An Introduction From the book APPRENDERE I CONTESTI (Mastering Context) By Umberta

 

Entering into a new context is no easy task for a mental health professional. Social and mental care workers  enjoy wide appreciation within their profession; over the years, due to health service reorganization and spending cuts, their work has become increasingly harder. When a worker first enters an established workforce, he must make his mark and build up his confidence in order to earn his place amongst colleagues who already share a point of view and who function as a whole organized by a consolidated praxis.

The systemic frame, of which I consider myself an Italian representative, constitutes the core of this book. I teach on the post graduate course in Health Psychology at the University of Rome La Sapienza, this has enhanced my systemic frame and thinking, since it has underlined the need for a thorough praxis (?) which gives importance to resources and evolutionary processes within organizations and systems (individuals, families …).

Systemics (HvF2003) and health psychology are the poles of this book. They propose a common know-how and a practice which I consider transversal to contexts and professions. Division into different models and training schools is no longer useful; the time for inventing new models is over. What is needed is in-depth study; as yet the systemic paradigm has not been fully explored. It still has great potentialities. We might refer to interventions as being either good and economical, or redundant and collusive; we could go so far as to refer to some as useless, counterproductive and harmful.

Over the years, I have worked in Italy as a supervisor in different settings (mental health clinics, hospitals, socio-sanitary organization, private associations). I have worked alongside both young and senior professionals. The young ones would often approach the task of entering a new context without first having made themselves familiar with the formal rules or without questioning the games that might be played within that context. In their naivety, they found themselves without the necessary tools to apply leverage to their projects. They risked colluding with the games they found operating and being trapped into some “dangerous” coalition. Sometimes they would merely fill the psychological role placement of someone who had just left the institution.  The second group ran the risk of not keeping up to date with progress and change in the field, particularly in client/helper relationships. … (?). We learned together  that a team is always stronger when working as a whole rather than when each one of its members works alone. My experience has taught me to highlight mistakes and difficulties, moments of impasse and choice, as well as successes and virtuous circles . … I strongly believe that reflecting on a possible impasse helps to reveal clinical work at its best, if it is not judged or criticized.

I have learned a great deal from working in public settings: they offer such possibilities! I still take any opportunity I can to listen to professionals’ experiences since I consider them the best way to learn inclusionary circular  patterns and dialogical encounters, both of which provide an opportunity for lively transformation. (discuss)

My first clinical experience as a trainer was in 1971 at the Child Guidance Clinic at the University of Rome, Italy (Child Neuropsychiatric Center). Families and  volunteer psychiatrists and psychologists alike were prevented from having any understanding of what was going on. Clinical practice was a magic ritual for the experts and the initiated. It was like finding oneself in a sect, where only the lucky adepts could say their word. Verdicts came from afar, threatening and definitive, often obscure. I used to think that the psychoanalysts who worked there shared some sacred knowledge and private jargon. I am speaking of the years when there was no contamination between psychological models (?);this arrogance/shutting oneself off in an ivory tower (?) was merely a defense mechanism and a means of preserving one’s identity. We could experiment in the field what had been learned from the books written by the founders of the different training programs. These programs were difficult to access, expensive and – in Italy – highly focused on private practice. Psychoanalysis was still declined as a singular model, had special status and was considered a privileged intervention with as yet no comparisons in terms of results. It was available to only a select few.

In Italy there was a group of pioneers who practiced family therapy. With great enthusiasm, colleagues would meet weekly to read Bateson, reflect on contexts, dreaming they would revolutionize psychiatry by applying systemic thinking. I felt discouraged by the long path ahead of me, by my ignorance and by my lack of confidence. It was easy to feel fearful (fear, respect, ignorance?) about the workplace one had to perform in. It was clear that in order not to “suffer”, one needed to decode each context and find one’s place within it. A comfortable place, not a cumbersome one.

Learning how to enter and move within an organization is not easy. One must learn to take it step by step, accepting the fact that initially one is a stranger and will not feel at home but precarious. There are multiple strategies and tactics involved; this book is an attempt to reveal them. I have repeated this process many times throughout my career and it has invariably been a source of learning and, at times, anxiety and enthusiasm.

