Therapy from a narrative perspective emphasizes an elaboration of constraining monologues to liberating dialogues and/or the deconstruction or rewriting of problem- saturated stories to stories of courage, strength, and competence.
The act of constructing stories allows one to organize and remember events in a coherent fashion while integrating thoughts and feelings. In essence, this gives individuals a sense of predictability and control over their lives. Once an experience has structure and meaning, it would follow that the emotional effects of that experience are more manageable. Constructing stories facilitates a sense of resolution, which results in less rumination and eventually allows disturbing experiences to subside gradually from conscious thought. Painful events that are not structured into a narrative format may contribute to the continued experience of negative thoughts and feelings. ... Psychotherapy usually involves putting together a story that will explain and organize major life events causing distress.
Extensive research has revealed that when people put their emotional upheavals into words, their physical and mental health improves markedly.
Dr. Brian Broom, New Zealand (details at bottom of article)
Critiquing the somatization model
Many protagonists for mind/body approaches use the language of somatoform disorders and somatization (the terminology of the Diagnostic and Statistical Manual of Mental Disorders IV), referring, for example, to the processes “by which an individual, ‘hiding’ from threatening psychological information … expresses his or her emotional distress in … physical symptoms or maladaptive behavior” (Wickramsekera 1998). In this framework somatoform disorders are characterized by symptoms suggesting a physical disorder, a lack of organic findings, and evidence (or a presumption) that psychological factors are involved. In contrast to Groddeck these definitions subscribe strongly to a notion of psychogenesis, a notion of a mind compartment acting on a body compartment to cause disease.
In my view, the terms somatization and somatoform disorders, as conventionally used, implicitly or explicitly represent constructs rooted in mind/body dualism - disorders are attributed to emotional factors being inappropriately expressed in the body;
Kirk & Christine's illnesses are expressions of their stories. The last thing they need is to be judged - so to .... Does this mean that they are to blame for their problems? It is not that the mind causes the body to be sick, or that the mind hides from ....
the physical presentation and the verbal presentation express concurrently aspects of the same total personal reality .
What sort of illness did Patient Z, with her manifestly thickened skin and her “shell” metaphor, have? Was it organic or functional? [real or psychosomatic] Which elements of her data should have been attended to, and which regarded as superfluous in the task of treatment? A majority of physicians would not consider the language/story/meaning data offered by her to be useful. On the contrary, physicians generally take their first responsibility to be a diagnosis, especially the diagnosis of physical disease.
patient is essentially an object. In our alternative view, the patient
must also be
seen as a subject with a meaningful story relevant to the appearance of
More modern support for unitary assumptions can be found variously in neuroscientist Pribram’s holographic theory that the whole being is expressed in every part (Ferguson 1982); or in physicist Bohm’s implicate and explicate reality states where “we do not say that mind and body causally affect each other, but rather that the movements of both are the outcome of related projections of a common higher dimensional ground” (Bohm 1980); or in theologian Gunton’s notion “of the world as an order of things, dynamically related to each other in time and space. It is perichoretic in that everything in it contributes to the being of everything else, enabling everything to be what it distinctively is” (Gunton 1993). (The notion of perichoresis is stronger than permeation or interpenetration. It allows us to talk about the experience of mind and body without ultimately separating them.) Finally, the philosopher Shalom (1985) takes us full circle back to Groddeck, arguing cogently that the person is not reducible to a combination of body and mind and therefore that the problem of mind/body integration is not soluble by attempting to connect mind and body categories as if they were fundamentals.
only 15% of the patients presenting with the 14 most common symptoms for outpatient internal medicine assessment had organic findings. Thus, “nonorganic” symptomatologies form a major fraction of internal medicine practice and expense, and they are likely to become an increasingly important issue in the era of managed care (Barsky & Borus 1995).
The question is when does something become “organic” rather than “functional?” Is a patient’s chronic vasomotor rhinitis (rooted in a chronic grief reaction) with severe nasal obstruction and complicated by sinus infection, or a patient’s florid five-year facial rash (while maintaining, as she put it, a “brave face” on her husband’s depression), organic or not? ... Thus, terms like “organic” or “functional” or “somatization” do not adequately categorize what they attempt to describe. Organicity turns out to be a construct of the biomedical perspective. It exists when there is something that can be observed by the biomedical observer. A condition is “organic” when there is clear or irreversible physical change, or when it can be treated with physical means. “Functional” and “somatization” are often used when it cannot. “Somatization” tends to be used when there are either unmeasurable changes (for example, pain states, chronic fatigue) or reversible or self-limited phenomena (for example, chronic urticaria or irritable bowel syndrome).
We see no difference between the two groups (196 organic or 151 nonorganic) in terms of the presence of apparently relevant story aspects. The notion that an organic finding rules out psychological factors (or story) is in our view a very questionable assumption.
I prefer the term story to “psychopathology” because it allows notions of patients’ subjective “meanings” into the arena without having to judge the meanings as severe enough to be abnormal. ... [Brave Face woman had] no history of depression or psychiatric help-seeking, and who cannot easily be psychiatrically classified. She would be ruled out of the Manchester Somatization Study! But she improves after a session of empathic listening and the framing of her symptoms as her physical way of expressing her difficulties in the relationship with her husband, her language way being in the use of the term “brave face.” In a sense, both physical and language conduits of expression are metaphorical.
From a unitary personhood point of view, Patient B is expressing the same story concurrently in her body, thinking, language, behavior, and relationships. As pointed out, physicians operating out of a dualistic paradigm involving mind and body compartments will reflexively move to decide whether the problem arose first in either one or the other.
it is the physical genital data that is attended to for many years by numerous clinicians, and the “inadequacy” story is never heard. This is reminiscent of Wickramsekera’s story of the man who had two million dollars’ worth of investigation before his story was attended to (Wickramsekera 1998). This is not a rare phenomenon. We see similar cases every day. The “blow out” of health costs world-wide is partly due to the accelerating availability of technology in a climate of excessive expectations. These expectations are partly rooted in a physical fundamentalism, the biomedical model, which assumes that most answers to disease will be technological. Inevitably this engenders costly repetitive attempts to discover organicity. Meanwhile story is ignored and is effectively invisible.
I certainly believe that rigorously addressing the physical aspects of patients is crucial to good practice, but physical fundamentalism implies that ultimately the only things that really matter are those things that can be measured. The handmaids of physical fundamentalism are methodology, measurement, mathematization, objectivity, jargon, standardization, instruments, and rating scales (Rotov 1991). Story does not easily fit this perspective and its derivative approaches and technology.
