EDITORS' INTRODUCTION

Having set the scene in an earlier chapter on the theme of culture and psychotherapy, in this chapter Tantam deals with therapist–patient interaction and expectations of the patients from the therapeutic encounter. There is a distinction between a patient's expectations at the beginning of the encounter and as therapy progresses these expectations change. Expectations will be influenced by previous experience (whether of counselling, which may actually increase the likelihood of continuing with treatment) or other treatments. The expectations that therapists carry with them are also important in therapeutic adherence. The expectations that therapists carry depend upon a number of factors, including their own cultures and their experiences with members of other cultures. The world view of both the therapist and the patient has to have some common values so that therapeutic work can begin. Cultures have unique and common values and some values which are common to other cultures. Similarly, between the therapist and the patient there will be common values and unique value. Empathy as a process by which the thoughts, feelings and emotions of an individual can be understood is a key component of the therapeutic encounter. Becoming more culturally aware of and therein becoming aware of and meeting patient's expectations and dealing with patients in an empathic and compassionate manner will improve therapeutic engagement and outcome.

EDITORS' INTRODUCTION

Psychotherapy has been a major part of therapeutic armentatrium in managing patients with mental illness. Often seen as a product of Western Eurocentric tradition, it is argued that not all psychotherapies are suitable for all cultural groups. Cultural norms of different psychotherapeutic interventions are often indigenous but these get ignored when groups move to other cultures. Tantam in this chapter emphasizes that there are clear ethnic and cultural values that are important in determining therapeutic needs and interventions. A person is immersed in a culture but is consigned to a class or ethnic group. Members of a class have specified status, social influence, health and opportunities for wealth creation. Ethnicity and religion are related to organizing principles of status in society. Western psychotherapists and psychotherapy draw on two cultural traditions which are intertwined within Western psychotherapists, and psychotherapy draws on two cultural traditions which are intertwined within Western European thought. The success of causal explanations in aetiology and in therapy has secured their pre-eminence. Personal identity is a common issue in psychotherapy and this varies across cultures as do the concepts of self. Tantam emphasizes that cultural values are affect laden, which must be taken into account in any intervention. Provision of psychotherapy across cultures means that the therapist not only has to deal with unfamiliarity and uncertainty created by novel ideas or situations, but also means dealing with the emotional flavour of the novelties. This will be further affected by the way in which culture transmits emotional flavours.

In the previous chapter, persistent and disabling emotion was considered from the point of view of the client who found it useful to consider it to be an emotional malfunction or the consequence of a habit. The treatment approaches considered in that chapter had many values in common with medical practice. Indeed, many practitioners combine these approaches with drug treatments. These shared values include attributing problems to illness or pathology rather than to personal agency, emphasizing the causes rather than the reasons for things, and minimizing responsibility for anything but being a good client. Additional values inherent in symptomatic and motivational approaches include social cooperation, and the priority of the future over the past. Family members, if they are involved, are recruited as therapeutic assistants and they, and the therapist, are seen as helpers. Whatever has happened in the past, there is optimism and potential relief or change in the future.

The symptom-relieving approaches considered in Chapter 6 assumed that neither past emotional experiences nor current interpersonal conflict was relevant to the therapy. If we wanted to use metaphors of emotional flavour, we could say that symptom-relieving approaches are sweet rather than salty (if conflict is the salt), and sour rather than bitter (if the past is the gall).

Many people, including many therapists, consider that a psychotherapeutic approach that takes no account of interpersonal conflict is too saccharine, and that the past must be faced, however bitter it might be.

Feeling stuck with your client? The client has threatened suicide? Do you dread the next session? Has the client become over-familiar, or unreasonably hostile? Do you feel that it's time to end the treatment, but you can't bring yourself to do it? If so, read on …

Psychotherapies progress in different ways. Some seem to be quite straightforward. Others seem to be a series of crises. The most common pattern in longer-term therapy is for there to be a series of sessions in which the discussion between client and therapist seems to be a fairly predictable working out of themes raised in an earlier session. Then there may be a crisis that, if it is surmounted successfully, throws up new themes for working through over the next few sessions.