In the mid-seventies, I left for the United States. I was a trainee in family therapy at the Philadelphia Child Guidance Clinic (PCGC), the most famous systemic training center in the U.S. at the time. I was sent to the south branch in the black-Italian section of town. As a fearful young student, I was cautious. I would go around on my bike and was suspicious of everything, full of prejudices and a priori ideas. Very soon I started to interact with people: at lunchtime we would stop work and all together – professionals and clients  – would watch one of the first TV soap operas, eating and commenting on the plot at the same time. I quickly became “Doctor Umba” (my name made African, therefore part of the context). To be considered an insider and to participate to the common culture made me feel part of the “family” and enhanced the learning process. Having been given this nickname, I felt less frightened. Nothing bad (untoward) ever happened to me during this period: was I protected by the community or, feeling reassured, was I moving less clumsily in the context? My confidence rose. Learning to participate has been fundamental, as much as finding the courage not to hide behind my professional role and the courage to show my feelings, be they of fear or enthusiasm. My newfound courage helped me to imply that I could speak up, ask questions, and that I had the right not to know in advance.

I learned to read through the reams of rules which organize each daily action; rules determined by cultural aspects, some explicit, most tacit: my Italian background, the American culture, the black American group, Philadelphia, the PCGC, the south branch, the different roles within (bureaucrats, paraprofessionals, psychologists, the sub-group of the trainees) were just some of the variables.

Not only was I “new” to the profession, I was also a foreigner. I felt in a weak position but at times I managed to turn this to my advantage. I could ask questions, show my curiosity and doubts, explore different domains, be cautious with words. I was acutely aware of my right not to know. This gave me the courage to work out the alliance with the other trainees; to establish a relationship with my teachers and the other professionals; to stop fearing my supervisor; to understand the official map and the hidden one – which counts more – learning the rules of the context, exploring bonds and opportunities. I was able to build up an idea of the functions and chores, of similarities and differences. Only later, after I had been hired, was I able to propose one or two projects, coherent with some strategic hypothesis I had made. It was fundamental to first adapt to the context which proposed specialized interventions.

One day the director of the bank inside the Clinic, an acquaintance of mine, told me an anecdote about a young Italian, who came from the same town in Italy as I did and who had just started working at the bank. He was worried that this young man had some serious problems as he remained after hours at work, whilst everyone else left on time. My new friend was surprised at my explanation: his colleague was behaving as if he were still in Italy, where if you want to upgrade you need to show you are a hard worker. The Italian bank clerk had taken it for granted that all contexts are alike, that there are no differences between Italy and America. Nor had he reflected on the fact that the meaning behind every action is influenced by cultural aspects, not only geographical and social ones.

Another American anecdote: I had been asked to work as a consultant for a school in Philadelphia. The Dean had asked my for my intervention when a student was caught copying from a classmate. In Italy this kind of action is not considered serious, whilst  American culture, as I well knew, considers it a heavy misdemeanor. I did not comment but showed what I thought to be a strong reaction. Despite my indignant protests, the Dean requested the clinic to have me substituted: I was a foreigner and deemed insufficienty sensitive to the values of that system.

On that occasion I learned how culture and values pass through minimal non-verbal clues: the raising of an eyebrow, the drooping of the corner of the mouth. I learned how these signals represent a means to exclude or incorporate others. I had thought I could enter the school without first having worked on a trusting relationship with the Dean, which would have implied our getting to know each other. I understood the way in which “elsewhere” hides in small imperceptible clues, which we are not aware of signaling. I learned that we subliminally read a hint from others and we interpret it according to our grids, rarely sharing these interpretations, hardly every questioning them. I found out that the culture we live in is more than a dress we put on. It is a “mental” dress which accompanies us and which is difficult to take off.

I hope this book will help people not to make mistakes such as the one the Italian bank clerk made, or mine in the Philadelphia school. The aim of the book  is to explain entrance into socio-sanitary systems, to connect with the different positions professionals might occupy. I will analyze the rules by which contexts are moved; the traps one risks falling into; possible collusions which derive from a non-reflexive stance; actions which block (drown) professionals in repetitive processes or burn them out. (???)

