In this final chapter I connect the trainees' feedback with some of my original speculations, before moving on to comment on a number of related training issues for the future.
On the whole, the message from those trainees who took part in the survey confirmed many of the earlier reasons for setting up the module. For example, they concluded that taking part in experiential work had helped them to become more sensitized to their clients' experience of therapy; they appreciated the variety of ways in which they had been encouraged to reflect more carefully on what it felt like to be in their clients' shoes. This could be described as a development of their capacity to use empathy and compassion in their professional role.
They also commented on the significance of the leaders' role in helping them to bridge the gaps between their own and their clients' experience, between their personal and professional persona, and between their theoretical knowledge and their clinical practice. They also demonstrated the proposition that "Optimally, the self and the role of the therapist can exist in an acknowledged, functional, creative and respectful marriage" (Haber, 1994). The trainees confirmed my belief that if the leaders shared some of their own experiences with the group, this could lead to group members being more open; it would also become self-evident that the need for maintaining confidentiality was a mutual one.
As anticipated the group experience per se was acknowledged as a potentially beneficial forum for learning, provided that factors of size, frequency, and regularity of meetings could be ensured. The nine hours allotted to the PPD meetings of the small groups (Institution B) during the first week of the training proved invaluable, rapidly creating a cohesiveness within the groups. Further positive effects commented on by group leaders, course staff, and trainees include the trainees' willingness to work together, a sense of mutual support, and a considerable degree of openness. What is less clear is whether there would be a shift in the ethos of the module from a personal/professional training tool towards a more therapy-oriented milieu if the groups were to meet more frequently. Some recognized parallels with clients voicing their feelings and opinions "publicly" in the process of therapy. A common denominator between families in the early stages of therapy and trainees in the early stages of training is that everyone is vulnerable to feeling de-skilled, despite their competence in other aspects of their lives.
One unexpected outcome was the rapid establishment of personal connections between many of the trainees in the small group within the first few intense meetings of the module. This in turn appeared to produce a more relaxed effect in the supervision groups as well as a greater openness between the staff and the trainees. However, due to the size of the large group, trainees complained of a lack of safety in the group and, as a result, felt uncertain about how much to invest in it. Thus we may have missed an opportunity to support the emotional needs of some of these trainees during the course of their training and their changing epistemology. Typically, many would be dealing with major personal events during the two years; for example, in a recent cohort of thirteen, six trainees or their partners became pregnant. Others have had to cope with major losses, such as bereavement and separation, changing family structures, conflicting personal and professional demands for time and energy, moving house, changing jobs, and so forth. In addition, many described their social life as being put "on hold". One trainee summed up the experience of being on the course by quoting her sister, who said: "After two years, I'm glad to have you back." In some cases, in response to some of these stresses, trainees have opted for personal therapy and hence to the potential model confusion described in Chapter 2.
Trainees may have a variety of motivations for being on the course: for some, it may be predominantly a question of career advancement; for others, it may have more to do with curiosity and a wish to develop new ideas; for yet others, there may be an element of wanting a break from the routine of their jobs. An early supposition was that regardless of the circumstances, the PPD module might have a role in helping trainees to recognize their adventurousness in taking on new challenges and learning the inevitable limitations of what any training course—or, indeed, family therapy itself—could offer. A useful parallel could be drawn here with the clients' experience and expectations of therapy
The module was used as a "safe-enough" setting in which to air complaints and grievances. The large groups may have been more prone to use the group context to seek out support for their views from trainees with whom they rarely had contact. They also might have felt freer to do so, because the group leader(s) at that time were external to the course and therefore not involved in their assessment. As discussed in Chapter 3, participants in the small groups may sometimes have been more inhibited because I was both the module leader and filled other roles on the course.
My original hope, confirmed by the trainees' responses, was that the module would help trainees to acquire a greater awareness of the complexity of becoming a therapist through the lengthy discussions, the use of experiential exercises, and the skills training across systemic models. My assumption was that an expansion of their repertoire of responses and techniques could lead to therapists being more flexible and therefore more likely to find a suitable "fit" with their clients. Clearly, research is needed to validate these impressions.
During the time it has taken to produce this book there has been an upsurge of interest in trainees' personal training needs in Europe; no doubt this has been spurred on in Britain by the establishment of the United Kingdom Council for Psychotherapy (UKCP). As a result of this move to a greater coherence amongst psychotherapists, some differences in training methods in the various family therapy teaching institutions have now become more apparent. This may have spurred on the recent encouraging move by Confetti—a group of representatives of the various family therapy institutes—to hold discussions about possible approaches to the personal and professional aspects of family therapy training.
