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Journal of Family Therapy (2011) 33: 153167
doi: 10.1111/j.1467-6427.2010.00501.x

A theory of clinical practice: the cognitive and the


Paolo Bertrandoa
Today the extent of the difference between theoretical models of therapy
is under discussion. There have been proposals to abandon such models
altogether, or to create others, such as integrative or meta- theoretical
models. This article proposes, through the analysis of a clinical situation,
the possibility of building a theory of practice which could account for
most of the aspects of the therapeutic process that remain tacit and
implicit. Such a theory could help us explain what concretely happens
when a therapist is doing therapy, and also how theoretical models
interact with the everyday practice of therapists.
Keywords: systemic therapy; narrative therapy; clinical theory.

As therapists we all share a conviction that our favourite theory
provides the best guide for clinical practice. Theory is supposed to
give us a worldview that directly dictates our actions. The therapist
has learned from books and training situations what she should
observe in clinical practice and this is meant to accord with her
favourite model. She then translates these observations into a set of
therapeutic actions which she believes are coherent with the
model. The terrible complexity of therapeutic events is thus reduced
to the simplicity of theories, and manuals may then be constructed
that allow novices to perform therapy in the right way, avoiding
mistakes. From this perspective the relevant theory is all that matters:
the ignorance about clinical realities is hidden.
Theory, therefore, would dictate practice. Donald Scho
n (1983)
described this model of practice as the model of technical rationality.
In Scho
ns work on the epistemology of the professions, this model of
technical rationality implies that professional activity consists in
Direttore, Associazione Episteme, Torino Piazza, Sant Agostino 22, Milan 20123, Italy.

r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.


Paulo Bertrando

instrumental problem solving made rigorous by the application of

scientific theory and technique (1983, p. 21). According to this model,
professional practice is situated at the bottom level of a hierarchy topped
by basic science, which dictates the general principles of the field. The
connection between basic science and professional practice is applied
science, which draws from basic science the techniques for diagnosing
and solving problems. These in turn are used by professionals in their
practice. Within the model of technical rationality, practice conforms to
theory, and if it does not there is a problem with the practice. Now, it is
rather easy to see that this does not necessarily follow, and that in
everyday clinical practice things are radically different.1
We can start from one point. It is comparatively easy, for a reasonably expert therapist, to understand what another reasonably expert
therapist is doing, independently from the theoretical orientation of
both. On the other hand, it is usually rather difficult for an inexperienced trainee to understand what another inexperienced trainee of
another orientation is doing. This would mean that, for experienced
practitioners, there is a way of understanding each other that goes
beyond theoretical belonging, and that this apparently has little to do
with models or techniques.
I remember a colleague who had begun research on the actual
practice of therapists with different orientations. He described how
some cognitive therapists, whose sessions he had recorded and
analysed, were very close to psychoanalysts in their style of therapy,
whereas other cognitive therapists appeared to be quite straightforwardly behavioural. He asked me to give him two random examples
of my individual (systemic) therapy sessions. Of the two I gave him, he
described one as very close to cognitive practice, the other as quasianalytical, which raised in me some doubts about my own systemic
identity (then again, he considered my style to be quite passive, not
directive enough, which made me suspect that I would probably have
found his sessions too overtly strategic). All this may mean that we do
not yet appreciate many of the influences on our practice.
When I work as a therapist, I perform a series of actions with some
consistency, which I can usually justify following my favourite theory.
Another observer, however, may always (or at least often) challenge
my explanation, by noticing in what I do a different sense and a
I will leave out of this discussion some complex issues (e.g. what exactly is a clinical
theory, the difference between a theory and a model, and so on). Although such issues are
surely relevant, this discussion maintains its sense without having to deal with them.

r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.

