The Sins of the Pathway

Systems change. A word that may be exactly right in one situation may not be appropriate in its new context. If this is not pointed out, then unhelpful associations may be imported and alter expectations or practice. This may not be in the interests of the proper running of the system.

The use of the word “pathway” is a good example. Some CAMH services have introduced “pathways” and these have replaced “teams” as the service unit in which treatment takes place. It should immediately be obvious that this might cause problems because the functions of a pathway and those of a team are very different. They are in different semantic categories, for a start.

During a Twitter discussion on outcomes in CAMHS a twitter-user asked a perfectly reasonable question. She wanted to gauge the level of agreement with the idea of specific “therapy pathways” for those who have suffered “childhood adversity”. I expanded on my disagreement in five tweets. The five-part argument, which focuses in turn on notions of Adversity, Therapy, Pathway, Control, and Development has a direct bearing on Therapeutic Attitude, so here it is.

Why do I argue AGAINST “specific ‘therapy’ pathways for those who have suffered childhood adversity”?

1) Adversity  

Life traumatises, so all clinical services need to attend to trauma. All should be “therapeutic”.

Some adversities eclipse others and adversity is subjective, but no childhood is without adversity. I am not a Rebirther or a Primal Therapist, but I suspect that birth is itself profoundly traumatic. I have often thought that a number of things children experience around birth, and in the normal process of growing up, are likely to feel cruel and intrusive – nappy-changing, for example, or the denial of something important for what feels like an indefinite period of time. The context of these things can define them as abusive or not, abuse being socially defined. But the context can also undo (or compound) the inherent trauma. Negative experiences are explained, positively connoted and reframed, assuaged, and atoned for, through the miracle of “good enough” parenting. These parenting behaviours are the therapy that the fortunate child receives for their early childhood adversity. If the adversity is sufficiently ghastly, if the parents are not able to provide this normal level of lay therapy, or if the parents are themselves the source of the adversity, then professional intervention is likely to be necessary – possibly to remove the child from an ongoing trauma, or support the parents, educate or alter the environment, or, indeed, provide some form of circumscribed psychotherapy.

Clinical services, represent a deviation from health and can themselves be traumatic. Take, for example, the extraction of teeth. All of these clinically imposed traumas should come with a pre-packaged antidote to trauma. All clinical interventions need to be handled therapeutically. This does not only mean through the use of skill and aseptic technique to minimise the physical harm done, and anaesthesia to remove pain and memory, but also by contextualising the event and giving it a positive narrative significance. In Being With and Saying Goodbye I refer to this sort of thing as “between the lines”. What we do explicitly (on the lines, as it were) is important, but what we do to and with the patient, between the lines, is also important and needs to be part of the therapeutic venture.

So “childhood adversity” is a tautology. The presence of adversity in childhood is a question of degree, not one of dichotomous presence/absence. We need to have an expectation that adult interactions with the child contextualise the adversity and either buffer or heal the trauma. The intensity and duration of this interaction, and the set of skills brought to bear, will depend on the child’s need, and the adult’s position and capacity. As trauma is ubiquitous, clinical services need to be therapeutic.

2) Therapy

Here is my off-the-cuff definition of therapy. Therapy is the bringing professional skill and experience to bear on the matter of relating to people in order to help them back to a healthy trajectory

If “therapeutic” means helping to restore health then all clinical services should be therapeutic, and many of the things parents do are likely to be so as well. Most of this would not be “therapy”, though. The parent has skills and experience and they relate to their child, but that is not their job or professional expertise. It comes as part and parcel of being a parent to that child. If the skills and expertise amount to professionalism, then this person is not acting as a parent or a member of the public, but in their professional capacity. If, furthermore, they explicitly use the relationship in some way to achieve their aim which is to facilitate the restoration of a healthy developmental trajectory, then this is therapy, and they are being a therapist. It is primarily the relationship that is the tool. It requires skill and experience, and they are doing it as their job.

However, the timing and nature of therapy need to be sensitive to the needs of the individual, their capacity to tolerate various tensions, and the capacity of parents to tolerate supporting their child in therapy. The last notably involves tolerating not-knowing what is going on in the therapy.

