Wednesday, 22 July 2009

applying theory in the clinic

For the last year I've had the privilege of working in a primary care setting and working with a wide variety of people with a wide variety of problems. Some people have struggled with bereavement or other losses, others have struggled with managing sporadic anxiety or panic, others find it hard to manage their relationships without frequent explosions of anger, others (often those who have experienced childhood sexual abuse) turn to physical means (cutting, pills, medicines, suicide attempts, alcohol, exercise, too much or too little food) to manage feelings that are experienced as overwhelming and intolerable, others struggle to motivate themselves or to hold onto hope, and so on.

Given this wide variety of problems, it is perhaps not surprising that I've not found any one clinical perspective, theory, or model which helps me both to understand what is going on for each and every one of my patients, and to know what to do. There have been times when I've thought that an accelerated psychodynamic perspective, or a CBT approach, or a narrative therapy model, or a solution-focused method, or a mindfulness-based approach, or a person-centred stance, or a purely behavioural tack would do the trick. Sometimes this happens after I've just been on some relevant training in, or read the latest book regarding, the particular model in question! Thankfully my clinical experience soon prevents the development of an unhelpful manic theoretical omnipotence.

This is not an easy situation to manage, and I want to start by exploring the reasons for this. One has to do with getting to grips with the different 'instruments' of the different theories. Imagine that we are asked not only to play the violin in an orchestra, but also to be able to pick up the oboe or trombone at any moment. This is not easy, because the techniques and the learnt habits are really quite different - the embouchure may require different strengths and weaknesses in the lips and cheeks in the different cases. But the situation with the therapy situation is even more complicated. For in the therapy situation, and especially for the less behavioural therapies, the instrument is the therapist him or her self. It is then not merely that I must do something different, but perhaps that I must also be something different, when working with different people with different problems. Of course there is a sense in which the most important thing is that I be myself, in the room, with the patient. And the fact is that some therapeutic modalities simply don't come very naturally to my nature. However hard I practice, it will always be the case that I take much more naturally to the violin than the tuba.

This, however, is only a small part of the answer to the original question. And to say of the relation between model and patient/problem that it's merely a matter of 'horses for courses' seems to radically underestimate the conceptual complexity regarding what a 'good fit' amounts to here. As already suggested, this is partly because the therapist must not only know, but in some way embody, the theory in question: we do not then have simply a matter of an objective matching of theory to data. And living the theory - what in any particular case this will look like - depends in part on the sensibilities of the therapist. But it is also, I believe, due to the status of the models not simply as presenting different hypotheses regarding the origins of distress, but also as presenting quite different perspectives.

Much has already been made of the different values embedded in the different therapies - symptom relief or characterological change, etc. I'm not too fussed about that, and prefer to get my own values from my own life and to make the patient's values the drivers of the therapeutic process. At other times the multiplicity of perspectives provided by the different therapeutic models seems to me to inspire a too-quick retreat to a theoretical constructivist position. As if the theories were just different and incommensurable ways of making sense of the same data. My experience counts against this: It seems that some theoretical perspectives just do work better and can also meaningfully be said to fit better in certain kinds of cases. Nevertheless it also seems unrealistic to me to take the possibility of talking of 'fitting' here as indicative that, after all, the theories really are best thought of as different hypotheses.

So what more can be said on the relation between theory and 'data'? Here's how I've come to think of it. I've always been struck by the way in which some models seem to bring alive understanding in the midst of certain cases, but to merely redescribe others in a way that adds little (other than a smug sense of continued professional expertise in the uni-model practitioner) to what was already known. The concept of repression brings alive the phenomenology of hysteria; the concept of thwarted mourning works very well for certain cases of depression; the CBT perspective on anxiety disorders works rather well for those of my clients who are middle class, generally well-adjusted, but struggle with episodes of panic; ideas developed in the midst of attachment theory (to my surprise) seem to have their day in thinking of cases of health anxiety; a Rogerian focus on authentic listening and the provision of recognition never goes amiss but again seems particularly apt when working with patients who have had too little of being accepted for whom they are in their earlier life; a focus on behavioural activation seems to work wonders for the more biologically depressed patients who just do not have enough 'life' in them at the time; a focus on intrapsychic conflicts nicely does the trick in others; catharsis is sometimes hugely pertinent but often only of initial and short-lived therapeutic value; offering and thinking in terms of 'containment' seems very helpful for those who frequently feel overwhelmed; 'mentalisation' cuts the conceptual mustard for many 'borderline' cases... and so on.

To simplify even further, it might be suggested that the different models are conceptually organised around different core emotions. CBTists are driven by 'anxiety', Kleinians are motivated by 'guilt', Counsellors are preoccupied by 'loss', etc. And for any one patient it will always be possible to redescribe their inner life and their difficulties in such terms. After all, there are complex inter-relations between these experiences when they are situated in the ramified lives of any one individual. But it also remains true that some perspectives bring alive and speak more to some cases than others. Some cases are more ready to be spoken of in terms of, say, loss - this readiness is itself part of the phenomenology of the patient. And some concepts start to become tired and fray when over-applied outside of their zone of maximal unconcealment. Some therapists, too, have an ear best poised to hear narratives of guilt or loss, and can locate these in life stories in which we might otherwise feel they feature as sub-plots at best.

Attentive readers will notice that I've not-so-subtly distanced myself from (realist notions of) either truth-apt representation or (idealist notions of) incommensurable conceptual schemes, only to end up with a set of expressivist (speak of or to, bring alive, etc.) metaphors. Well, that's fine by me. Admittedly I should like to be able to say more about what it is for certain uses of language to resonate with, rather than aptly represent or conceptually organise, their intentional objects. That however will have to wait for another day.