FRAGMENTS AND DISCONNECTIONS: MOVING AMONG THEORIES IN CLINICAL PRACTICE

Interview given by Rolf Sundet, Ph.D., professor emeritus at the Health and Social Sciences School belonging to the University of South-Eastern Norway in Drammen, Norway. He graduated in Psychology and was trained as a Family Therapist at The Dulwich Centre in Adelaide, Australia, and at the Institute of Active Psychotherapy in Oslo, Norway. He has worked clinically with couples and families for 35 years, although his experience in mental health care and assistance contexts had started ten years before, as an assistant nurse in wards at Mental Health institutions. Since 2016, Professor Sundet devotes exclusively to teaching at the University of South-Eastern Norway. However, he also engages in counselling and monitoring activities in different Norwegian clinical and institutional context, for being active in the Mental Health service. He developed most of his career in clinical practice at Mental Health institutions from Norway and the United Kingdom. It is worth noting that, in Norway, the clinical practice in Family Therapy is part of the basic Mental Health care services and that, in general, clinical professionals work based on their inclusion in health services.

In 2017, we were honoured to have Professor Sundet in Brazil due to his participation in the Escola Franco e Franca Basaglia International Mental Health Congress, invited by Professor Dr. Clarissa Mendonça Corradi-Webster (FFCLRP-USP). On this occasion, we held scientific meetings in the Graduate Program in Psychology with the participation of undergraduate and graduate students, where we were able to explore more in-depth certain aspects related to Professor Sundet's practice and theoretical developments, in addition to presenting him the ongoing projects at the Laboratory of Research and Study in Group Practices (Laboratório de Pesquisa e Estudos em Práticas Grupais, LAPEPG-USP). In that meeting we initiated collaborative work with Professor Sundet to enable academic internationalization and cooperation visits and actions. Thus, in 2018, the first author made a technical visit to the University of South-Eastern Norway funded by the São Paulo Research Foundation (FAPESP - Process No. 2015/21316-1), in which the professor contributed with the discussion regarding the authors' central research question about the integration of theories and techniques into the Family Therapy clinical practice (Paula Ravagnani, 2019; Paula-Ravagnani, Guanaes-Lorenzi, Sundet,2022). It was in this context that this interview was held.

The topic of this interview is clinical practice in Family Therapy (FT). More specifically, the use of different theories in the clinical practice by the therapist. Multiple topics were freely addressed in that conversation, so that the subject matters went back and forth in a spiral that, at each (re)visit instance, added a broader, more complex and embodied perspective over his more than forty years of clinical experience. Given the fluid nature of that conversation, the report below is edited material that highlights the moments when we more directly addressing the issue of using different theories in the clinical practice.

Interviewer: How did you become a Family Therapist?

Rolf Sundet: It took me many years to really say that I'm a Family Therapist. When I was seventeen years old my neighbour came home and said: “Rolf, you have to apply for a summer job at the Mental Hospital because that's a very interesting job”. So, later on, I got a summer job at the local psychiatric hospital and found out that I was actually good at it in the sense that I felt some kind of mastery, and I kept working there every summer, holiday, Christmas and Easter. I also wanted to travel at that time, so I went to England and started to work in a mental hospital as a Nursing Assistant. When I came back to Norway, I kept working in Mental Health institutions for two or three years after High School. At that time, I had a mate who was taking an exam to get into university and I thought: “I can do that too”. So I sat for an admission test and started to study Psychology. I worked in mental hospitals together with nurses, psychologists and physicians who were very good at what we called working in therapeutic communities (Campling & Haigh, 1999), which included all different aspects of the everyday world; for instance, we had a kitchen group and cooked together with the patients. These mental hospitals were psychodynamically oriented and, at that time, I started being interested in Freud and Ronald Laing. Then I discovered Wilhem Reich. We studied a lot of Skinner and Behavioural Therapy at the University. And I had this feeling that theories constrained me. Thus, it's always been hard for me to be loyal to a single theory. I had a lecturer that I found very interesting because he was very good at bringing up new theories, and he introduced me to the Systems Theory, Gregory Bateson and Humberto Maturana. I started to read Bateson's Steps to an ecology of mind (Bateson, 1972), and that was the first time I felt that I was not really constrained by the theory: it has opened up towards diversity. So I did my dissertation on Systems theories and Cybernetics (Sundet, 2009a). My interest was theories around systems, the development of the Systems Theory, Cybernetics, Bateson's cybernetic epistemology, first- and second-order cybernetics and Maturana's proposals (Maturana & Varela, 1980). But, clinically, I was still a Nursing Assistant. When I finished Psychology, I thought: “I'm going to work with adults” because that's where my experience was. I didn't know any specific method that I was trained in. So I probably worked more trying to make sense of what I had experienced as a Nursing assistant. Today, I'd probably say that I was good at working with ‘common factors’.

