Book Review: Collaborative Therapy With Multi-stressed Families; From Old Problems to New Futures

By William C. Madsen

New York, London, Guilford,1999 358 pp., 35.00 (hardback)

William Madsen has written a profoundly inspiring, compassionate, and helpful book that engages the reader in the kind of empowering conversation that he invites us to have with our clients. In the spirit of his therapeutic stance, he does not preach, ridicule other models of therapy, or claim ownership of "the truth." Instead, he examines cultural assumptions about clients, problems and the process of therapy, the effects of our practices on our clients and ourselves , what our preferred practices would be, and how we might get there, all based on a model of respectful collaboration. Madsen focuses with empathy on the relationship between the families confronted by overwhelming problems and inadequate services and the therapists who often feel lost as to how to help or confused by their clients' sometimes angry or seemingly apathetic responses to their efforts. Madsen offers us a socially conscious resource model of therapy that is fundamentally influenced by ideas from narrative therapy but that integrates concepts from other models. Most importantly, he includes the voices of the people who come for help and those of the front-line workers he has met in his years of consulting. The author's own voice of experience and creativity is woven throughout the book.

Madsen begins by exploring the demoralizing effects on therapists of the pathologizing discourses in which so many of us have been trained. By contextualizing the loss of connection to our clients as well as the loss of a sense of competence, vision, hope and balance, the author offers us a sense of new possibility. One idea from narrative therapy is that people live their lives by stories. The central focus of Madsen's approach is the relational stance toward clients in which the therapist is an accountable "appreciative ally" who collaborates with families in a search for their stories of strength and resilience that lie outside the problem saturated descriptions so often used to define them. These rediscovered stories open up for clients new ways of viewing themselves and reveal their own preferred ways of living. The author acknowledges that holding to this stance can be a challenge for overwhelmed therapists working with multi-stressed families, often in over-stressed service systems. He offers us countless stories with which we can relate, dialogues between therapists and families and concrete strategies to keep our focus.

Madsen's chapter on assessment is rich in its discussion of the effects of our formulations on clients. He states that "our assessments have the potential to be self fulfilling prophesies" and points out that we can choose to think in ways that support "understanding families in non-blaming and non-shaming ways." He encourages a shift from "understanding problems in terms of what causes them to a search for what constrains individuals and families from living differently." This lens expands our awareness to include constraints that operate on a number of levels, (including biological, individual, family, social network, and sociocultural) and an appreciation for how they affect people's lived stories and for the often courageous ways in which clients resist such constraints. Madsen's exploration of troublesome patterns common in relationships reemphasizes the importance of not confusing problems with the people who are affected by them. He offers a wonderful alternative assessment outline that stays true to the theme of his book.

In his chapter on "engaging reluctant families," Madsen looks at various conceptualizations of resistance and their consequences. He then addresses how to engage these families, viewing therapy as a "cross-cultural negotiation between a particular therapeutic microculture and a particular family microculture." I found it refreshingly humbling for him to point out that not only is collaboration a "two-way street," but that resistance can be as well. His chapter on developing therapy contracts focuses on establishing goals from a collaborative and relationally respectful stance.

Madsen extends his cross-cultural metaphor for therapy in his chapter, Invitational Interaction, An Anthropological Approach to "Intervening." In suggesting a conceptual shift from the therapist as expert to that of learner, he reexamines the traditional concept of intervention which, he writes, "can pull us into an instrumental orientation where we enter families with the certainty of a missionary rather than the curiosity of an anthropologist." Yet Madsen is clear in wanting the reader to know that he isn't suggesting we "abdicate our own values and knowledge . . . and accept all aspects of how families operate." His discussion of the "place of [the therapist's] values and knowledge" in therapy is an example of how Madsen embraces complexity and balance in his work. This and subsequent chapters (Taking Apart Old Problems and Putting Together New Lives, Elaborating and Solidifying New Lives and Developing Communities to Support New Lives) examine specific clinical practices drawn from the narrative approach to therapy including his chapters. I was particularly moved by Madsen's use of the termination interview to further thicken clients' new stories as well as to recognize and tap into their wisdom and experience by soliciting their ideas for others struggling with similar problems. In his chapter, The Larger Helping System as an Appreciative Audience, the author explains how powerful the responses of helpers can be in "either expanding or repressing" clients' preferred stories. Madsen examines problematic interactional patterns that can develop between helpers and clients and he pays attention to the effect that dominant cultural norms can have on helpers' beliefs about families who deviate from these norms. Here, his main focus is working with other helpers with the goal of "developing an appreciative professional audience for the enactment of new stories." The last chapter, Envisioning New Futures, Revisioning Human Services, addresses the institutional structures that provide the context in which the work is so often done, a context that too often leads to frustration and "burnout." This chapter moves beyond clinical work alone to the "building [of an] appreciative organizational culture."

The author has written an incredibly ambitious and readable book that challenges us while offering page after page of useful clinical practices that work for families and serve to reconnect us with our own preferred stories of hope, vision and connection. As both a teacher and a therapist, I am grateful to Bill Madsen for this inclusive work that will empower both beginners and experienced clinicians of all theoretical backgrounds to engage respectfully with individuals and families, even while working in the midst of dehumanizing systems.

Rachel Dash is an Asst. Professor and the Director of family therapy training at West Virginia University Health Sciences Center, Department of Behavioral Medicine and Psychiatry. She has a particular interest in collaboration on leadership development, self advocacy and resilience within rural communities.