In 1980 for the first time I was hired by a Mental Health Consultation Center in Rome. Along with other psychologists, I entered as a generic entertainer (“Can you play a guitar?”). The context had been characterized psychiatrically; psychiatric nurses and MD’s organized interventions coherent with their specific training. They were proposing medication and generic social interventions, framed by shared optimism. It was a step in the right direction from the horrors of the asylum politics. How was one to adapt to this very psychiatrically defined context? What could I do to make my entrance and begin working? How was I to find my space without being consumed by the generally accepted bad habits or being thwarted by envy and prejudices?  My aim was to offer interventions which were quite different from their usual praxis, without being expelled from the system (???)  What could we propose, specific to our psychological background, without being symmetrical? How could we integrate without creating two contra posed blocks?

The culture of the Consultation Center I was in was strictly medical. Both psychiatric nurses and MD’s colluded  on mental illness. The arrival of psychologists implied the introduction of a new culture which would render the context more complex, more interesting. What would the schedules be and how would we be introduced (?) Processes and times have differed from place to place. In my case, seemingly well disposed psychiatrists would open a dialogue with us, only to substitute their generic encounters with clients with “sessions”, something they had never done before. They improvised a new know-how, in order not to leave things in the hands of us newcomers. The risk was of instigating a competitive approach as to what to offer clients. A further risk was of creating a psychotherapeutic single culture, thereby foregoing the chance to utilize the resources implicit in the public workplace (many different professional figures, many different stances, positions, roles, many types of interventions possible other than psychotherapy).

The second (most important) cultural debate within Italian public clinics involved psychologists and their differences. Followers of Franco Basaglia (responsible for the opening up of asylums) proposed a global, social positioning, refusing psychotherapy and the differentiation of types of interventions. Their stance was social, ideological and interesting. The other side proposed a psychotherapeutic stance. Psychotherapists coming from differing training grounds were proposing specific dual interventions, based on the concept of curing the person rather than just taking charge of the problem. These services had run the risk of becoming the branch of a private office, where patients were taken into charge (not clients of public structures but patients of medical settings), where technicality and isolation would predominate. As systemic, neither approach appealed to us. As a fully trained psychologist, I proposed in my work setting a different path which was greeted with both enthusiasm and criticism: 1. the one way mirror, 2. inter-disciplinarity, 3. the group as a thinking unit, 4. the whole clinic taking charge, 5. dialogue amongst professionals, 6. falsification of the process through feedback from the family. It was at this point that I realized how the systemic frame allows the integration of differences, how it functions as an added value. The possibility to work with differences and the option to discuss and share different points of view was the most innovative and interesting aspect of that period.

This third option was opened up by systemic thinking and practice:

At the end of the 70’s, Mara Selvini Palazzoli was the supervisor of a group of systemic clinicians who shared a common frame and were entering socio-sanitary and managerial contexts for the first time. They had distanced from psychotherapy in the private setting and were interested in reflecting on how to move in a new work placement, avoiding all the subtle traps and games. Two very interesting and up-to-date books resulted from this experience and helped me very much in my new work experience. I still suggest their reading to my students as they analyze rules and relational games which organize each singular context. These books help to put the professional on his guard as he enters into an Organization, either as a consultant or proposer of a project.

And more systemic processes: students of the Milan school (Luigi Boscolo and Gianfranco Cecchin) in the 80’s were one of the groups reflecting on the differences between the private and the public setting, not considering them interchangeable. I shall forever be grateful for the creative dialogue and friendship given me by my  Italian colleagues, among whom Marco Bianciardi (), Laura Fruggeri (), Gabriela Gaspari, Lia Mastropaolo (), Massimo Matteini (), Andrea Mosconi (), Pio Peruzzi (), Valeria Ugazio (), Maurizio Viaro (), which have stood the test of time. Nor shall I forget the collective conversations on the difficult work in the public setting () during congresses held in the eighties among groops gathered to reflect on the Milan teachings. Debate underlined the need to reflect on practices that took context into consideration. It was clear that professionals in the public setting had acquired knowledge from within and were proposing interesting “new” practices, redefining their jobs. Contrary to the Anglo-Saxon tradition, in Italy systemic thinking and practices began in the private practice training schools, offering a private frame of psychotherapy.

