Tuesday, 12 June 2012

what do therapists do?

OK, so I don't really know much about what other psychological therapists do. But I do know something - although not perhaps very much - about what seems to be effective in what I do - when, that is, what I do is effective. What strikes me is the diversity of the different things done, and the hopelessness of coming up with some unitary clinical philosophy to encompass them all. (Two interesting books that come to mind in this regard are Yalom's The Gift of Therapy and Gilbert and Orlans' Integrative Therapy. I should say though that the following list is pulled out of my own, rather than someone else's, hat.)

    Carl Rogers
  1. Listening. Sometimes what people seem to need most is just what many people think of when they think of what it is that a counsellor does. John is miserable, but doesn't quite know why. Perhaps he doesn't dare to articulate to himself why; perhaps he doesn't know how. By listening to what he has to say to me, John's own sense of the meanings that drives his life is enhanced. He gives form to them in his communication; my acknowledged receiving of his communication provides a scaffold for him to distinguish between genuine meaning and inner muddle; and by being accepted for who he is, by me, with just those feelings that he has, he can bear to acknowledge some of his own nature to himself. When talking with me John feels safe enough to articulate himself in both senses of the verb: he verbalises his thoughts, and at the same time gives them structure. Proto-thoughts and proto-feelings elaborate themselves into true thoughts and feelings. What I offer and what John receives is understanding and recognition - and we do better if we think of these primarily as ethical, rather than psychological, categories.

  2. Encouraging moral courage. This isn't often talked about, but I've noticed it surfacing in my work
    Brian Martindale
    a few times recently. I once went to a talk by the psychiatrist and psychotherapist Brian Martindale who in passing talked helpfully about 3 kinds of guilt: a) disavowed and projected (someone else is guilty not me), b) self-punitive (beat myself up about my failings - the 'harsh superego' of the psychoanalysts), c) reparative guilt (I accept my feeling, learn from it, and take reparative action with respect to my relationships or (if that's not possible) substitute reparative action in the real world). Corrupting oneself by not facing up to the moral challenges that life brings is so easy. And a certain type of counselling (oh you shouldn't feel guilty because you couldn't help it because, dear me, look at your terrible upbringing) makes this so much worse. Projective and self-punitive forms of guilt are simply unhelpful. What makes people feel better about themselves, though, really, is facing what they've done and taking constructive, morally courageous, action. (Lander and Nahon's 'existential integrity model' spells this out further.) Having a dual sense that your therapist is both i) accepting of you as a person with value whilst ii) still not going to let you off the hook regarding what you did wrong is a pretty good starting place.

  3. Bearing misery. Mary's beloved mother has recently died. The pain of grief is so much that she, perhaps unwittingly, shies away from feeling it. Unable to mourn or 'let go', she clings to her mother's memory. It isn't easy to spell out exactly what is meant by 'letting go', because after all it is an important part of successful mourning that one be able to draw on, savour, the memories and images of the lost beloved. But suffice it to say that there is a big difference between holding onto them as a way of trying to keep hold of the form that the relationship had in the past, and holding onto them within an acknowledgement of the death of the beloved. My job as a therapist is to help her to believe - through my manner, through what I say, and how I say it - that the pain of loss is, will be, bearable. That it really will ease with time. That grief is important and healthy - that the feeling of grief is the body's acknowledgement of the reality of the loss - and it is the whole person, and not just the mind, that must come to know this loss, adjust in the form of its living expectancies (that her mother will indeed no longer call or come through the door). That a different kind of relationship - yet still a genuine relationship - can replace the one that has been lost; that Mary's mother can now, in a special sense, come to live 'inside her'.