The exclusion of story is not just a manifestation of organic/functional splitting but also a result of what has been called essentialization (Rotov 1991). [[j's note: compare: existentialism; universal objectivity essence dis-cover penetrate appearance]] Essentialization describes the process by which a person’s particular illness gets assigned to a labeled disease category. The process is as follows. A disease is a pattern of symptoms, signs, and technological findings recognized by physicians. For example, to belong to the asthma disease category a patient must have essential findings (cough, wheeze, certain abnormalities of lung function, etc) in common with the rest of the patients who make up this disease category. The physicians focus on what these individuals have in common, on that which is essential to belong to the
asthma category. Herman (1995), in critiquing randomized controlled trials, which rest entirely upon essentialized categories, defined bias as “the tendency to see what we are looking for and to overlook whatever challenges the paradigm framing our observations.”
Patient data can be divided into two categories: the essentialized physical/group/measured data, and the story/subjective/individual/not measured data. Medicine neglects the latter. In this climate, Patient Z, discussed at the outset of the paper, is screened for the essential physical features of the connective tissue diseases, but the “I have gone into my shell” data is excluded. Patient B is treated for 15 years for possible fungal, bacterial, and viral infections of the genital tract, but her “inadequacy” and “celibacy” themes are never observed. This neglect of story is repeated many times a day in clinics the world over, constituting medical neglect of scandalous proportions.
we see no difference between the two groups (196 organic or 151 nonorganic) in terms of the presence of apparently relevant story aspects. The notion that an organic finding rules out psychological factors (or story) is in our view a very questionable assumption.* I hope to make this point as strongly as I can with an assorted cluster of case histories. I give three in some detail, but to show they are not rare and inexplicable exceptions to the biomedical “rule,”
the patient with a facial rash who says she is keeping a “brave face” on her husband’s depression
Patient Z with skin thickening who has gone “into my shell.”
[see focus case #3]
|• Female age 34; 8 years of nonallergic nasal congestion, facial soreness, puffy eyes; began when her mother was diagnosed as having scleroderma; patient says, “I will always grieve.”|
|Female aged 54; developed supraventricular tachycardia when working in a cardiac catheter lab, then Crohn’s disease when treated badly by her colonic surgeon employer.|
|Female age 50; chronic eye inflammation for 2 years; diagnosed as Sjogren’s disease; exhausted by wandering around the world with her religious husband; says, “I am tired, I can hardly open my eyes,” and is angry and frustrated. Husband would not allow further discussions.|
|Female age 52; 20 years of cystitis, hematuria, vaginal discomfort, and lachrymation; sexual abuse at age 8; cystitis unremitting since honeymoon; she says, “I was such a go-er but I crash after sex; every now and again I give in to sex”; “I feel sickened.”|
|Female age 26; 2.8 years of chronic diarrhoea and many investigations; husband works too hard and they had moved away from her beloved father; she says, “I hate arguing”; after she told her husband “I am not going to be treated like shit any more,” her diarrhoea remitted.|
|Male age 42; 10 years of severe tendinitis (visible swelling and redness) of any exercised region of the body; longs to be free in the wilderness, hunting and shooting; had a very stifling controlling mother, and experiences his wife like that; symptoms appear to be a metaphor for physical constraint.|
|Male age 76; 40 years of severe facial dermatitis (requiring oral steroids) following a bitter family conflict; was cheated of his farm inheritance; he bought the farm next door, and “it [the family farm] was constantly in my face”; problem cleared when away from the farm for long periods.|
|Female age 54; 6 years of urticaria and inflammatory bowel disease, both flaring each year in September; has a rigid workaholic husband who refuses intimate relations; she starts each year hoping things will change but by September “my hopes begin to sag,” and “how else can I show what I feel.” She feels frustrated, angry, lonely, and afraid. In our experience, chronic urticaria often represents anger and frustration.|
A woman with an athletic husband and many musculoskeletal
... the problems are manifestly organic, the body and language dimensions say the same thing concurrently (as if they mirror one another and emerge out of the whole), the biomedical treatment model is inadequate, and the symptoms resolve while the patient works with the clinician on the meaning of the problem. The language used in the stories given by the patients is uncannily relevant to the illness presentations, and has clear metaphorical or symbolic status.
The Wrong Way to state this:
"you unconsciously wished it upon yourself"
It is mistaken to say that the mind caused the body's expression - both express the same set of issues.
Persons present their responses
to the world in a
Patient B is an example. She feels inadequate, vows to become “celibate,”
avoids male/female relationships for many years, and concurrently develops
The patient will be seen as expressing him/herself in multiple dimensions simultaneously, and will be responded to multidimensionally; [~ multiple intelligences ??]
• Educating the patient about mind/body connections. Patients with physical symptoms rooted in story are trapped not only within their own defensive style but also within the dualistic paradigm of orthodox Western medicine, which neglects and stigmatizes illness with emotional connections. Patients need a clear explanation of the nature of somatization and, more importantly, of how common and “normal” it is (Goldberg & Bridges 1988).
Medicine as Contact Improv; Contact Improv as Medicine [-J]
In Greer’s paper and in many of the comments, the emphasis appears to be on essentialized mental categories such as anxiety, depression, passive coping responses, stress, hopelessness, “fighting spirit,” hardiness, resilience, sense of coherence (Greer 1999), emotional well-being, family support, social and cultural issues, socioeconomic factors, .... These abstractions have great relevance. They are more categorical, measurable, researchable, and fundable according to orthodox views as to what constitutes good research. They are also nomothetic—that is, as if derived from laws—and therefore more clinician-centered than story. Story is extremely patient-centered and idiographic— that is, particularistic—and emphasizes the less measurable and highly individual aspects of psychological functioning such as imagination and meaning.
the “core clinical
skill” (Duffy 1998) is the capacity for physician/patient dialogue. patients
their emotions rather than offer them directly, and physicians mostly bypass
these clues. clinicians can be
trained to “encourage the personhood of patients to re-emerge in clinical
attunement to the macro- and micro-life events surrounding an individual’s
symptom emergence and to the way that the individual describes these events or
alludes to them.
