THE ARGUMENT ..................................................................................................158
RESISTANCE ..........................................................................................................................159
RUPTURE ..............................................................................................................................160
WHEN SOLUTIONS BECOME PROBLEMS AND VICE VERSA ..........................................................161
RE-NEGOTIATING THE PROBLEM .............................................................................................163
REPAIR .................................................................................................................................164
RESOLUTION .........................................................................................................................166
DISCUSSION......................................................................................................................... 166
THE INTERACTIONAL PROBLEMS.............................................................................................167
THE ATTEMPTED SOLUTIONS ..................................................................................................167
THE CONSEQUENCES..............................................................................................................167
SUMMARY AND DISCUSSION OF THERAPY 2 ......................................................................... 168
NEGOTIATING GOALS.............................................................................................................168
RESPONSES TO BLAME AND SELF-BLAME.................................................................................169
EXPLAINING OR ARGUING ......................................................................................................170
TEAM WORK..........................................................................................................................170
THE THERAPEUTIC DANCE ......................................................................................................171
CHAPTER 6....................................................................................................................... 174
INTRODUCTION ................................................................................................................... 174
PART 1 – A SUMMARY OF THE FINDINGS .................................................................. 175
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