In my view, the particular PPD module described here is one such valuable training approach. In the past, there has been some confusion as to the purpose of this PPD module—that is, whether it was intended to be a form of therapy or a form of skills training. I believe that this confusion partly reflected an uncertainty and lack of concensus as to whether work on the self of the therapist was a training requirement. The lack of an over-arching policy in the field remains a controversial issue, but as trainers in family therapy we do have the responsibility for declaring our position. It is true that some trainees may not feel the need for self-exploration in a therapeutic context; however, I would argue, as stated previously, that having such an experience can induce greater empathy with clients, and that it is likely to lead to therapists' greater self-reflexivity and thus may avoid inappropriate attributions.
The therapist's personal family life has both immediate and remote determinants and, if unexamined, can play a major (though unconscious) role in shaping the therapist's ideas about fairness, normalcy, and the appropriateness of roles in family life. The therapist cannot escape his/her background but may be able to use it advantageously in building certain kinds of alliances, It is imperative that therapists be aware of the nature of their personal family experiences and the influence these experiences exert upon them. [Catherall & Pinsof, 1987, p. 157]
An opportunity for personal exploration both in therapy and in the PPD module is, in my opinion, more likely to produce therapists who are more competent and more compassionate.
Although I believe that ideally trainees should have personal experience of family therapy, there is a case for spreading the net wider. For those trainees unable to attend with their families/partners for a few (two to four) family therapy sessions, I would propose that inviting significant others outside the immediate family network could be a viable alternative. For example, some trainees have commented that they had already worked on family issues, and their current preoccupations tended to be related to their work situation; this group might find it more relevant to invite professional colleagues instead. Another and possibly more feasible option might be to invite trainees to attend with member(s) of their friendship network, given that the latter might now play a more significant role.
The difficulties of drawing in geographically distant, possibly unmotivated, and otherwise-occupied family members, friends, or colleagues should not be minimized. But I am not convinced that these difficulties are insuperable if, as trainers, we are prepared to experiment with a variety of options. If we can agree in principle to the need for some experience of personal therapy for the trainees, then we will also need to tackle the following questions:
From the point of view of equal opportunities, we would have to ensure that selection for a place on the course would not favour those who chose family therapy, rather than any other option, for personal exploration.
If family therapists reach consensus in favour of personal therapy as a condition of training, this could lead to only those who can afford private therapy being eligible for training. Courses are already extremely expensive, professional bodies are providing less financial support, and a further outlay could preclude some trainees from less well paid sectors such as social work, nursing, occupational therapy, and teaching from applying. Indirectly, this could affect the number of people from minority cultures coming into the field, since a large proportion enter through these routes. Given that the availability of therapy on the National Health Service is already extremely limited, the likelihood of making more such time available for training purposes is extremely unlikely. Will this lead to yet another situation where unto those who have (the means), it (the opportunity for therapy) shall be given?
Equal opportunities for acceptance on courses may also unwittingly be eroded if, at the point of selection, when all other criteria are matched, preference is given to trainees who have already had some personal therapy. If it is the case that previous therapy is seen as a positive weighting factor, trainers could reasonably be accused of being disingenuous in not declaring this as a precondition or an advantage in terms of selection for training. Any such statement would also have to clarify which model, if any, would be prioritized.
Without research to suggest otherwise, then common wisdom, the therapist's own knowledge, and an accumulation of clinical experience have convinced many therapists that personal therapy, which leads to greater self-reflexivity, does make an appreciable difference to competence in therapeutic practice. If this is the case, what are the implications for those therapists who did not have such an opportunity? Would they have had a more equitable chance to become more competent and sensitive if personal therapy had been made mandatory?
To take it a step further, could it be said to have been unethical not to provide training in a mode that was consistent with the trainers' own beliefs, reflected their own experience, and was considered by them to be in the clients' best interests?
In emphasizing the interaction and overlap between personal and professional dimensions, there is a tacit assumption that trainers have the right—and indeed the responsibility—to intervene in relation to private issues where these, in the trainers' view, impinge either on the trainees' clinical practice or on their capacity to manage the demands of a rigorous training. Would it not also be ethical for all training institutions to make a formal statement to this effect?
Deciding on the nature of personal preparation required on a family therapy training is a complex issue. To be both logical and consistent, the trainee treating families should have the experience of being in therapy with his own family. However, even if trainers were convinced that it was a necessary process, and trainees were willing to issue the invitations, what right do we have to make such a powerful intervention in these family systems—what pressures are we indirectly exerting on behalf of one member of a family who chooses to pursue a particular career? In any case, it is unlikely that all family members conscripted in this way would be willing or feel the need to expose themselves in therapy. Pursuing such a policy could create a further dilemma in relation to equal opportunities: would those trainees whose family or partner was unwilling to undertake therapy not be eligible for selection on the course?