The time of onset [/exacerbation] of the illness should be seen as a faultline, a place where defenses give way, a place where significant story material can be seen.
the story in the macro: see if story material repeats itself. For example, a patient gets headaches at age 13 when her father dies, at age 17 when a boy breaks a relationship with her, and chronic headaches begin at age 21 when she is pregnant and the father of the child abandons her.
the story in the micro. recent => advantage of freshness of memory, and much clearer and more detailed information. We expect the symbolism and the emotional nuances of the macro- and micro-stories in any one patient to mirror one another.
questions allowing story to emerge. One of the most useful of questions is, “What was the most interesting,
difficult, important, worrying, memorable, hard, significant, tiring (etc.)
thing going on for you around the time or just before the time you got
ill?” It is extremely important to give the patient the idea that, though you
are looking for something that may be affectively negative, you are still
allowing him/her to choose how this will be described.
Many patients will deny relevant events if they get locked into a word that does not fit. For instance, some people claim they “never get stressed!” It just is not allowable for them to acknowledge it. For them the word “significant” may be a very acceptable euphemism. They might acknowledge that a change of job, or house, or the arrival of twins is very “significant” but refuse to own the “difficult” or “stressful” aspects. Some will allow “stressful” but not “worrying,” the former term being a little more external and admitting less vulnerability.
• The clinician must be a “terrier” while also offering a “holding” empathy. The clinician must develop an acute listening capacity and determination to pursue fine details of the patient’s story, becoming a terrier determined to sniff out the truth, while developing collateral skills of holding the patient empathetically so that the patient can tolerate such interest and the clinician thus avoids a persecutory stance (Meares & Hobson 1977).
• Emphasizing the view that it is the patients who “know” the truth. The expertise of a standard biomedical doctor centers around his/her ability to diagnose, an ability to come up with a label for a pattern of essential symptoms and signs that the clinician recognizes as having seen before. [J's note: compare Taeji's "I can assume I know you, and I know myself, and I know what kind of a dance we will have"] In the story approach, the clinician goes beyond this essentializing and discovers fresh every time a particular patient’s emotional truth, as discerned from the patient’s language. The balance shifts from sole emphasis on the clinician’s quiver of diagnoses to include the patient’s unique subjective pattern or story waiting to be discovered. [J: Doctor as facilitator, not analyst?]
• The need to go slowly and, from the little that is given, find what is needed. Most clinicians go far too fast, and end up sliding across faint or meager hints of story. Even well-trained psychotherapists find listening to nuances difficult. It is the little hints that are so important, and a clinician in a hurry will nearly always miss them. Indeed, most clinicians are not really very patient – or client-centered, and listen mainly to those things that support the clinician’s diagnoses and theories. In the story approach, all nuances of affect and meaning are potentially relevant.
Some clinicians find the notion of interconnectedness not only hard to accept but also impractical, because they imagine they will have to listen to a lot of patient talk to get the truth. On the contrary, it is often a matter of listening very carefully to a little of the patient’s talk, and taking it very seriously. In an average doctor-patient encounter, a clinician is flooded with tidbits of story but most of this is either not attended to or is actively screened out.
language and symptoms are seen as different projections of the patient’s gestalt and are inevitably connected....All information should be seen as emerging out of a patient’s unitary reality, which has physical, story, and other dimensions. The truth is there to be seen.
The tip is always connected to the rest of the iceberg. Anything is connected to everything else. Everything the patient proffers is ultimately connected to that which is fundamental to the person’s healing needs. In a sense it does not matter where one starts.
[[[[[[[[[[[[[Borges' The Fauna of Mirrors]]]]]]]]]]
Your problem is that you are:
linear, dualistic, atomistic, reductionist, ; use reified categories;
• Rather than operating out of a linear psyche-to-soma or soma-to-psyche dualistic interpretation of the data, it is better to see a patient as a personal identity, or an I, or an I am. The I is expressed in dimensions of experience that conventionally are categorized separately and compartmentally as body (in Patient B’s case, genital inflammation) and mind (the celibate vow) and behavior (avoiding male/female relationship).
• The categories of body, mind, and action are not reified into entities or compartments,
patients always manage to convey something that leads to what is helpful. This is very difficult for most clinicians to comprehend because Western culture is not only dualistic but also atomistic. [[J's note: compare: reductionist] Reality is carved up into compartments, and, further, into bits and pieces. It is easier to comprehend bits than to grasp the whole. The net effect is a pervasive assumption of disconnection rather than connection.
The clinical examples given here illustrate the panorama that comes into view when one works from an assumption of connection. Once the assumption of connection is established, the clinical skill of putting the bits of information together into an increasingly coherent story is quite easily achieved.
It can also be extremely useful to share other patient’s stories (with adequate confidentiality). Such stories imply universality, and, not infrequently, the patient will identify with an aspect of the anecdote and lead the clinician to much more relevant material.
Pre-emptive strikes can also be helpful. For instance, in the first therapy session I might say: “Iam going to ignore your physical symptoms—not because I am not interested in them, but because I am really interested in them, yet if I focus on them,I will not help you get to the solution”; or, “I might annoy you by constantly pursuing feelings, when what you feel most is your troublesome physical symptoms”; or, “For a while you may find all this puzzling, uncomfortable, and difficult—just tell me if this is so and we will deal with it together”; and so on. By this means, one is preempting hurdles frequently encountered early in the treatment relationship.
• Believing in the mind/body connections against the odds. ... elements that may derail story-gathering and consequent treatment. ... dualistic residues in the patient, therapist, or doctor can cause major problems. The patient may continually swing back to a focus on physical symptoms. The therapist may lose heart, and give up belief that story is relevant. What is developing into a good psychotherapeutic journey may be derailed by other involved doctors who are not “on board” and who continue to reinvestigate out of their own needs or anxieties, thereby fomenting the patient’s anxiety and a return to a body-only focus.
[chakras ...] 167 *Our ongoing studies concern: the role of various organ systems and anatomical zones as preferred sites for meaning; patterns of meaning typical or generic for the range of human dilemmas out of which stories come; and clinical response to story-oriented therapies.
If the therapist has the wit to see it, the truth is there to be seen in the first session.