The systemic movement, the Milan and post-Milan teams, were making this happen. (post Milan groups in Italy were Milano, Bologna, Padova, Genova, Torino, Treviso, Palermo; the Swedish group (Mia Andersson, Ernst  Salamon, Klas Grevelius ), the Fifth Province in Dublin (Imelda McCarthy, Nollaig ByrnePhilip Kearney), the Norwegian (Tom Andersen, Marie Flack), the group of Calgary (Karl Tomm, Robin Routledge, ), the one in London (David CampbellElsa JonesRos Draper,  John Burnham), the one in Cardiff (Philippa Selligman, Brian Cade, Bebe Speed), the Galveston’ (Harlene Anderson, Harry Goolishian), the KCC in London (Peter Lang, Martin Little, Elsbeth McAdam), The Marlborough Family Center again in London (Eia Asen and his colleagues), the Portugal gang (Helena Marujo and Luis Miguel Neto). We were trying to work as a cybernetic brain. They were mythical times. We strongly believed in shared work and the advantages of more minds reflecting together. We were able to pull together many different competences, many projects. Hearts were beating in unison. This experience taught me to surf rather than to seek control. It gave us the opportunity to let go of the unreasonable idea that we need to understand everything. However, we had to arrive at such a fundamental notion through experience.

With time, I learned that people who work together share a common dignity; that a statement made by a nurse must receive the same attention as one made by a psychiatrist. At the time, this was not obvious! I understood that the fewer the psychological interventions, the better the results, thereby favoring processuality rather than session upon session of psychotherapy. I learned that I could share concrete and interesting narratives with my clients,  who were the experts of their life whilst we professionals were the experts of change. I found out just how much psychological jargon is in danger of being over abundant and abused in our western culture. I experienced that working in a team becomes a guarantee for respecting complexity, an antidote to the risk of  both simplifying what happens and becoming homeostatic. For the first time, teamwork appeared to me an alternative to a unite single culture.(?)where there is no need for falsification.

A further choice lay open to me: whether or not to adopt a constructivistic stance. Meeting Heinz von Forester, Humberto Maturana and Francisco Varela was a key factor in my decision. Through which lenses does one observe clinical narratives? They are not dealt to us as a gift. The choice is ours as to which stance we take, it has to do whith our character more than with rationality. Which theoretical frames and actions are needed to intervene? ……………………….To work respecting differences implies that each one must make herself clear (we don’t need to negotiate but to be explicit) concerning the symbols of the organizational culture we are part of. Those symbols determine the way in which the clinical system (the client, the professional, the family, the social group of the client, our colleagues, other professionals participating in the same conversation) is represented in the situation and throughout the consultation. (???) In constructing a shared narrative, each participant will enhance certain specific information., understating some aspects, underlining and extracting others; will make hypotheses and form opinions; will attribute roles and values to actions, relationships and meaningful (??) people, including herself. Each participant will make his own interpretation of the clinical context which has just been formed. What does it mean for a professional to take into account such differences? It means to be able to consider plurality as a resource, a cultural enrichment and not – from a dicotomical viewpoint – an obstacle. It means to accept the inevitable presence of more than one culture, to consider meanings to be constantly evolving, far from being a static and coherent, homogenous image.

What else did I learn in the mental health clinics in the eighties? That we intervene with first and second order interventions which are quite diverse (see page xx); that the professionals need to be explicit when choosing at  which level they intend to act, choosing wherever possible the most generic intervention. I learned that the clinic itself can become the holder of the healing process, allowing clinicians to rotate without creating a fracture in the evolving therapeutic process.

The nineties were characterized by clinicians undergoing more than one training course. Confronted by the mysteries of the mind and of relationships, by psychopathology and institutions, it became evident that we all needed new tools to improve our comprehension and consequently improve our ability to help. Connecting into psychic and relational aspects enriched us and gave us more complex lenses with which to work in a dens modality (??) The systemic paradigm was used more and more and consequently was better understood; the levels of recursion became higher (??)