A theory of clinical practice


different rationale. Sometimes, even when reviewing a recording of

one of my own therapies, I feel an awkward sensation: that therapist
(myself), when I look at him from the outside, does things I cannot
properly understand, at some times even contradicting my preferred
ideas. Moreover, if I review that recording more than once, I find in it
different shades of meaning that refer to different explanations of
what I did.
Briefly, we are never fully aware of all the meanings we generate in
therapy, neither for ourselves nor for others; yet we feel compelled to
generate some ideas about what we are doing. Then again, how many
times have we followed all of the rules of our favourite school? And
any time we did not follow them, what has been the result? Above all,
when we did follow them, if we ever did, are we sure things went
better? Perhaps the fact is that it is impossible to do therapy by
following a finite set of rules. Thus, in order not to be overwhelmed by
indefiniteness, we justify our actions with a theoretical reference that
tends to be little more than wishful thinking. However, if this is so,
what are we doing in therapy, and why?
In order to propose an explanation and a possible solution to this
dilemma, I would like to introduce the notion of implicit knowledge.
We could say that this consists of all knowledge that is not explicitly
prescribed by theory. In what we do there is always more than is
contained in our theories, and also something more than we are able
to describe. Although all our work is grounded in a theoretical model,
much of our practice is not contained (or containable) within that
model. Of course, such a proposal creates in turn new questions about
the role of explicit and implicit knowledge of therapy. In order to
clarify, and hopefully answer, some of these questions, I will first
propose a clinical example.

Clinical example: Norbert

Norbert is a 23-year-old university student at his towns School of
Economics. He is the first child of middle-class parents in their early
fifties. His only brother, aged 21, is studying medicine. He comes to
individual therapy complaining of a series of symptoms. He is
haunted by the idea of not being a successful enough student, and
every time he is hit by such thoughts he feels obliged to harm himself
by tearing his hair out, banging his fists and head against the wall and
so on. After such actions, which he describes as self-punishments, he
feels relieved, though only for a little while.
r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.


Paulo Bertrando

His compulsive behaviours are favoured (he says caused) by his

studying. He studies a lot, he completed his BA with highest honours,
his marks are among the best, yet he feels that this is not enough; he
still has to give his maximum in order to be better. He cannot even
imagine a world where he is not achieving the highest marks. Outside
the university, things are no different. He can barely accept the
simultaneous presence of more than three or four people around
him, since he has the feeling he must keep everything and everybody
under control; with too many people around him he cannot do this,
and that makes him feel tense and anxious. He has few friends (at the
moment, my only true friend is my past girlfriend), an uncertain
relationship with his current girlfriend (he gets extremely anxious
when he fights with her): all in all, a relational world that is very poor
and sparse. He does not talk willingly about other people, and he
prefers to talk endlessly about himself, his feelings and his symptoms.
It is always the therapist that brings other people into the picture.
He refers to his relationship with his brother as irrelevant. Talking
about his parents, his impression is that he can just make them not
displeased, rather than please them. It is as if their default attitude is
to be displeased with him, and he has to fight for them not to be
displeased. When they seem pleased (when he took his BA, for
example), he feels that they are just pretending: that they are not
really satisfied with him. He has, he says, turned his parents into a
hostile inner audience (his definition), a sort of inner court of justice,
where he cannot feel safe from a negative judgement. He has to strive
in order to prevent the court from condemning him. No effort pleases
him or makes him happy, because he knows intimately that the
struggle will begin again in a short while.
Sex, to him, is not gratifying at all. He arrived at sexual intercourse
late in life; he feels anxious during the act, and has even experienced
full-fledged panic attacks afterwards. He feels judged by women, and
sometimes he fails even to feel pleasure: orgasms become purely
mechanical. He feels gratified only by eating food. He likes bread, pizza
and other substantial foods. He says, After all, food cannot judge you!
Two possible therapeutic pathways
Now, facing such a situation, different therapists with different backgrounds might follow different pathways. I will try to outline two of
them. I will not follow my own orientation (a variant of systemic
therapy in the Milan tradition: see Bertrando, 2007), since doing so
r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.