Some of the crises to be considered in this chapter are shown in Table 11.1.

General principles of managing crises

It would not be possible to write this chapter without some outcome criterion. If a person kills himself, people sometimes say, ‘He's better off dead’. If a person remains miserable or confused or frustrated, there will always be someone who says that that person is more realistic about how life really is, than if he or she had been happy or goal-directed or fulfilled. If any outcome is as good as another, there can be no criterion of what constitutes competent psychotherapy.

What is Sophie offering? And is it anything to do with health? In an illness-led service such as the British NHS, happiness seems like an accidental consequence of lack of illness, rather than something for which the doctor could, or even should, aim. Happiness might be the stuff of escapism, of Mills and Boon fantasy, or of religious zealotry, but not of the clinic or everyday life. Or so it might seem. Argyle (1997) has argued that happiness is an important determinant of long-term health. Happiness is also the single most important determinant of quality of life according to a panel of UK residents brought together to develop the WHO International Quality of Life instrument (Skevington, Mac Arthur & Somerset, 1997).

How important happiness is, what constitutes happiness, and whether or not its absence should make us change our lives, are all questions that can only be answered in relation to our personal values. What to a psychotherapist might be hedonism might to his or her client be the activity that makes life worth living.

Stories of happiness

Long-term therapy requires some theory of what it takes to be a person – a theory of human nature (Trigg, 1999).

Narrative approaches to psychotherapy have become rapidly established in family therapy (Sluzki, 1992), and are increasingly influencing individual psychotherapy. They recognize that the need to tell one's story is an important impulse for people in distress, and that telling one's story to a receptive audience lifts some of the burden of the events depicted in it.

Narratives bring together the three elements that we have already seen contribute to a person's concerns: actions, values and emotional meaning. Indeed, literary narratives have been viewed as responses to fundamental concerns, and a limited range of them at that. Illness is one of these concerns, and ‘taking a history’ is a narrative response to it which will be familiar to all doctors.

The ‘narrative turn’, as it has been called, in the intellectual life of the twentieth century reflected the weakening of a commonsense world of reality to be discovered, and replaced it with reality which was constructed and, potentially, deconstructed. The early psycho-analysts were strong influences on the development of the narrative approach because of their emphasis on the hidden reality of the ‘unconscious’. However, these early psycho-analysts were not free of their positivist inheritance, and believed that they were describing a psychic reality. Narrative theory has grown sufficiently large, however, to be able to bite the hand that fed it, and to challenge this reality. Surely, narrative theorists would argue, the unconscious is just another story?

This chapter is about addiction: why it is difficult to give up a way of life that has become destructive or to relinquish certain ways of reacting, including symptoms, which have gained a hold despite being unwanted. It is also about how people give up their addictions, and therefore about what therapists can do to help them. It will turn out that overcoming an addiction is rarely a matter of vanquishing it but more often a matter of giving in to a realization of the need for something bigger and more powerful than oneself, a process that Heidegger terms ‘releasement’ (von Deurzen, 1997). The word ‘addiction’ is used advisedly here, even though it is no longer fashionable. It has generally been replaced by the words ‘dependency’, as in chemical dependency, or by the term ‘misuse’, as in substance misuse. Dependency connotes a particular image of someone who is needy and dependent on other people. There is no evidence that these personality traits are particularly linked to becoming addicted, however. Misuse does not capture the imperative nature of the problem. Heroin, as an illicit substance, is misused every time that it is used. Yet there are people who manage to confine their heroin use to a level which they would not consider to be problematic. The ‘demandingness’ of heroin addiction – its admixture of pleasure and self-destruction – is not really conveyed by the much more neutral term, ‘misuse’, which could apply equally well to the recreational user.