  4. Facing and managing anxiety. At the heart of most emotional disturbances is a difficulty with tolerating anxiety. Anxiety: that sense that the self is overwhelmed, breaking down, going mad, dying, unable to cope, facing terrible rejection or shame, in danger of losing what matters to it, and so on. How is it dealt with by those who can't fully face it (i.e.: how is anxiety dealt with by all of us)? Well, in every which way; through a hundred  'defence mechanisms' and 'safety behaviours' we try to minimise our awareness of it and its impact on our lives. But in the process we damage ourselves (e.g. through splitting and projection we lose important parts of ourselves) or damage our relationships and our lives (e.g. by agoraphobically staying indoors). And so the therapist's job is to promote his patient's willingness to feel her anxiety, to find ways to manage it or ride it out, and through the relinquishing of her defences, to recover her inner and outer life. The CBT therapist has a particular story to tell about  this: that anxiety extinguishes by itself if one rides it out, simply through exposure to it. Accordingly we have systematic (or non-systematic) desensitisation, exposure therapy, etc. What they have to offer their patient at this point by way of therapy rationale are some (alleged) scientific facts about the anxiety curve - the way it peaks and (despite one's worst fears) falls again if one stays with it. The psychodynamic therapist has a different take: that what is essential is the patient's introjection of the therapist's containment of their anxiety. The therapist conveys that the anxiety can be tolerated, and it is the patient's taking on of this belief - their growing belief, say, in the CBT therapist's rationale, rather than the exposure alone - that enables them to face their fear. There are other situations, however, in which it seems to me to be more helpful to think about managing, rather than facing, anxiety. These are cases in which the mind naturally boggles at the enormity of a task (e.g. writing a dissertation). Here a helpful strategy is to develop a plan and break down the tasks for each half-day into much smaller, manageable, thinkable, chunks.

  5. Ludwig Wittgenstein
  6. Promoting unthinking trust. When we are anxious we naturally enough try to increase our control over our situation, use our rational mind to evaluate the evidence, be extra-careful in what we reveal of ourselves by managing our expressions and movements, give ourselves grounds for belief rather than taking matters on trust, and so on. The trouble is that such strategies of cognitive control often backfire. The bandwidth for conscious control is far too small, and the data which requires to be processed in (say) a social situation far too numerous, for us to stand much chance of successfully meeting life's challenges this way. We just end up more and more anxious. Furthermore, as Wittgenstein notes in On Certainty, grounded belief necessary bottoms out in unjustified and unjustifiable bedrock certainties. We risk digging up the group beneath our feet if we are always asking whether we have better justification for placing our feet here or there. Or: the more we look for reasons to believe that our partner is being faithful to us, the more we check their phone log etc., the more rather than less paranoid we become. In Groddeck's original sense of the term, what we need here is less ego and more id. More automation, more unconscious control, a greater degree of what Heidegger and Eckhardt call 'releasement' (gelassenheit). A greater pre-reflective and unreasonable trust in our world, in the future, in our body's own functioning, in our own sanity, in our lover's faithfulness. Taking the risk of developing such trust, with the sense of vulnerability that this involves, is vital to the expansion of the hegemony of the descriptive unconscious's control over the field of our action. This in turn frees up our reflective and controlling minds for work where they really are called for.  

  7. Developing insight. Jonah keeps getting into arguments with his wife. He feels put down by her all the time. In therapy I find myself feeling like I must be ever so careful not to offend him. And sometimes, I notice, he can be rather subtly dismissive of what I say - almost as if he is mounting a pre-emptive strike against what he seems to imagine will be criticism from me. We come to see, together, how Jonah has developed a hyper-sensitivity to clues that he is being put down. A magnifying lens for denigration is firmly fixed in front of his eyes, with the result that many false positives are registered along the way. Other lenses, of tolerance and forgiveness, or more straightforwardly of interest and mutual appreciation, have somehow become demoted. As he tells the story of his life we wonder together whether Jonah's experience of being brought up by a highly critical and discouraging father might have something to do with his oversensitivity. I get enough of a handle on the subtle uncomfortable sensations that I am offending him or that I am myself in some opaque way under siege to be able to 'bring this into the room'. There is enough trust and warmth in place ('alliance') for Jonah to be able to trust that my overtures to think about this difficulty of his are not further instances of attack. Without explicitly labouring it, what we do is to work through Malan's triangles of conflict and persons: i.e. good-old-fashioned psychodynamic therapy. Jonah comes to understand that some of his ways of reacting and some of his sense of his experience belong now more to the past than to the present, and can be left there.