Interviewer: That is, common factors being a name that you give nowadays when you see yourself back in those days?

Rolf Sundet: Well, in Psychotherapy research today there's been at least two ways of looking at Psychotherapy. One way is that it is a theory-specific activity. So that has led to the idea of what is best: cognitive therapy, psychodynamic therapy, systemic therapy, etc. And you've done all these Randomized Controlled Trials (RCTs) to try to prove which one is the best therapy. And we now know that they're all good, none seems to be better than others, there are very small differences, and those differences probably have something to do with contextual factors. So, the other hypothesis is that Psychotherapy helps people because there's something common in all theoretical models, and what is common usually has to do with expectations, hope, therapeutic relationships and, especially, therapeutic alliance. So there are theories and specific techniques that seem to be helpful, and then there's what we call extra therapeutic factors - things about the client and the client's context. And it seems that the relationship factor and the extra therapeutic factors are the most important for success of the therapy. So I think I was good - well I don't know if ‘good’ is the best word, but at least I survived as a therapist helping at least some people by being good at creating relationships, working with therapeutic alliance and also attending to people's lives, interested in what it is in people's lives that makes them survive, for instance. That's what I learned as a Nursing Assistant: that I was good at creating relationships with people. To make a long story short, in 2001, I started working in a Family Team and that's when I really started to think about myself as a Family Therapist. So, it took me almost 20 years to be confident in calling myself a Family Therapist. That's how I became one.

Interviewer: When working as a Family Therapist nowadays, can you tell me what the main theories and methods that guide your clinical work are?

Rolf Sundet: I have some theories and ways of working that I like more than others. I've always liked the different systemic, post-modern, narrative, and now dialogic ideas; the ways of thinking developed on Family Therapy from the beginning of the 80s, especially with Tom Andersen, Harlene Anderson, Harry Goolishian, ideas on post-structuralism and post-modernism. I've been interested in John Shotter and his concepts of joint action, withness thinking, and those kinds of concepts. I also like to be informed about Developmental Psychology, Daniel Stern's ideas. And I also think that reading research is important. Thus, relation and relationship are two general concepts that really help me.

Interviewer: I don't know if it happens to you, but it happens a lot to me: when I tell someone that I'm a Psychologist, the immediate question is: Which approach do you use?

Rolf Sundet: In all my career I've been asked “What kind of psychologist are you?”, and what they mean by that is: “Are you dynamic or systemic, etc.”. What I tell people is that I'm a clinical psychologist, that's it. I'm not fond of the term ‘clinical’, so I used to say that I'm a practitioner of Psychology in Psychotherapy. But I wouldn't connect any theory to my name.

Interviewer: Earlier you mentioned Gregory Bateson and his influence in your relationship with theories. What did you see in Bateson's ideas that changed the way you felt about theories that broadened your ways of seeing things?