Block KI 1999 Psychooncology and total survivorship. Advances in Mind–Body Medicine 15:244–251
Bridges KW, Goldberg DP 1985 Somatic presentation ofDSM 111 psychiatric disorders in primary care. Journal of Psychosomatic Research 29:563–569
Broom BC 1997 Somatic Illness and the Patient’s OtherStory. A Practical Integrative Mind/body Approach to Physical Illness for Doctors and Psychotherapists. London/New York: Free Association Books
176Advances in Mind–Body Medicine (2000) 16, 161–207
Dr. Brian Broom, MB, ChB, FRACP, MNZAP
Institute for Integrative Health Studies, Christchurch, New Zealand
Dr. Broom initiated the Arahura Centre in New Zealand where his practice combines Internal Medicine consultation and Psychotherapy. This unusual combination has led Dr. Broom to a proliferation of understanding and approaches to physical illness which he has documented in his 1997 book, Somatic Illness and Patients Other Story: A Practical Integrative Mind/Body Approach to Disease for Doctors and Psychotherapists. The Institute for Integrative Health Studies is a Division of Arahura.
Google: "integrative health" christchurch zealand brian
Google: arahura zealand "integrative health"
Bruce Wallace, MindBody Trust Secretariat
PO Box 708, Onetangi, Waiheke Island
Phone: 09 372 5541, Email: bruce `@` mindbody.org.nz
Newsletter edited by Dr Renske van den Brink. r.vdbrink `@` mindbody.org.nz .
|Adv Mind Body Med. 2002 Fall;18(1):16-29.||Related Articles, Links|
Nova Southeastern University, Fort Lauderdale, FL 33314, USA.
For centuries western cultures have adopted a dualistic perspective toward people's health. The "self" has emerged as an independent entity from others as well from the body. Human distress has been psychologized and depression and anxiety have been attributed to intrapsychic structures and processes. Nevertheless, many nonwestern cultures still adopt holistic perspectives. Within these cultures, distress is manifested through physical rather than psychological complains. Therefore, psychological approaches, based on the independence of the self, may not be fitting for these societies. Instead, based on the assumption that nonwestern cultures are holistic and less psychologized and their problems are social rather than intrapsychic, a biopsychosocial approach is suggested. In addition, nonwesterners have a different concept of reality. For instance, within some communities fantasies and delusions are appreciated, constitute part of a normal life, and are considered to be the "real reality." Furthermore, complains are often described in metaphoric language. Accordingly, a biopsychosocial model of metaphoric therapy is proposed in which therapists would incorporate their clients' metaphoric imaginative culture. Metaphoric intervention also allow for changes in the biological, psychological, and sociocultural reality of the client.
PMID: 9397334 [PubMed - indexed for MEDLINE]
Related Articles, Links
|A biopsychosocial model of
metaphor therapy with holistic cultures.
Clin Psychol Rev. 1997 Nov;17(7):719-32. Review.
PMID: 9397334 [PubMed - indexed for MEDLINE]
Related Articles, Links
|Somatic metaphor: a clinical
phenomenon pointing to a new model of disease, personhood, and physical
Adv Mind Body Med. 2002 Fall;18(1):16-29. Review.
PMID: 12518467 [PubMed - indexed for MEDLINE]
Related Articles, Links
|[Body-centered psychotherapy IKP
(Institute of Body-Centered Psychotherapy): holistic psychotherapy]
Ther Umsch. 1996 Mar;53(3):217-24. German.
PMID: 8900884 [PubMed - indexed for MEDLINE]
Related Articles, Links
and the invention of metaphor: the effectiveness of symbols revisited.
Cult Med Psychiatry. 1993 Jun;17(2):161-95.
PMID: 7693395 [PubMed - indexed for MEDLINE]
Bakal D, Steiert M, Coll P, Schaefer J.
Related Articles, Links
experiential mind-body approach to the management of medically
Med Hypotheses. 2006;67(6):1443-7. Epub 2006 Jul 11.
PMID: 16814941 [PubMed - indexed for MEDLINE]
Related Articles, Links
psychotherapy IKP: holistic psychotherapy of anxiety disorders]
Ther Umsch. 1997 Oct;54(10):585-90. Review. German.
PMID: 9432749 [PubMed - indexed for MEDLINE]
Ramos Gorostiza P, Virseda Antoranz A.
Related Articles, Links
|Delusion as psychopathological
Actas Esp Psiquiatr. 2005 Jul-Aug;33(4):221-30.
PMID: 15999298 [PubMed - indexed for MEDLINE]
Related Articles, Links
|Using metaphors in therapy:
dichos and Latino clients.
Soc Work. 1992 Jan;37(1):55-60.
PMID: 1371892 [PubMed - indexed for MEDLINE]
Related Articles, Links
|Estranged bodies, simulated
harmony, and misplaced cultures: neurasthenia in contemporary Chinese
Psychosom Med. 1998 Jul-Aug;60(4):448-57. Review.
PMID: 9710290 [PubMed - indexed for MEDLINE]
Related Articles, Links
of a bodily mind.
J Am Psychoanal Assoc. 2001 Spring;49(2):535-68. Review.
PMID: 11508376 [PubMed - indexed for MEDLINE]
Related Articles, Links
intelligence: a new perspective integrating Eastern and Western healing
Holist Nurs Pract. 2006 May-Jun;20(3):147-51. Review.
PMID: 16672815 [PubMed - indexed for MEDLINE]
[No authors listed]
Related Articles, Links
|Making the mind-body connection
improves DM efforts.
Healthc Demand Dis Manag. 1999 Oct;5(10):145-9. No abstract available.
PMID: 10661975 [PubMed - indexed for MEDLINE]
Related Articles, Links
|Medicine and story: a novel
clinical panorama arising from a unitary mind/body approach to physical
Adv Mind Body Med. 2000 Summer;16(3):161-77. Review.
PMID: 10934504 [PubMed - indexed for MEDLINE]
Related Articles, Links
|Use of non-verbal construing and
metaphor in psychotherapy.
Int J Psychosom. 1991;38(1-4):68-75. Review.
PMID: 1723396 [PubMed - indexed for MEDLINE]
Watson WH, McDaniel SH.
Related Articles, Links
therapy in medical settings: working with somatizing patients and their
J Clin Psychol. 2000 Aug;56(8):1065-82.