A theory of clinical practice


might limit the discussion. I will focus instead on two other models:
those of cognitive and narrative therapy. Clearly there are many
variants on these traditions as well; hence I will use in my example
Aaron Becks cognitive therapy (Beck, 1967, 1976) and Michael White
and David Epstons narrative therapy (Epston and White, 1992;
White, 1995; White and Epston, 1989). These may appear to be
very different from each other, but operationally are they so dissimilar? I will first describe the probable pathways these therapies might
take in Norberts case.
Cognitive pathway. First of all, if I were to follow this pathway, I
might look for a diagnosis. The most appropriate diagnosis, which
includes the repetitive compulsive behaviours aiming at a reduction of
anxiety, would be that of obsessive-compulsive disorder (OCD) (DSM
IV-TR: American Psychiatric Association, 2004). I cannot exclude a
concurrent Axis II (personality disorder) diagnosis altogether, but for
clinical purposes the OCD diagnosis may be sufficient.
The second step would be to delineate the major maladaptive
patterns. On a macro level, I might map out Norberts feelings and
reactions, understanding the overall relationships between external
events and internal distress. More micro-level attention would be placed
on specific cognitions, thus identifying and modifying misconceptions
and wrong syllogisms that lead to maladaptive reactions. In Norberts
case, I could use questioning and guided discovery in order to help him
realize that his compulsive, self-harming behaviour is not closely connected to some specific event, but rather to a certain set of events linked
to studying. I could then reconstruct the stages of the development of
his symptoms (this is comparatively easy, since he is vividly aware both of
his symptoms and of the surrounding circumstances).
Tracing back his patterns of response, Norbert could become more
and more aware of how he developed his hostile inner audience.
This could be linked to a pattern of reaction from others, fixed in the
past, in which he has not been acknowledged for himself and his
needs have not been met. At this point, I may be able to help him
neutralize his automatic thoughts, the cognitions that generate his
symptoms. This should help him see a pattern where external events
give rise to cognitions which, in turn, stimulate the rise of a negative
affect. Higher level cognitions could now be substituted for automatic
cognitions, enabling Norbert to distinguish ideas (idiosyncratic
cognitions) from facts (actual events).
These automatic thoughts would now have to be checked against
actual evidence, with a careful, piecemeal exploration of events in
r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.


Paulo Bertrando

Norberts life. If I managed to accomplish this task I could then help

Norbert substitute new core beliefs2 for his previous, dysfunctional
ones. This process would be, of course, slow and painstaking, possibly
moving back and forth between progress and relapse. In the end,
though, if some definite change in his core beliefs could be accomplished, Norberts behaviour and feelings might become different,
possibly leading to a problem dissolution.
Narrative pathway. In order to follow this second pathway, I would
begin an inquiry about the clients life, trying to understand the
dominant narrative(s) in it. In Norberts case, the dominant narrative
could be centred on the polarity success/failure, where he is compelled
to strive for success in order to avoid the danger of failure in the face
of his parents. Such a dominant narrative could have been established
within a family culture centred on success and self-affirmation, where
other values (e.g. communality, mutual support) were devalued.
I could now help Norbert trace some unique outcome in his life, i.e.
certain instances in which he did not behave or feel according to such
a dominant narrative. Through the use, on my part, of unique
outcome questions, Norbert could understand specific facts of memories, leading him to see a difference, and reconstructing step by step
how he had been able to make a difference. If I were to succeed in
finding a unique outcome, I could then start to build a new narrative,
disconnected, a least to an extent, from the values of the dominant
one, allowing Norbert to experience and express a different set of
feelings and beliefs that are more helpful to him. This process may
also be described as, first, reconstructing the way he (historically)
came to internalize the dominant narrative, becoming, in a way, one
with it and, second, deconstructing that narrative so that it has less
power over him.
Now, I could proceed to stabilize these changes, retracing the steps
of the problem dissolution before reviewing the changes he would be
able to see in his vision of himself and of his relationship with his
significant others in a more helpful future. This would enable him to
pass from the domain of sheer experience to the domain of description and story retelling, and foster in him a different sense of himself
and the kind of person he is. If I were then able to put change in a
temporal perspective, I would allow him to envisage a different

It is interesting, for the Batesonian therapist, to find in some of Becks writings the term
premises to indicate what other cognitive therapists define as core beliefs (see Beck, 1967).

r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.