Rolf Sundet: Bateson's work is about difference and differences that makes a difference. It's about connections. For every system I point to, there's a methodological act that I do. I could see the person as a system. But I could also see the person as a part of a larger system that we call ‘family’, and I could also see the family as a part in a larger system that we call network, for instance. This aspect of the theory expanded the possibility to focus on social aspects. Due to my experience as a Nursing Assistant, I believed that people changed from things that were not spoken in therapy. I had also experienced patients who said: “Why can't I talk to this psychologist who works in the kitchen?”, which actually wasn't a psychologist, she was the maid. And what they were talking about at the Psychology Institute at my time? Contingencies, reinforcements, psychodynamics and the Theory of Conflicts. I think that Bateson somehow broadened it and together with Maturana and his concepts of structural determinism, structural coupling, and the notion that causation doesn't work in an instructive manner. Those ideas opened the focus on diversity, specificity, on the difference that makes a difference, and made it possible for me to include many more of the experiences I've had as a Nursing Assistant. And, as I said, I had this feeling that theories very easily constrained me and demanded me to look at something. If I were an old-school psychoanalyst, the demand was to look at inner conflict and you had to understand the patient's emotional expression as transference, etc., and these sorts of things didn't fit my experience. Sometimes they did fit, but others it was something else, and I didn't have words for those other things. Thus, during my career I tried to create words that could help me to meet the richness of experience.

Interviewer: And how do you use the different theories you had studied in your career in your daily work? For instance, some authors define integrative approaches as those in which the fusion of models creates a new framework, which, at a meta-level, is able to explain how different ideas are connected. Thus, the combination of theoretical concepts and techniques originates a new theory or approach.

Rolf Sundet: I've never believed in this kind of therapeutic integration, where you mix together different theories and create a new one. I wouldn't call myself integrative, I'm all for fragments and disconnections. And, one funny part is that I started to write a paper some years ago in Norwegian, where I stated that I'm ‘loose’ in my relationship with theories. And then I found that Sheila McNamee's paper on promiscuity (McNamee, 2004). I think I developed some of the same thoughts that she developed in that paper. I have a promiscuous relationship to theory. I use it and abuse it as I find it fitting in the therapeutic context. But it's a post factum description. Tom Andersen used to say that practice always comes first. In my experiences with working in Mental Health hospitals I've always tried to find a helpful way of being together with people. For instance, when somebody said that it was wrong to use constraints on a patient, I would agree with that, but then I was working as a Nursing Assistant and, suddenly, I had this woman who said: “I demand to be strapped down in my bed. I'll have that instead of medication because medication ruins me”. And by that I realized that you have all these conceptual diversities, so whatever choice you make to say: “This is how the world is”, the world always offers you an opposite. Another example is that, at one point, I thought that Cognitive Therapy didn't fit at all, but then I started to meet this client who said: “If it hadn't been for Cognitive Therapy, I would've never gotten rid of my problem”. So, then I'm challenged in my belief, and Bateson was the first one who offered me a language to describe these experiences, especially with his concept of epistemology as a circle between ontology and epistemology. Well, it was not Bateson that has made me, because the experiences were there before I met Bateson. But then having met Bateson, that was a difference that made a difference. I read in your notes [mentioning the author's data analysis, see: Paula-Ravagnani, 2019] that you referred to Sheila McNamee (2004) and then you referred to Victoria Dickerson (2010).

Interviewer: Yes. Dickerson (2010 ) has a piece in which she states, as I understand it, that a Family Therapist could integrate theories and methods that have the same epistemological background. She distinguishes three epistemological bases: systemic, structuralism and post-structuralism. Each one has a particular definition of person, problem and change. Therefore, an integration that crosses resources from these different epistemologies is not rigorous, and may create confusion and misunderstanding for the therapist, who wouldn't be able to distinguish the notions of person, problem and change in which his or her work is grounded.

Rolf Sundet: I think she's constraining again. For instance, I've been working now on causation, where there are two ontologies that could be differently shaped around causation, and these authors also say something like Dickerson (2010), that if you choose one ontology, that's incommensurable with the other. And I think: “yes, it probably is in an academic sense”. So, it might be that when you want to explain your work, these are different kinds of explanations that are incommensurable, they don't fit together. But in the clinical practice, I'd go into and out of structuralism, systemic thinking, post-structuralism and I'd say that Dickerson is very structuralist when she asserts this. She's not post-structuralist for me, or at least she's not systemic because systemic for me, but also post-structuralism, allows the opposite. So, I think she's dichotomizing, and she says that if you've taken one you can't have the other. So, if I understood her correctly, I'd say that, yes, theoretically this might be true. But when you put that kind of constraint on a therapist, you constrain his or her possibilities for actions in the world. So, for me, that means that practice is always more important than theory. There's also another point, that if you act as if a theory is true, then it's no longer a theory. If you act as if there are systems out there in the world, as concrete things in themselves, then it's no longer a theory, it's a fact, a description of how the world is. I always say that for theory to exist as a theory, you need at least two theories, because if you have only one you have a tendency to believe in it [as a truth].