PMID: 10946733 [PubMed - indexed for MEDLINE]
Medically unexplained symptoms: the biopsychosocial model found wanting. [J R Soc Med. 2004]
From developmental metaphor to developmental model: the shrinking role of language in the talking cure. [J Am Psychoanal Assoc. 2006]
Clinic for Mind-Body Medicine, Calgary Health Region and Department of Medicine, University of Calgary, Rockyview General Hospital, 7007 - 14th Street S.W., Calgary, Alta., Canada T2V 1P9. email@example.com
This article outlines an experiential mind-body framework for understanding and treating patients with medically unexplained symptoms. The model relies on somatic awareness, a normal part of consciousness, to resolve the mind-body dualism inherent in conventional multidisciplinary approaches. Somatic awareness represents a guiding healing heuristic which allows for a linear treatment application of the biopsychosocial model. The heuristic acknowledges the validity of the patient's physical symptoms and identifies psychological and social factors needed for the healing process. Somatic awareness is used to direct changes in coping styles, illness beliefs, medication dependence and personal dynamics that are necessary to achieve symptom control. The mind-body concept is consistent with and supported by neurobiological models which draw on central nervous system mechanisms to explain medically unexplained symptoms. The concept is also supported by a recent hypothesis concerning the role peripheral connective tissue may play in influencing illness and well-being. Finally, somatic awareness is described as having potential to enhance understanding and conscious use of inner healing mechanisms at the basis of the placebo effect.
PMID: 16814941 [PubMed - indexed for MEDLINE]
Psychoanalytic Institute of New England, East, USA. Arizzuto@massmed.org
Patients' metaphors in analysis may allow access to ineffable experiences. This is understandable, since the mind is a bodily mind, and language is a fully embodied function of this mind. That is, both are dependent for their existence upon the physical body. The ontogenic accumulation of perceived sensory impressions and affective processes far exceeds what can be put into words. Research in cognitive psychology suggests that the active mind functions in such a manner that later perceptions are organized by means of earlier ones. However, since the mind can know only its own representations, it inhabits two ever unknown realms: the external world itself, and the domain of internal unconscious processes that sustain the mind's functions. As a result, the world and the self we know are constructed by the mediation of our bodies. In language also, the active mode by which we perceive, process, and feel makes our understanding of words dependent on previous experience. The fact that the limbic system is activated immediately in the moment of processing experience means that all modalities of representation include an affective valuation. This inevitable processing of information through the mediation of affectively valued bodily perceptions gives the metaphorical function - the human capacity to organize experience and life in metaphoric ways - the ability to create linguistic metaphors that can capture and express otherwise inexpressible psychic experiences. This manner of understanding metaphor has implications for psychoanalytic technique.
PMID: 11508376 [PubMed - indexed for MEDLINE]
By 1990 constructivism was being rapidly replaced by social constructionism (e.g. Gergen) which seemed to have greater aesthetic appeal to family therapists (e.g. Hoffman, 1990) who much preferred an image of individuals in conversation rather than withdrawn into the near solipsism of constructivism. Social constructionism sees reality as that which people construct together through language. Families invent that which they hold to be true in constant dialogue, both with each other, and with the wider cultural systems of meaning that our world offers us. The role of the therapist is then to co-construct with system members a new - hopefully more helpful - version of reality. Some social constructionists accepted that therapists would inevitably have their own theories about what was going on in the system, but these were considered as unavoidable biases. Since reality was only that which was constructed in dialogue, there was no other basis for choosing between these biases than, perhaps, social acceptability. Bateson's territory and, indeed, any other notion of external reality seemed to be quietly dropped as a reference point.
Social constructionism prepared the ground for the latest wave of critique; one which seems to have completed the paradigm shift away from any notion of the therapist holding an objective or outside view of the family system. The last seven years has seen the incorporation into family therapy of the postmodern philosophy of Foucault, Derrida and Lyotard or, at least some versions of their views. (For a sympathetic introduction to postmodern thinking in psychotherapy see Shawver, 1997 and this list of her brief notes on aspects of postmodern thinking.) Foucault, Lyotard and Derrida each, in a different way, call into question the legitimacy of our preoccupation - from the Eighteenth Century Enlightenment onwards - with developing rational, objective views of our world. Lyotard (1979) defines "postmodern" as a position of incredulity towards the big ideas - or metanarratives - of science, Marxism, humanism etc. (We need not take "incredulity" to mean dismissal - as some family therapists seem to do - but as scepticism to the claims of universality made by these major systems of thought.) In questioning our awestruck commitment towards these big ideas, Lyotard helps us to reconsider the legitimacy of small narratives in which the terms for discussion are locally defined. Derrida, in his work on the analysis of texts, challenges the notion of correct interpretations by discovering other legitimate readings cast into the shadows or - deferred - by the attention demanded by the "correct" reading. (Later we will see that we do not have to take Derrida to mean that all readings of a text - or clinical situation - are equally valid.)
A major translator of postmodern thought into family therapy has been Michael White (e.g. 1991) - currently, perhaps, the most influential voice in our field. White's narrative therapy picks up Foucault's view that individuals internalise the social attitudes (discourses) that powerfully define who people are and how they should live their lives. In working with anorexia, for example, White would wish to notice with the client or client family the powerful discourse that requires people (especially women) to be thin in order to be acceptable. He helps clients to resist succumbing to these dominant stories and, instead, to regain authorship of their lives by developing their own preferred self-narratives. (However, in taking the power of culture seriously, we need not overlook - as some narrative and constructionist therapists seem to - that self-narratives are also generated in intense personal relationships and modified through testing against the constraints of external reality.)
One further distinction worth drawing in contemporary family therapy is between those who assume that there may be deeper issues to be explored which underlie surface presentations of the presenting clinical problem (structuralism) and those who assume that what constitutes a problem is the system of those connected through language who agree to describe a particular situation as problematic ("post-structuralism" or postpositivism [FOOTNOTE 3]). The "poststructuralist" group (solution focused therapy, narrative therapy, and collaborative language systems therapy) have, in practice, tended to be more schismatic than other groupings in family therapy, establishing separate journals, conferences and teaching institutions. It is by no means clear whether family therapy can avoid splitting along this hairline fracture at some future point. Smaller groupings are not undesirable in any field of endeavour and the notion of local knowledges in family therapy is in line with the general drift of this article. My concern though, is that these changes are partly driven by an over-reaction to the apparent authoritarianism of the early models - especially in their use of theories as blueprints for living. There is a new tendency to turn away from notions of any reality outside of our constructions, to abandon clinical theory (as hopelessly structuralist) and such a polarisation of structural and post-structural positions that they become straw men. This seems to me no basis for a helpful division.