  8. Promoting both reflection and immersion. When we are anxious our minds tend to fly off into the feared future or into the guilt- or regret-saturated past. So when frustrated we may berate ourselves fiercely without much thought as to the extent to which this is either deserved or, more importantly, actually helpful. When socially anxious our capacity to distinguish between what we worry other people think of us, and all of what our experience of them can tell us, is decreased. But although our minds get lost in the past or future, our capacity to know that what we are experiencing now is a temporary state of mind, which conveys limited and possibly erroneous information about our situation, is lost. This terrible feeling now, this foreboding, this hopelessness, this sense of shame, this brokenness in my relationship, seem to intimate to me the whole of my past and the inevitability of my future. And then tomorrow I get up from the happier side of the bed. The mood-constrained nature of memory leaves me unaware, or perhaps somewhat aware and somewhat baffled, by the auto-diagnoses and auto-prognoses of yesterday. As a therapist my job is to hold onto the knowledge that feelings pass - and also to promote this knowledge as a living possibility. This explains the high regard which therapists have for 'reflective function'. By coming to be able to stand back from and show understanding towards my experience, I learn to better weather its storms. Furthermore, by becoming aware of my habitual self-criticism as a strategy that automatically gets wheeled out in certain circumstances, I can learn to negotiate with the inner critic. By being invited to distinguish very clearly between fact and fearful (or wishful) fantasy, I come to be able to face my actual experience. And yet it is important too that I don't start to detach from my inner and outer experience, becoming some unmoved point behind it all, cut off from the life and value of my emotion. The job of the therapist is not to promote, but rather to challenge, such schizoid defences. The point is to develop a dual capacity - to be able to enter into my feelings but yet be able to reflect on my moods.

  9. Encouraging inner fluency and curiosity. The instruction to 'know thyself' is well-known. My own sense is that such self-knowledge must however proceed from a recognition that one doesn't know oneself - and that there is something to be known. Without a sense of the unconscious we are left answering questions as to why our interactions go down the way they do with responses such as 'this is just what happens to me', 'well, it's always been that way', or 'she makes me feel...' or 'he is always making me react this way'. Without a sense of our own personal agency and subjectivity as extending beyond what can be immediately reported or expressed, we have little chance of growing as a person, taking any greater responsibility for our lives, being able to make changes to what we do, and becoming more in touch with our emotions. One of the therapist's jobs is to promote the patient's interest in him or her self. Questions are good for that, questions which open up a sense that there is something to be understood here. Investigating dreams is good for this too. By making links between the dream content and the patient's past, present and therapy, the patient comes to see that his brain is involved in the making of more meaning than he is consciously aware of. Hopefully he can also thereby be brought to a greater trust in his brain's capacity to make this meaning by itself, without the need for input from his conscious mind (cf 5. above). As he comes to know that he does not know himself, he comes to know himself better too, and he becomes able to own and fluently express and incorporate more of his emotion into his expressive life.

    Comment. Above I have listed what could be called various therapeutic activities. However if I'm honest I don't think we should take it for granted that what is therapeutic in well-conducted psychological therapy is its successful prosecution of various activities. This is, after all, an empirical assumption that may or may not hold good. The tacit presumption of this assumption becomes especially compelling in the kind of therapy research literature that likes to style what the therapist does as the provision of various 'interventions' the effectiveness of which can then be tested. I trust that at least I haven't slipped into that in the above. And yet I'm aware that, as I've matured as a therapist, two related changes have happened. On the one hand I am happier to trust that the client will be able to develop in ways that they need to develop in their own time, set their own goals, and try to meet their own needs. On the other I have a greater faith in the simple value of understanding: that what I mainly need to do is to continually open up an inner reflective space where thinking about my patient's experience can carry on. Over time, and all going well, the patient comes automatically to internalise something of the reflective function that I proffer back to them. Perhaps the last thing I need to do is to 'do something to' the patient to 'make them better'. Now what I'm interested in is what I will think of the above in a few years time. Hopefully it won't feel so off that I'll worry that I've been unhelpful to my patients. But hopefully it won't feel so on that there's been no use for growth.