In an effort to deal with this apparently contradictory situation, many trainers are already recommending systemically based individual therapy rather than individual psychodynamically oriented therapy for family therapy trainees, in the hope that this will prove to be more consistent with our theoretical model. However, this does not disguise the fact that being a client/patient in any form of individual therapy is a very different experience from the immediacy and complex interactions of being in couple or family therapy,
Over time, trainees have commented on their confusion arising out of differences in theoretical models and the contrast between their experience of individual therapy, whether systemic or otherwise, and their clinical practice with families. This was not just about being a therapist in one situation compared to being a client/patient in the other: it seemed to have more to do with differences in technique and belief systems. This, in turn, raises the issue of the desirability of congruence between the therapist's personal experience of therapy and the systemic therapy that they practice, a logical as well as an ethical conundrum that could have serious implications for training. As trainees have said, straddling two models is not just uncomfortable: more importantly, each model is likely to invalidate the other, and this could ultimately undermine both personal therapy and professional training.
Enthusiasm and over-optimism can sometimes lead trainees to have unrealistic expectations about their clients' pace of and potential for change during the process of therapy; there is a similar risk of assuming that any form of personal therapy will somehow also be able to transform the person of the therapist. Since no form of psychotherapy can produce a panacea, a more realistic goal would be an increase in the trainee's self-reflexivity which in turn would lead to an increased perception of the complexity of the process of change in oneself and others. Hopefully, an increased curiosity about oneself, as explored in therapy, generalizes to a healthy and productive curiosity about others.
It is important to acknowledge that within the different institutes here and abroad, trainers are experimenting with a variety of different approaches to the personal/professional issue. Examples include trainees making videos of their family and bringing them in to training for discussion; others are invited to take up some exploratory family therapy sessions with their family or partner at the start of the course; Hildebrand and Speed (1993) recommend "at least one lengthy consultation with each trainee and close friend, partner or family not to look for problems but to give them a first-hand experience of the way in which such encounters affect people" (p, 337). Some institutions use a traditional group work approach to focus on personal issues, while others argue that a closeknit family therapy team, working behind the screen, acts as a safeguard, noting therapists' trigger-points and often commenting on personal and professional links. Selvini-Palazzoli (Selvini & Selvini-Palazzoli, 1991) has described teamwork as a personal resource for the therapist. At the Prudence Skynner Family Therapy Clinic in London, a focus is maintained on the trainee's genogram, which is introduced as early as the pre-course selection interview and continues to be worked on throughout the training. Another position is that adopted by Hedges and Lang (1993), who employ "mapping" as a major method.
Moving away from current training methods, I would like to address the possibility of taking on a more innovative, proactive role in seeking out other systemic opportunities within training. I believe that many of us have paid insufficient attention to the people who will be most immediately affected by the trainee's preoccupation during their training. It could be both informative and reassuring for family members, a close friend or partner, or a professional colleague to meet the staff, to have an opportunity to ask questions, and to be told about the stages in the training that are likely to be particularly demanding. An informal event with staff and trainees, and the latters' choice of "significant other(s)" might also give the trainees an opportunity to demonstrate their competence and maturity in a role other than that of trainee.
Whatever decision is made regarding the integration of personal and professional aspects of training, I feel that there is also a need for a more informal contact between our trainees, those tangentially affected by their training, and ourselves.
There seems to me to be insufficient commitment, whether at a social or information-giving level, to reduce some of the mystique and anxiety surrounding "The Course". I have a suspicion that time limitations are not the only reason this does not take place; it is as if trainers have found it more comfortable to be teaching about family and wider systems than to be systemically interacting with them. The avoidance of such contact to date seems to me to reflect a psychoanalytic-theory base rather than being consistent with a systemic perspective.
In this book I have described one way to "mind the gap" between personal therapy and professional development using a module that focuses on the links between trainees' past and current life experience, their professional development, and clinical skills training in the group forum. In terms of improving the model, there is still more work to be done in relation to balancing and blending discussion, experiential work, and specific skills training as well as addressing the issues raised by the trainees. The inclusion of this or a similar module will hopefully be a serious consideration on training courses, although it may be less popular in contexts where senior trainers may not themselves have been trained in personal exploration. Where trainers are sympathetic to these ideas, they may have to compete with pressures of academic requirements and the perennial issue of time allocation. Has the time come for personal/professional development of family therapists to move from a position of marginalization to one of prioritization? I concur with Mason (1997) that "unless family therapy can make significant changes in relation to this issue—the exploration of 'self in therapy and thus in training—the respect given to it as a psychotherapy will ultimately diminish".