"Post-structuralists" such as Anderson and Goolishian (1988) in meeting the same family would assume that "anorexia" was a problem of collective definition within the system of those "in language" about it. They would hold no theory of underlying causes (or, at least, attempt to avoid influencing the family with these theories) and instead, see their role as that of "master conversational artist", exploring and helping system members to expand on the narrative coherence of their constructions. Anorexia would not be solved but "anorexia" might be "dis-solved" as a construction that determined how the identified patient and the family should live their lives. [this paragraph was not originally positioned here, but I extracted it from a section which I otherwise discarded, and it seems appropriate here]
The version of history I have provided concerns only the mainstream in family therapy. There are other lesser known epistemologies which - borrowing from postmodernism - we may call subjugated narratives. My website includes a commented reading list of papers from authors who feel that questions of knowing in family therapy still require further debate. I identify with the concerns of this group and in a series of papers and articles (Pocock, 1995a, 1995b, 1996, 1997a) I have sought to articulate a position which explores a middle ground between knowing and not-knowing, depth and surface, modernism and postmodernism; between the dangers of certainty of one hand and relativism on the other.
Having roughly sketched out both my view of the historical trends in family therapy and my position within it, I now wish to develop my ideas on what might constitute a more adequate epistemology. However before doing so, we need to pay more attention to the way the term "reality" is used in these debates. Many apparently unresolvable arguments become stuck because the protagonists use the same terms in quite different ways but without recognising that difference. Wittgenstein helps us to notice that language does not just point to things and does not provide us with reliable, non-negotiable meanings. What we mean by "reality" depends on the local context of meaning (or language game) in which the term is being used. We must work harder to tie down these contexts before we can have some genuine dialogue. When "reality" is being spoken of we may not know whether the term is being used by an objective realist to denote the idea of a world beyond constructions that can come to be known independently of any knower; or by a naive realist who just looks at the world and sees (like the hand raisers in Bateson's audience); or by a critical realist who believes that we can come to know reality better, but only through elaborating a constructed position; or by a social constructionist who considers reality only to be our mutually constructed views; or by a Foulcaldian who might see a reference to reality as an attempt by one person to persuade another to accept their expert viewpoint. (For some wonderful illustrations of the kind of epistemological trench warfare that can develop when terms are not defined see Edward Friedlander's Why I Am Not a Postmodernist.)
Let me try to tie down two definitions of reality: constructed reality and external reality. When we say we know something, or when we say that something is true we are always operating, I suggest, in the domain of constructed reality. Either on our own or with others we have created a view (or story) of our world. All knowledge - including scientific knowledge - is constructed. However, before you are tempted to reach for the standard counter-arguments of solipsism or relativism, let me quickly add the suggestion that external reality is ever present as context to this process of construction or story-making. How can this be?
Consider a man who every night, after work, walks home through a dark forest. In his head he has a rough map of the path; each time his internal map (or construction - since he has had to make it, or borrow it from others through language) does not fit and he strays off the path, he walks into a tree. He experiences this external reality not objectively, but as context to his map; one that acts as a painful constraint. He will, no doubt, re-adjust this map on the basis of its failure at that point and, after several nights (and numerous bruises) he may eventually be able to get home without accident. However, the man will know nothing objectively about the trees (they are just painful points of failure on his map) let alone the forest. External reality is that which always lies beyond our constructed reality. Any statement about our world always falls short of this external reality because language has inherent limitations for capturing external reality.
Let us flesh this out with another example. If you attempt to describe a chair, you will always end up with other kinds of description which you will never get beyond, no matter how hard you try. However, unless there is something externally real beyond the description "chair", you will fall to the ground if you try to sit on one. A convention of the best chairmakers will never manufacture a chair that they tell anyone about without also constructing a reality, and a three day conference of eminent social constructionists will never create any meaning chairish enough to be reliably sat upon. All truth is in the domain of construction. But all that construction is attempting to describe is in the domain of external reality. External reality may be precisely defined as that which language and description attempts to reach but falls short of.
The metaphor of "map" can draw our attention to the relationship between our constructed reality and external reality but it can also restrict our thinking by leaving out the power of constructions to define, not just our world (the trees and forest), but who we feel ourselves to be within that world. We should place alongside "map" another metaphor which is meeting widespread acceptance in psychotherapy - that of "story". "Story" encourages a view of a dynamically shifting sense of self in the world. We may hold many versions of ourselves negotiated, both in self-other relationships, and in the context of the big cultural stories (such as those which carry societal blueprints for gender). In this metaphor, some narratives of the self may become relatively unavailable for re-editing (which some call a core self) while other narratives will shift, depending on the context in which we do the telling.
Constructed reality is frequently political since, by defining who we are, it can so readily shape the power relationships between individuals and groups. When we hear the word "nagging" used by either partner in a heterosexual couple relationship, we may begin to suspect that the legitimacy of the woman's voice has been restricted by the patriarchal colonising of the bit of external reality that others might describe as "complaining" or "challenging". For many (pre-Zimbabwe) white Southern Rhodesians, their collective body of truth included the key premise that blacks had smaller brains than whites. External reality as context was, of course, present throughout the period of this discourse. Science, if consulted, might have constrained this prejudice but, naturally, external reality in this case would have had negative value to the white status quo so its use as constraint was implicitly proscribed.
It may be argued that we should put ourselves in the hands in science since it seems to be the most reliable and just arbiter of competing constructions about external reality. Science does have some special methods of controlled walking into trees which can yield tremendous results when the forest is not too tangled. Research into attachment and expressed emotion has for example, been of great interest to many family therapists. But it should be remembered that the products of science are, like all knowledge, constructionist. As Popper, Kuhn and Feyerabend point out, even with its brilliant controlled methods of stumbling in the dark, the choice of scientific knowledge still depends on social shifts of paradigm, on social acceptance of the newly constructed maps by a scientific community, and of a willingness to hold onto socially sanctioned theory even when criteria for falsification are available. And, when it comes to a dense tangled thicket such as the human mind, the price of scientific theory is, all too frequently, reductionism which inherently provides us with a misleading fit for psychological constructs. For therapists to depend on science alone, the cost of "validity" would be the loss of complexity. If we can avoid the naive belief in scientific objectivity then we may cautiously welcome careful science as an opportunity to test our clinical ideas against the constraints of external reality. But we also need to guard against theories becoming restricted to simple, sterile sketches of the human condition; ones that suit the political ends of the community which legitimizes them.