Working in different settings, I learned that the role I occupied determined my position within the system. The way one works can enhance one’s confidence. I learned that confidence and positioning (Campbell 20xx) define access to information and the professionalism by which we can move. We create either vicious or virtuous circles which define both our capacity to listen and to be listened to and the resulting access to information.(???) They determine the freedom we have in moving, the creativity, the possibility to explore options instead of repeating the same moves. How authoritative we feel determines the impact of our dialogue with potential clients; thereby determining the success or otherwise the failure/homeostasis of the projects we present (??)

As psychologists, the means we use is ourselves. We need to build up our “weight” from our positioning within the context. How rewarding it is to enter a clinic in the role of consultant or supervisor; how different it is to enter as a trainee (without a definite role, when it is the student who needs the institution rather than vice versa). When we occupy a definite position we can decode the ongoing dynamics as they reveal themselves to us before our very eyes: few secrets, no magical sect to hinder us. It is encouraging to know that we can start off on the bottom rung and work our way up, participating also from this humble position to change. It can be useful at times to act as a shadow and get to know the feel of the place, to adapt to the other workers who are already familiar with the work context and to observe their interventions and proposals. How beneficial it is to be able to shed expectations and fears, to abandon one’s firmly held ideas, rather as one would hold on to a lifebelt in a stormy sea. Just as in a stormy sea, we need to take courage and swim, rather than remain clinging to the rocks. In a new psycho-social job, we need to take the plunge and risk it.

In the eighties and nineties, once a mental health professional had been hired by an institution, she could expect to follow her career path and stay there for good. Nowadays, psychologists and psychiatrists, nurses and social workers, pedagogues, MDs, set up cooperatives and work contemporarily on different projects with different institutions. They propose projects and interventions which change over time, following a deadline based on the mandate. They must be prepared to change plans and strategies, to design proposals in accordance with the ever-changing needs of the context. We are confronted with processual (?)events which give clinicians a chance to build up their confidence in a very subtle manner even though  they can create anxiety.

The socio-sanitary process is being subdivided into specific sectors of intervention more and more. Enterprises and cooperatives are mushrooming up. In the psychic field, some protocols are organized (interventions with migrants, practices to define the adaptive competence of foster parents, projects in the domain of eating disorders….). In Italy organization differs enormously according to the geographical location. Drawing up guidelines means we do not have to start from scratch each time; it enables us to consider  previous experience as a source of learning and a reflexive tool. It helps narrow down choices and – at times – obliges us to abandon normal procedures, to question premises/premises (??), to confront new ways of thinking and working. I am in favor of diversity in procedures. I love polyphony of interventions, providing they respect up-to-date research. All too often interventions are proposed a priori, they are linear and often collude with the providers’ expectation and wishes. These proposals end up being homeostatic,  made rather to salve one’s conscience and give the impression of intervening rather than being a pragmatical means of evolution. Null interventions, at times iatrogenic (Mia Anderson), simply confirm the danger and impossibility of a condition which is defined in advance without taking into consideration the context. I draw a distinction between reproductive and transformative interventions. The former are fundamentally a one-way transfer, a downpour of information and actions, which emphasizes the “funnel-hat” learner (??) or context; they are called upon to maintain the status quo of the previously received knowledge. Transformative interventions and inquiry emphasize the interwoven circular interaction of knower and known. The snake Oroboro comes to mind; the archetypal snake who eats his tail in the process of creation. Following a cybernetic approach, I shall propose that different arenas (classroom, clinical office, child guidance clinic, workplace offices are formally the same context: all provide space for  bringing forth  creative transformations. They differ in their culture, history and values. Any agent of change must consider these differences and value them.

On all these transformative aspects, I shall try to reflect with the reader. I shall share with him my ideas on how to engage a context for transformative projects through the dancing of relational interaction   (through the choreography of relational interaction ??) I shall speak about encounters, mutual influence, relational interdependence, mutuality and ecological complexity. I trust this book will help to dilute anxiety by offering tools for reflection and intervention. (??). What I am proposing in this book, is the utilization of a constsructivistic systemic frame to enable one to read what actually happens. This option has opened up new possibilities in all types of health settings.

 

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