A theory of clinical practice


future, and to find possible (non-hostile and outer) audiences with

whom to share his new understandings about himself.
Implicit knowledge
The interesting fact, here, is that it is comparatively easy to describe
the two pathways as being quite different from each other. If I look at
them from their respective theoretical vantage points the differences
are huge. Beck could have said that therapy may be used . . . to help
the patient gain objectivity toward his automatic reactions and
counteract them [and] to modify the idiosyncratic cognitive patterns
to reduce the patients vulnerability (Beck, 1967, p. 318). To which
White could have replied that a narrative therapist is instead interested in providing a context that contributes to the exploration of
other ways of living and thinking, [and in assisting] persons to step
more into those stories that are judged, by them, to be preferred
(White, 1995, p. 19). Interestingly, though, Beck could have described
Whites work in cognitive terms, and White, in turn, could have done
the reverse (albeit with some more difficulties) with Beck.
We could do more or less the same with any clinical situation. What
makes such a double description possible is, I believe, the fact that
several of our therapeutic actions are dictated by implicit, rather than
explicit, knowledge. Implicit knowledge, in turn, is also twofold.
Partly, we can identify it with what Boscolo and Bertrando (1996)
define as the untold aspects of the therapist: the layering of different
theories and praxes she has been exposed to in the course of her
personal and professional life, which end up in constituting a set of
prejudices, often unconscious, within the therapist herself (see Cecchin et al., 1994).
My prejudices entertain a complex relationship with my theories,
and sometimes contradict even my preferred one. For example, I
(following Bateson, 1968) believe that relationships and contexts are
seminal for the therapeutic enterprise, but I feel and justify my actions
with a description about a self having purpose. This could be termed
egocentric prejudice (e.g. I act outside relationships). Equally, I
profess a collaborative practice which does not seek to direct my
clients choices, but at the basis of that practice lies the (often unsaid)
ethical principle that I must promote an individuals well-being.
I would therefore neither expect nor encourage personal sacrifice
whatever the client may wish. This could be termed individualistic
prejudice (see Doherty (1995) for a thorough critique). Prejudices,
r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.


Paulo Bertrando

often embodied in therapeutic hypotheses, guide at least part of the

therapeutic process (see Bertrando, 2007).
However, I believe that in my therapy there is also an implicit
knowledge which guides my way of acting which is over and above my
prejudices and is indistinguishable from my actions. As such, it is often
the most difficult to put into words. This is why it is usually learned by
trial and error, or by imitation: by observing teachers at work. It
cannot be contained as such in manuals or sets of instructions. In
order to develop it, we must participate in the practical activities of
real clinical situations. I propose to define this embodied knowledge
as procedural implicit knowledge.
We can use the idea of procedural implicit knowledge to observe
how models work in practice: Let us search . . . for an epistemology of
practice, implicit in the artistic, intuitive processes which some practitioners do bring to situations of uncertainty, instability, uniqueness,
and value conflict (Scho
n, 1983, p. 49). The theoretical model, here,
rather than a guide (or a set of guidelines) for the therapist,
constitutes her horizon. Within such a horizon, the therapist acts by
trying to understand the uniqueness of the case and the situation.
What I am dealing with, in other words, is Polanyis (1966) tacit
knowledge, Argyris and Scho
ns (1974) theory in use, and Scho
(1983) reflection in action. All those definitions share at least one
common feature: they refer to a kind of embodied knowledge that I
show through my actions, and that requires little or no conscious
reflection on my part.