What I am saying in this article is that an adequate epistemology should include both the notion that what we know is always a constructed or storied reality and the notion that external reality is always present as context and, in some circumstances can act as a constraint to our stories. Note how this eclectic combination refuses to split easily into the usual dichotomies of idealism vs empiricism, narrative vs science and modernism vs postmodernism. Indeed, on closer inspection it is not so far from what some postmodernists are already talking about. Derrida, for example opposes the popular misconception (inside family therapy too) that deconstruction means that all interpretations of a text (or, indeed a clinical situation) are equally valid. Instead he explains that "one cannot refer to this real except in an interpretative experience" (Derrida, 1972) and that text may become more understandable within context which "does not exclude the world, reality history." (Derrida, 1972) He is also irritated by relativist readings of his work - "Every week I receive critical commentaries and studies on deconstruction which operate on the assumption that what they call 'post-structuralism' amounts to saying that there is nothing beyond language, that we are submerged in words - and other stupidities of that sort." (Kearney, 1984 p.123)
And for Lyotard, postmodernism does not insist that reality exists only in language (as many family therapists believe) but as something unpresentable and beyond language. "Finally it must be clear that it is our business not to supply reality but invent allusions to the conceivable which cannot be presented." (Lyotard, 1979 p81)
As the novelist Salman Rushdie says - "every story is an act of censorship" - each telling requires inclusion and exclusion (Rushdie, 1985 - quoted in Parry, 1991).
In that moment the issue of the boy's feelings about his father could be temporarily rescued from the shadows of the dominant narrative which held that the relationship was unproblematic. Depending on our theoretical loyalties we may call this a bringing into consciousness or - to a more postmodern mind - a deconstruction of the dominant story. A more complex, painful but ultimately, perhaps, more enabling version lay partly obscured in the not-considered-in-the-moment (or what Derrida calls différance.) The boy and his mother seemed to be able to invest that idea with some value and in that short period of locally determined understanding some new possibilities for change opened up.
We may assume that there were causes for this child's behaviour - but ones of such staggering interwoven and dynamic complexity that the word "cause" itself needs to be treated with great caution, in case it seduces us back into the familiar modernist trap of blinding us to the partiality and incompleteness of our understanding - suggesting, instead, that we can truly come to know. The totality of that which is really going on in this family, as with all others, remains firmly out of reach to any of us. The best we can hope for is that these local understandings and transvaluations can allow family members some pragmatic negotiation of its constraints.
In summary the thesis of an expert exploration of the objective reality of the client or family and the antithesis of an unconstrained process of mutual creation of reality are both rejected. Instead, I believe that something transforming may happen for the patient or family only through the synthesis of collaborative exploration and social creation of meaning within the never-fully-known context of the externally real.
"They are survivors. If you don’t have respect for their strength, you can’t be of any help. It’s a privilege that they let you in—there’s no reason they should trust you—none. You can’t know the terror—it’s your worst nightmare come true—a nightmare from which you never awaken. It’s unrelenting. There has been no safety; no one, no time, no place, no thing. All was tainted. Hope was obliterated, time and time again. That they are sharing their stories with you is in itself a supreme act of valor." (Adapted from banner hanging at River Oaks Hospital, New Orleans, Louisiana by Lon B. Johnston, April 2, 2003.)
Challenge the hierarchy of power and knowledge that empowers professionals to marginalize clients' descriptions by imposing allegedly objective knowledge.
Attempt to flatten the hierarchy by positioning themselves more as co-travelers, willing to learn from others.
Therapy from a narrative
perspective emphasizes an elaboration of constraining monologues to liberating
dialogues and/or the deconstruction or rewriting of problem saturated stories to
stories of courage, strength, and competence.
CLS is the process of creating a safe space in which people can participate in a conversation that continually loosens up, rather than constricts and closes down.
This is facilitated by a therapist posture that emphasizes collaboration, openness, and curiosity (not knowing).
CLS therapists are not intentionally trying to rewrite stories or externalize problems.
They value elaborating dialogues from stuck monologues to more liberating dialogues.
Narrative deconstruction emphasizes deconstruction and power in therapy.
|questions that invite clients to consider how certain narratives shape their lives|
|questions that invite clients to examine times when they were able to refuse living by problem-saturated narratives|
|separating the problem from the person (externalizing).|
Freedman and Combs (1996) distill the essential ideas of narrative theory down to 4 constructs:
|realities are socially constructed|
|realities are constituted through language|
|realities are organized and maintained through narrative|
|there are no essential truths.|
We develop our self-image and our view of others through the particular context of our relationships.
If ideas, perceptions, and beliefs that support problems are constructed, that means they are malleable.
We cannot change the events of history, but we can change the interpretation.
Creatively using language, discourse, or conversation is the art of both branches of narrative therapy.
In the narrative deconstruction approach, emphasis is placed on deconstructing problematic or oppressive meanings so that new, more empowering stories can emerge.In the conversational elaboration approach, the basic premise is that human systems are language-generating and meaning-generating systems.
Communication is seen to define rather than be a product of sociocultural systems.
Because the problem is socially created in language, it is also resolved in language.
"The therapeutic system is a problem-organizing, problem-dissolving system" (Anderson & Goolishian, 1988, p. 372).
We are born into cultural, contextual stories, and we take on personal stories through our lived experience.
Therefore, new, preferred stories of self must extend beyond the therapy hour by being lived and circulated within the client's community.
White (1995) says, "If stories that we have about lives are negotiated and distributed within communities of persons, then it makes a great deal of sense to engage communities of persons in the renegotiation of identity" (p. 26)."The hard-won meanings should be said, painted, danced, dramatized, put into circulation" (Turner, 1986, p. 37).
Client victories can be reinforced by literally including family, friends, and colleagues in the conversation.
Being born at a certain time as male/female; within a particular region, family, and socioeconomic level; and learning a particular language, religion, cultural values, and so on, shapes one's meanings and stories.
Consequently, meanings and stories are not neutral.What is valued and privileged are culture, gender, and class specific.
Whatever is privileged in the dominant culture, whatever sexism, classism, racism, and heterosexism exists in the culture, shapes our language.
Because therapists, like fish, live in the waters of their culture, they are often inducted into therapeutic practices that inadvertently collude with oppressive cultural practices.
Many therapies that have been
influenced by modernism are often described in terms of having a beginning,
middle, and end of the therapeutic process.