Interviewer: When you say that, it seems to me that it's closer to this idea of promiscuity, as you said, a loose relationship in which theories will be seen as discursive options, a way to talk about the world and relate to it.

Rolf Sundet: Yes. I was trained as a psychologist hearing my teachers say that you have to follow the theory. I had a teacher who said that when you don't know what to do, you must look at the theory and do what the theory prescribes. I never felt comfortable with that. For me theory can never fully decide, it is not an imperative that tells you what to do, it always suggests actions. And I understand Sheila McNamee (2004) when she talks about discursive options that you can choose. So, there are situations in which I choose to work in a way that could be described as structuralist.

Interviewer: But it is, as you said, a post-factum description.

Rolf Sundet: Yes. The philosophical position that I've been interested during the last year is pluralism. Any problem has many solutions, and this fits for me. I think that instead of creating specific theoretical therapy models, we should create descriptions of ways of doing therapy, which should be formulated in some kind of language. Theories supply us with language, but we have to remember that theory is not a fact, theory is just one way of specifying it. Thus, I believe in developing theoretical vocabulary because it helps us see new aspects. But when we create the theoretical vocabulary that helps us distinguish things that we haven't looked at before, then we need to transform the theory into daily language again. Thus, for me, theory is something that comes and goes. Otherwise, we end up creating specific models for therapy, and then somebody says: “Well, we have this and that model, what about combining them into a third one?”. Then we're into this type of integration that just keeps constraining us. So, if Tom Andersen is right that practice comes first, the danger is, as he said: “Any descriptions, and also my descriptions, always have the danger of constraining us”. Michael White also referred to this idea by saying that the world is always richer than the stories we tell; that's why we can tell new stories, because we discover unique outcomes, exceptions that we integrate into new stories. I'm afraid that theory might constrain me and that's why I'm promiscuous and disloyal to theories. However, I think therapists should be constrained by something, and that something is the client's response.

Interviewer: In what sense should the client's response constrain the therapist's actions?

Rolf Sundet: Let's see. I work with narrative practice and the client is also taking part in working narratively, for instance, with externalizing conversations. I believe in this framework and the client feels it's OK, but there's no change. That's why I think it's important to use feedback tools systematically when it comes to therapeutic processes. We can investigate if what we're doing is actually helpful. I can look at the client's response and if he or she isn't getting any better, that should constrain me and I might stop using externalizing conversations and look for other ways of working. That's what I mean by being constrained by the client's response: whichever way I'm working, I need to check if it's helpful and, if it's not, I should change my ways. I find Sheila McNamee's oriented way much more interesting (McNamee, 2004). I'm just as fond of fragmentation as I am of integration. What I mean by fragmentation is that, if something, part of a theory, only partially fits the client, I would rip the theory apart and only use that part.

Interviewer: In this sense, how do you see the integration of ideas that belong to different epistemological traditions? For instance: systemic and social constructionism or, as you said, psychoanalytic and systemic ideas, behavioural, etc.

