Thursday, 24 November 2011

therapy as ethics: from intervention to recognition

I've recently come to the end of a three year post as a clinical psychologist working in an NHS primary care service. And have been looking back over my clinical notes and teaching session notes from this time. Much has changed me in the last couple of years, including my experiences with the 150 or so patients that have graced my consulting room.

What I notice, when I look back, is a significant change in my clinical understanding and clinical practice. It would be too easy to gloss this at the level of the 'model' I most typically deploy - having moved from a mainstay use of cognitive-behavioural, ACT, solution-focused, narrative, and schema-focused modes of formulation, towards something best characterised as psychodynamic. But characterising the move in that way, on the basis of the model used, misses - in fact it seems to me it covers over, obscures - what I now feel to be what is essential to the change. I shall call that, instead, a change from 'intervention' to 'recognition', and will now try to spell out what I mean by that.

When I started out I think I took myself to be in the business of formulating the patient's difficulties, and then - either from within my own expertise, or in closer proximity to the patient's own comprehension and wish - developing and deploying an intervention. The intervention might, for example, have involved exploring with and explaining to the patient the disorder-maintaining function of certain 'safety behaviours', and inviting them to relinquish these in the knowledge that anxiety is self-limiting. Or it might have involved asking them a series of 'solution-focused' questions designed to elicit an anti-depressive sense of self-efficacy and possibility. Or it may have involved formulating the patient's emotional difficulties as the product of certain habitually deployed 'defence mechanisms', and trying to push through these defences; to intervene in, or disrupt their hold on, the patient's emotional functioning.

I think it is still true that the above are what I do much of the time. And perhaps that is often-enough not such a bad thing, even if I suspect that intervening is too often something I do out of laziness or defensive omnipotent narcissism. And I think it is true, too, that no doubt certain skills get 'internalised' and so I have come to automatically, unreflectively, deploy therapeutic skills. But what I want to resist here is the idea that the growth of the therapist away from a conscious deployment of 'interventions' is best explicated in terms of an internalisation, automatisation, of such therapeutic knowledge, models, and skills. That is the tempting but banal thought; a thought which, I believe, it takes philosophical reflection to 'undo' (hence this post appearing in this blog).

One way of describing part of the difference in me over that time makes reference to becoming, rather than delivering, the therapy. What I mean by this is something like: rather than providing 'psychoeducation' to the patient at an explicit, conscious, level - about the nature of anxiety for example - this learning is instead something which gets embodied at an implicit, unconscious, level in the therapeutic interaction. The patient comes gradually to automatically, unreflectively, internalise my own tolerance of, and capacity to carry-on-thinking in the midst of, anxiety. And this happens in and through my own non-intervention-driven interactions with the patient in the room. What I am claiming, that is, is that this really isn't primarily a matter of my automating my interventions. What matters is not whether I have an automatic capacity to draw on a piece of knowledge, but whether I can automatically 'contain' their anxiety, keep on thinking, non-reflectively metabolise their projections, and the like. This is not a matter of intervening on my part, automatically or not, but a matter of being able to continue relating to the patient as to a person, despite their defensive (fear-motivated) evasions of their own personal being - their unconscious evasions and distortions of their autonomy, responsibility, agency, and inner integrity.

I don't mean to suggest by this that skill and knowledge are not needed on the part of the therapist who practices therapy as 'ethics' rather than as 'intervention'. They surely are, but it seems to me that the real skills are often not in knowing what interventions to perform how on whom, but rather in explicitly or tacitly recognising such forms of disturbance as may otherwise lay latent within, and prove disruptive for, the therapeutic process - recognising them so that the helpful recognition-providing conversations can continue, unabated, un-derailed.