Returning to Norbert
So, what happens to the clinical case I presented, and to the two
pathways I tried to draw, if I look at them from the vantage point of
procedural implicit knowledge? I could describe the process roughly
as follows for both of my possible pathways:
1. I try to create a basic dialogical consensus with the client.
2. Together, we single out a problem.
3. I look for something that is not immediately available in the clients
awareness, helping him to become more aware of it.
4. He is gradually brought to see some patterns underlying what
happened in his life.
5. At the same time, I look for specific examples in order to
substantiate general understanding with actual events.
r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.

A theory of clinical practice


6. I try to help the client develop an emotional rather than an

intellectual awareness.
7. At the end, we re-evaluate present instances together, and then
project the consequence of such a review into the future.
At the level of procedural implicit knowledge, then, there is little
difference between the processes of cognitive and narrative therapy.
This leaves open several points: among them, the precise nature of
such knowledge, the possibility of articulating it in words, and its
relationship to explicit (theoretical) knowledge.
A theory of practice
What is my procedural implicit knowledge made up of? When I try to
understand it, I immediately encounter some problem. On the one
hand, I act according to that knowledge, but I do not know exactly
how to say it, because if I should articulate it every time, I would lose
the overall vision of what I am doing (Polanyi, 1966). On the other
hand, I learned it mostly outside words, and therefore I need to make
an effort to articulate it. Moreover, implicit knowledge has so many
facets, and is so manifold, that any attempt to articulate it in full will
ultimately be frustrated. But why, I could ask, must I perforce make
explicit what is implicit? Is it not enough to observe the teacher, learn
to do what she does, and then possibly become a teacher myself,
following the example of Zen monks, who hold true knowledge
illumination to be ineffable?
First of all, it is not true that I operate only in this way. I also have an
explicit theory which I lean on to an extent. If I do not know
anything about my implicit theory, I will always try to act according to
the explicit one, and I will be blind to the actions I perform according
to my implicit theory and the prejudices linked to it. If I, instead, just
confide in the untold, I risk falling into a sort of therapeutic mystique,
a cult of intuition and spontaneity: I act in this way, following my
intuition, and therefore I must be right. In short, both denying
implicit procedural knowledge and relying solely on it entails danger
for the therapeutic enterprise.
Moreover, if I cannot state my implicit knowledge, it is almost
impossible for me to correct it or even to understand when it needs to
be corrected. Unaware of it, I will defend it against any evidence, and
it will be difficult for me to teach it, to transmit it to somebody else.
The only option will be to show myself in the act of performing
r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.


Paulo Bertrando

therapy, with all the possible misunderstandings implied. Of course,

to put all my procedural implicit knowledge into words is still
impossible, but to make it more shared is still a relevant outcome
(Argyris and Scho
n, 1974).
It would be useful, then, to build some theory of practice on these two
aspects of practice. By this I do not mean a theory of technique: a theory
of practice is a way of describing and explaining in the most systematic
way what occurs in the practice of therapy, whereas a theory of
technique is a way of verifying how much a set of techniques adheres
to a general theory. In this sense, a theory of practice is a descriptive
theory, whereas a theory of technique is a prescriptive theory.3
Such a theory would start from what the therapist actually does in her
daily work, and would use this as a basis for a theory of action. However,
this is not the same as setting aside models in therapy (Hoffman, 1998),
nor to embrace a common factor approach altogether (see Hubble et al.,
1999). I believe that, in order to understand the process properly, it is
first of all necessary to draw a distinction between what the therapist
does, what she says she is doing, and how she motivates what she does.
Both of my hypothetical therapeutic strategies with Norbert try to single
out, among other things, patterns in Norberts life about which he is
unaware. They perform similar actions, although they justify them in
distinct ways. Descriptions and motivations are very different, whereas
actions are more similar. The issue then becomes: how can we arrive at a
better description of such actions?
One way of thinking about this is to go back to Donald Scho
n and
his observations on the kind of knowledge put into action by professionals (a category which of course includes therapists). According to
n (1983), the professionals work is informed by a peculiar kind
of implicit reflection and knowledge that he defines as reflection-inaction. This means that the professionals knowledge is contained (as
far as it concerns her profession) within her action, and that to put
such a knowledge into practice in other words, to act coincides with
reflection, thus resolving the dichotomy between thinking and doing.
This enables the therapist to respond appropriately, not in standard situations, but in unique situations (to an extent, all clinical
situations are unique), and every time such actions require some
reorganization (sometimes radical, other times marginal) of her field
The theory of practice I propose resembles what Morris Eagle (1984) defines, referring
to Weisss work, as an autonomous theory of therapy, besides showing strong analogies with
ns (1983) epistemology of professional practice.

r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.