Rolf Sundet: I'm ambivalent. Now I have a saying that ambivalence is simply sensitivity to complexity. Ambivalence has a very bad reputation in Psychology. And, for me, this speaks a lot of the existential situation of being human. Every time I think I found the answer, somebody kicks me on my leg and tell me it's different. Thus, I'd be interested in mixing systemic and psychodynamic, and I also think that there's much more overlap, a lot of the things that psychodynamics theories speak about you can find in systemic ideas, but in a new language. So, let's go back to the question: “How do you see the integration of ideas that belong to different epistemological traditions?”. At the moment, I'm not interested in epistemology, I'm much more interested in ontology. How do I really think the world is? Ontology for me is referred to our theories about the world. As they are theories, they'll never be true. And it's important to remember Bateson's concept of epistemology, which was something more than theories about knowledge, it was also about an answer to this question: What is the world like? It was an ontology and epistemology circle. Thus, Dickerson's ideas (Dickerson, 2010) are important in an academic sense, as it's important to create coherent theories so that we can generate research questions to be tested and investigated through different kinds of research methods. So that's the useful thing. At the same time, the problem with research is that you constrain yourself within a given way of thinking, and that means excluding things. You could argue to that in a research context, because your aim is to investigate this and not that. But when you transfer that logic into the therapeutic context you no longer exclude concepts and theories, you exclude persons. So, I think that, in practice, theoretically incommensurable ideas go well together. I have this idea that in theoretical work, when you work as a scholar, you have these kinds of paradoxes; for example, the systemic theoretical model clashes with the post-modern ideas, they're incommensurable. But that's the aim of theory; these things can be dilemmas in the practice. And let's remember that problems you solve, dilemmas you live. It goes back to what Michael White said: “Life is always richer than the theories we have”. I've worked with clients who had been seen as difficult to collaborate because they “did not dare to move outside their comfort zone”, all these types of descriptions. And my experience is that when you start asking people: “How would you like to work on your problem? Do you have any ideas about what we should do and what we should not do?”. They don't really know, but you can start to investigate and follow people in their suggestions. Issues such as resistance and motivation disappear and my experience is that symptoms also can disappear.

Interviewer: It's interesting because it seems that in this movement, this orientation towards the clients, you were also able to move away from the comfort zone of theories, the constrains of theories to see what that person in particular would want for his or her life, his or her treatment.

Rolf Sundet: Yes. So, if I should use the concept of comfort zone it would be with practitioners who stayed within one theory.

Interviewer: The boundaries of one theory.

Rolf Sundet: But then, again, I know that it's not true either because, for instance, I have a friend with whom I've trained narrative practice. And he said he'd never do anything else but narrative practice. However, he also states it very clearly when he feels that he's not able to help people and that this has to do with his way of practicing therapy: it doesn't necessarily make sense to the client.

Interviewer: And exploring a bit more this stance towards theories, in what sense do you think that this view of being promiscuous or disloyal would be different from an eclectic position?

Rolf Sundet: Originally, I created a concept for myself; if I wanted to state my position, I'd call it a radical eclectic one. And what I meant by that is that being eclectic is when you pick and choose from everything you know. But when I look at the etymology of ‘radical’ it has two meanings: one is that something is rooted in something and radiates from that. Thus, radical have both these concepts of being rooted in something and, at the same time, moving out to the end of things, the extreme. Thus, a ‘radical eclectic position’ means that I'm rooted in something and that, from there, I'll branch out and use whatever I need. What am I rooted in? Then it's back to the client's experience, the client's response. That's just another way of saying that I think I should be rooted in and, by that, constrained by the client's response. Thus, what I've learned is that whatever I do, I have to develop some kind of structure with the family or the client. That means that what we did last time we might do the next time, and if we do something different is because we decided that what we did should not be done again; or it can mean doing the same think again and again, repetition. Thus, there should be a collaboration creating a co-structure.

Interviewer: Let me see if I understood. This structure is based on the story of the relationship; what you've done, what you haven't done; what worked, what didn't work; more than the different technical resources you might have, which would be an eclectic stance, is that it?

Rolf Sundet: Yes. But let's see, for instance, if it was a person with anxiety who said: “I know I really have to train”. Then I'd pick a structure, for instance from a Cognitive Behavioural Therapy handbook, and suggest we would follow that. Thus, for me, technique is basically a structured way of doing something in a planned manner, with a start and middle…

Interviewer: Yes.

Rolf Sundet: So, it must be the experience that is meaningful, but you always need to check if what you're doing is leading anywhere.

I: And while you're telling me that, it's making sense for me why feedback is so important in our practice ( Sundet, 2009b , 2012 ). Because if the structure lies on the story of the relationship, you need to have constant feedback and meta-communication about whether the relationship is being helpful or not.

Rolf Sundet: Yes.

Interviewer: There's this understanding that working in an eclectically way would be less thorough, less careful.