From a post-modern perspective, however, narrative therapists are more interested in an ongoing collaborative conversational process of learning about clients‘ stories than interpreting, intervening, or imposing therapists' views or theories on them.
|Data Collection and Assessment|
|Planning/Contracting and Intervention|
Engagement: The Initial Phone Call
Therapy begins before the client
enters the therapist's office.
How the client decided to seek counseling, who (if anyone) influenced the decision, and generally what the client's concerns are important questions to consider during the first call.
Engagement: The Initial Meeting
In the initial meeting, central themes are established and discussed. These themes are woven throughout the therapy, so the entire process should feel connected. Some useful questions to help establish central themes and focus are
|What is the concern that brings you here?|
|How is it affecting you and others?|
|What has been helpful with this situation?|
|What has not been helpful?|
|How long has it been a concern?|
|What are your ideas about how the difficulties began?|
|How do you hope the situation changes?|
Engagement: Multiple Helpers:
Getting Others on the Treatment Team
Narrative therapists are curious about:
|what others believe the problem is|
|their ideas about what may be making the situation better or worse|
|what solutions have been attempted and by whom|
|how useful the solutions were|
|who is most concerned|
|where and when the situation improves.|
Data Collection and Assessment: Ongoing Conversations
As therapists, we are in the
position of being learners about the lives of our clients. They teach us about
themselves—their concerns and hopes.
Together the teacher and learner define the problem to be addressed.
We learn about our clients and their concerns through a process of recursive or divergent assessment, where our questions are designed to generate new leaning, open space, and highlight change.
Planning/Contracting and Intervention: An Overview
Narrative therapy is about
conversation, dialogue, and mutually rewritten stories. It is not about
Interventions and strategies are terms that imply power and private knowledge held by the therapist, to be imposed on the client.
Therapy is not done to the client but with the client.
Some questions toward co-creating a therapeutic focus might be:
|What do you hope to accomplish by coming to therapy?|
|How would you know if you got what you came here for?|
|What would that accomplishment look like in your life, to you, and to others?|
|If the process were successful, how would I know or what might I see?|
Clients are viewed as having the
necessary strengths and capacities to solve their own problems.
The task of the social worker is to identify strengths and amplify them so that clients can apply these “solutions.”
In general, the past is de-emphasized other than times when exceptions to problems occurred.
The model orients instead toward the future when the problem will no longer be a problem.
When clients view themselves as resourceful and capable, they are empowered toward future positive behavior.
Behavioral, as well as perceptual, change is implicated because the approach is focused on concrete, specific behaviors that are achievable within a brief time period.
The view is that change in specific areas can “snowball” into bigger changes due to the systems orientation assumed to be present.
Given the difficulty in trying to outline the phases of solution-focused treatment in generalist-eclectic terms, this section will be outlined in the following way: joining (engagement), assessment (assessing the client relationship, assessing pretreatment change), goal setting (the miracle question, scaling questions), the exception-finding intervention, and termination.
Phases of Helping: Joining
The social worker gains
cooperation of the client in finding solutions by "joining" with the
client as the initial phase of engagement. "Joining" is the social
worker’s task of establishing a positive, mutually cooperative relationship.
Every problem behavior contains within it an inherent strength (i.e. reframing).
Normalizing is used to depathologize people’s concerns so that problems are made more manageable than when they were previously viewed as insurmountable.
Phases of Helping: Assessment
There are three main client
relationships in the solution-focused model:
"This sounds very hard. How do you manage?
How do you have the strength to go on?"
“Whose idea was it that you come to therapy?" and "What would they say you need to do so you don't need to come here anymore?"
Phases of Helping: Goal Setting
In the solution-focused model,
emphasis is on well-formulated goals that are achievable within a brief time
Discussion of goal formulation as starting as soon as the client comes in contact with the practitioner: What will be different about your life when you don't need to come here anymore?
Phases of Helping: The Miracle Question
In the miracle question, clients
are asked to conjure up a detailed view of a future without the problem. A
typical miracle question involves the following: "Let's say that while
you’re sleeping, a miracle occurs, and the problem you came here with is
solved. What will let you know the next morning that a miracle happened?"
Sometimes asking clients to envision a brighter future may help them be clearer on what they want or to see a path to problem solving.
Phases of Helping: Scaling Questions
The social worker helps the client
develop concrete, behaviorally specific goals that can be achieved in a brief
For example, rather than "not feeling depressed," goals might involve “getting to work on time," "calling friends," and "doing volunteer work". As this example illustrates, goals should involve the presence of positive behaviors rather than the absence of negatives.
Scaling questions involve asking clients to rank themselves on a scale from 1 to 10, with 1 representing "the problem'' and 10 representing “when the problem is no longer a problem." The practitioner then develops with the client specific behavioral indicators of the 10 position.
Scales offer a number of advantages:
A ranking will enable clients to realize they have already made some progress toward their goals ('You're already at a five? You're halfway! What have you done to get to that point?)
Scales can also be used to guide task setting:
("What will you need to do to move up to a 6?"). Clients identify specific behaviors that will help them move up one rank order on the scale. Finally, scales can be used to track progress over time.
Scales can further be used as a basis for the exploration of relationship questions. Relationship questions help clients understand the context of situations and the part they themselves play in interactions.
Phases of Helping: Finding Exceptions to Problems
The central concern of
solution-focused practice is identifying exceptions, times when the problem is
not a problem or when the client solved similar problems in the past.
Exceptions provide a blueprint for individuals to solve their problems in their own way.
Another way to seek exceptions is for the worker to help clients identify strengths they display in other areas, such as their employment or hobbies.
A further way to find and build on exceptions involves an intervention borrowed from narrative therapy, called "externalizing the problem”.
A final way to help clients discover exceptions is to prescribe the "first formula task" for homework after the first session. “This week notice all the things that are happening that you want to have continue to happen." The purpose of the task is to have clients focus on what is already working for them.
Phases of Helping: Termination
Because change is oriented toward
a brief time period in the solution focused model, work is oriented toward
termination at the beginning of treatment. Questions include "What needs to
happen so you don't need to come back to see me?" and "What will be
different when therapy has been successful?"
Termination is geared toward helping clients identify strategies so that change will be maintained and the momentum developed will [cause] further change to occur.
What would be the first thing you'd notice if you started to find things slipping back?" "What would you do to prevent things from getting any further?" and "If you have the urge to drink again, what could you do to make sure you didn't use?" might be typical inquiries to elicit strategies to use if there is a return to old behavior.
With all of the changes you are making, what will I see if I were a fly on your wall 6 months from now?