A theory of clinical practice


of inquiry and work. Her way of dealing with the situation is not
imposed by her theory, but rather interacts with her procedural
implicit knowledge.
In other words: the reflection-in-action of the therapist is her way
of moving among the elements of her theory, each time building anew
a unique model moulded by the therapeutic situation, a model that in
turn remoulds and modifies the situation. It gives the therapist the
agility she needs in order to face the mutability of clinical encounters.4
At the same time, though, the dialogue with the situation will bring
forth similarities in therapists of different orientations, precisely
because their priority is dialogue with the actual situation, rather
than theoretical consistency.
When someone reflects-in-action, he becomes a researcher in the
practice context. He is not dependent on the categories of established
theory and technique, but constructs a new theory of the unique case. . . .
. He does not keep means and ends separate, but defines them
interactively as he frames a problematic situation. He does not separate
thinking from doing, ratiocinating his way to a decision which he must
later convert to action. Because his experimenting is a kind of action,
implementation is built into his inquiry.
n, 1983, p. 68)

We could describe reflection in action as a way of putting implicit

procedural knowledge to work. By reflecting in action, the therapist
makes use of all her procedural competences, and brings them to
interact with the actual situation. Of course, she will also make use of
her explicit knowledge, but without letting it dictate the agenda: both
interventions for Norbert focus their attention on Norbert, rather
than on their theoretical ideology (this could help to explain why it is
easier for experienced therapists of different orientations to understand each other: they have long passed the phase in which theoretical
consistency was more important than actual clients).
At the same time, this kind of knowledge does not pertain to the
realm of the ineffable. An interesting similarity which Scho
n proposes
is the improvising musician: when she improvises, she cannot simply
The therapist always faces a unique case, rather than a type. The clinical case is not a
specimen representing a certain field of inquiry: it is the whole field of inquiry. This process is
different from the one postulated by the model of technical rationality. Instead of recognizing
in the new case a situation of the same kind of a preceding series, to which an instrument may
be applied, the therapist produces what Scho
n calls a generative metaphor, in which the
similarity between the new situation and the one previously experienced is metaphorical: it can
be felt, intuited, but not necessarily made explicit.

r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.


Paulo Bertrando

use the music she has learned (although, obviously, she cannot play
without knowing music), and she can apply pre-existing schemes only
to a limited extent. Rather, she must hear and feel the music the other
musicians are playing while she plays her own, and, at the same time feel
and hear the music she is playing within the overall sound. All in all, the
improvisational musician reflects on music by (and while) playing music,
and she listens to it while playing. But music, even improvised music,
can be transcribed, and the same musician (or another one) can always
get some understanding, albeit a posteriori, of the kinds of rules she
followed during her improvisation. Reflection in action is a process that
can be defined, with nothing mysterious about it.
Such a view of the therapeutic process brings into the picture the
concept of reflexivity which has been called upon by several authors
within the systemic field, such as John Burnham (2005), Carmel
Flaskas (2005; see also Flaskas and Perlesz, 1996), and bears some
resemblance to the concept of inner dialogue of the therapist developed by Peter Rober (2005).
To develop such a reflexivity, the therapist requires the dialogues
she weaves with clients, colleagues, supervisors, as well as situations,
readings and experiences. Any moment of this continuous dialogue
changes the therapists experience, and necessarily changes also her
way of reading her therapeutic work. This is why, whenever I
reconsider one of my sessions, I may find (and usually I do find)
something previously unseen in it. This is why any response by my
clients, in the course of the therapeutic dialogue, may change my way
of seeing what is happening. This also means that my work is always
open to new options. Ideally, I could endlessly review one case, one
session, and go on to find something new in it. In this sense, a theory
of practice is a hermeneutic of practice that allows me (and possibly
others, too) to find new sense in what I do, without ever drying up.
This is also why no practising therapist can be constrained within
the limits of one theory, fascinating as it may be. Any theory, with all its
prescriptions, will have to enter into dialogue with the clinical
situation, and that dialogue will shape practice more than any theory
can. What we saw when we looked at the similarities between the
cognitive and the narrative pathways was precisely that shaping.
The use of theories
Are theories, therefore, substantially useless, as some theorists in the
common factor tradition hold? Not necessarily. The use of theories
r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.