Rolf Sundet: Well, I think it's important to have a structure in what you do. I think it's important that you and the family have some kind of understanding on why we do this. But I don't think that it needs to be formulated beforehand in theoretical language. It could be negotiated as a conversational element of the therapy. I think that rigor and structure have to do with the clients experiencing that what they do is meaningful, makes sense and gives this feeling that we're doing something that's good to be done. Nowadays, in Psychotherapy research, it is stated that there's a gap between research and clinical practice, and that this gap should disappear. I think it's important that there's a gap between research and clinical work. It should be bridged, but it means that when you move from research to the clinical work there is a change. You have to relate to a clinical context in such a way that what is impossible in the theoretical domain might be possible in the clinical domain; and what is impossible in the clinical domain might sometimes be possible in the theoretical domain. That's what novels and science fiction are all about! If we keep that distinction and say that what you do in the practice can never be a complete fulfilment of the theory, then it could be okay to do theory integration, that you could create new kinds of theories mixing together post-modern, social constructionism, psychodynamic and behavioural theories. Because it wouldn't be ‘real’, it would be an experiment in trying to create different ways of talking, and you might find new things by doing this. But you should never think that what you created fits better with clinical work than other theories. I still believe that I don't think it's possible to make a theory of it all. The thought that I get out of this conversation, that I hadn't thought before actually, is that maybe theory integration would be very exciting if you really started playing around with different elements from different theories, not in order to explain what is in the practical world, but to see what kind of realities might be constructed.

Interviewer: So the challenge is how to bridge theory and practice.

Rolf Sundet: What I think would be helpful for me, and I'm struggling with these things also, is to think that if the Academia is one actor and clinical work is another actor, we know that it's important that these two actors are allowed to have their own perspectives. A last thought that's been important to me that is related to this is the difference between a problem and a dilemma. I think a problem is something you can solve, it can be hard to solve, but sooner or later you solve it and the problem does not arise again. A dilemma is different from a problem because it doesn't have any final solution. If dilemmas don't have a solution you have to live them; and you never really know if you are out of the dilemma. So, I'll always be uncertain when I'm in a dilemma. And this is sort of the relationship between research and clinical practice, it's more of a dilemma than a problem.

Referências

• Bateson, G. (1972). Steps to an ecology of mind: Collected essays on anthropology, psychiatry, evolution, and epistemology San Francisco, CA: Chandler Publishing.
• Campling, P., & Haigh, R. (Eds). (1999). Therapeutic communities. Past, present and future London, UK: Jessica Kingsley Publishers.
• Dickerson, V. C. (2010). Positioning oneself within an epistemology: Refining out thinking about integrative approaches. Family Process, 49(3), 349-368.
• Maturana, H. R., & Varela, F. J. (1980). Autopoiesis and cognition. The realization of living Dodrecht, HO: D. Reidel Publishing Company.
• McNamee, S. (2004). Promiscuity in the practice of family therapy. Journal of Family Therapy, 26, 224-44.
• Paula-Ravagnani, G. (2019). A integração de teorias e técnicas na prática clinica em terapia familiar (Tese de Doutorado). Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto.
• Paula-Ravagnani, G., Guanaes-Lorenzi, C., & Sundet, R. (2022). Learning from within: Therapists´ actions in daily clinical practice. Family Process, 62, 94-107. https://doi.org/10.1111/famp.12840
  » https://doi.org/10.1111/famp.12840
• Sundet, R. (2009a). Client directed, outcome informed therapy in an intensive family therapy unit - a study of the use of research generated knowledge in clinical practice Oslo, NO. Department of Psychology, University of Oslo.
• Sundet, R. (2009b). Therapeutic collaboration and formalized feedback: Using perspectives from Vygotsky and Bakhtin to shed light on practices in a family therapy unit. Clinical Child Psychology and Psychiatry, 15(1), 81-95. doi 10.1177/1359104509341449
• Sundet, R. (2012). Post-modern oriented practices and client-focused research: Possibilities and hazards. The Australian and New Zealand Journal of Family Therapy, 33(4), 299-308. doi: 10.1017/aft.2012.38

Publication Dates

• Publication in this collection
  22 Jan 2024
• Date of issue
  2024

History

• Received
  10 Aug 2020
• Accepted
  29 Sept 2021