A theory of clinical practice


can be manifold. According to Scho

n, the theory the therapist
explicitly professes has three main (potential) functions: giving a
general vision in which she can frame the events; giving some typical
examples for a comparison with the actual case; and circumscribing
the field in which the therapist is working. We can add even more uses
for them. A theory helps any therapist to give consistency to her
thoughts and hypotheses. Then it helps her to hold a definite
professional identity. It can have the function of an ideology an
element which, albeit sometimes disadvantageous, cannot be overlooked. It is after all, very difficult not to have ideologies. Consistency
and identity go together: a therapist lacking any of them would risk
becoming erratic and ill-focused.
Theories can also, even within the framework I have hypothesized,
have some specific effect upon clients. They may give, albeit subtly, some
orientation to the therapeutic work. We may say that their importance
has been overstated in the past, but this does not mean they do not have
any value. For example, in Norberts case, different theories brought
slightly different emphases: the cognitive pathway focused on the
relationship of the client with himself, his ideas, his set of beliefs; the
narrative pathway emphasized his relationship with his significant
others, the role they gave him, and the impact of his choices upon
them. Possibly, a systemic pathway would stress relationship in yet
another way, emphasizing the influence of others on him rather than
the opposite. Thus, albeit similar, the results of the procedure imply
some differences. It has been argued (see Bertrando, 2007, ch. 10) that
theories are not the major influences on the efficacy of therapy as has
been claimed, but they may be responsible for the kind of effect
different therapies have on different persons in Foucaldian terms,
they entail different technologies of the self (see Foucault, 1988).

Consequences and perspectives

The view I have outlined not only implies a different way of looking at
our explicit and implicit theories: it also points out possibilities for
research. Research in implicit theories may entail investigations about
what is contained in therapists practices, beyond their explicit theorizing. Such is the direction of the conversational research proposed by
Maurizio Viaro and his collaborators (Bercelli et al., 1999), as well as by
Kogan and Gale (1997). Another possibility, along the same lines, is to
give voice to clients and their perception of therapy, although most work
in this field has so far been anecdotal and unsystematic (Epston et al.,
r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.


Paulo Bertrando

1992; Perlesz et al., 1996). Further possibilities can be opened up if we

would apply to therapy the procedures created to highlight implicit
theories, such as those proposed by Argyris and Scho
n (1974, ch. 3), and
so far used only in non-therapeutic contexts. Such research might yield
unexpected results.
We should also consider the possible consequences of this approach
for training. It does not mean that future therapists can only be trained
in a purely experiential way, overlooking explicit theories, nor to train
them only with a pure theory of practice (if this exists). Rather it means
that training should highlight from the beginning the relationships
between explicit and implicit (procedural) theories, so that new therapists are more aware of their own way of working in clinical practice.
To sum up, understanding therapy from the point of view of
procedural implicit knowledge may have manifold consequences.
First, the fact that therapies deal with unique situations becomes
theoretically essential rather than accidental. Second, the therapist
becomes an actor who works with a theory without being subjected to
(controlled by) the theory. Third, the therapist is free to use not only
her preferred theory, nor only her professional competence and
experience, but all of herself in a fully human and present way.

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r 2010 The Author. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.

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