So therapy may be something that takes place during a young person’s path through life, or through clinical services, but there should be no expectation that they begin therapy on entering a pathway and leave the pathway the moment they stop or drop out of therapy.

In other words, therapy and pathway should not be contingent upon one another.

More needs to be said about “pathway”, and that comes next…

3) Pathways

Predetermined service-delivery “pathways”, like the glass slipper or procrustean bed, risk the mutilation of people in order to fit them in.

The idea of clinical pathways has become common in the last few years. Some say that that this was on an ill-founded (in CAMHS) expectation that payment-by-results would shortly be introduced. My own cynical belief is that the popularity of “pathways” in clinical service delivery is due to their providing what Menzies-Lyth would call an “institutional defense” against anxiety. The shift away from clinician-patient relationship as the primary clinical entity, to the pathway, depersonalises the process and therefore makes it easier to discharge a patient from, or deny them access to, services.

It would be perfectly reasonable to observe that an individual undergoes a journey through the service. They enter the service and, hopefully, leave it. In between, they will encounter a range of clinicians and staff. They will disclose information of various kinds, and endure or enjoy a number of questions, tests, and treatments. These things could be set out on a time-line, and calling this a journey would seem fair enough. The words “path” and “pathway”, though, introduce an ambiguity. Someone’s path can be traced after the event and may turn out to be quite different from the path laid out on the ground and paved or marked with signposts. The latter is an intended route, but the path that a patient takes through services may not be the intended one at all.

This language reveals at least two arrogances. It is arrogant to think of the path that the patient takes through the services as being the only important one. Far more important are the paths that they take through their lives. We all have hopes for these paths. We hope for an absence of severe or enduring pain. We hope for company. We might hope for children. None of us sets out on our journey hoping that it will include a period of psychiatric treatment. Concentrating on the aesthetic of a predetermined clinical pathway is to neglect, relatively speaking, the more important path of the patient’s lived experience.

The second arrogance is to believe that the service can decide the pathway beforehand. Service design needs to have sufficient flexibility to adapt to each individual patient’s needs, values, and circumstances. You cannot constructively start therapy when it suits the service if the patient is not ready or if therapy is not what they want. The nature and timing of treatment in mental health services is co-constructed – or should be. If it isn’t, then it is not likely to be very therapeutic. Forcing someone into a pre-determined path, like forcing minced meat and breadcrumbs into a sausage machine, is anti-therapeutic, even if the path is called a “therapeutic path”.

4) Control

Life knocks us off our healthy developmental path. Services should give back to patients the agency to determine their path, using borrowed resources

Anything that knocks people off their healthy developmental arc (anything that is traumatic, for example) should be responded to with the aim of restoring agency, if not total autonomy, as soon as possible. Some people may manage to negotiate this without assistance, but many will require skilled support of some kind. This dependency should be temporary and partial. That is to say that the person should retain a significant degree of, if not full, control of decisions, and if they do hand over responsibility, this should be returned by the end and incrementally throughout, if possible. So the aim of clinical services, where someone has lost or suffered a set-back in their control, should be to restore to them, to the extent that is possible, the agency or access to agency that they have lost. This should be done actually, but also symbolically. We should not, therefore, even appear to predict or dictate their direction through services. We can make suggestions and recommendations. We can offer alternatives. In retrospect we can ask them about their pathway through the services and, in particular, if there was anything that we might have done to improve or detract from it. We cannot, and should not attempt or claim to, set it out in advance.

5) Development

Life = development and does not stop at 18. Therefore developmental ethos should continue through adult and elderly services

It may be true that childhood and adolescence are times of particularly acute developmental change, but the whole of life is developmental, and autonomy should lie with the individual as much as possible throughout.

Coda
This is not an argument against therapeutic expertise, but an argument for it. Nor is it an argument against the consolidation within a team of expertise in specific therapies. All teams and practices should be “therapeutic” but therapy teams within services are justified by the expertise that they preserve and concentrate. They can be used for specialised treatment, but they also inform the culture of services as a whole.

The retrospective study of patients’ paths through the services is justified if it leads to smoother transitions and greater responsiveness to needs and values of the patient. Pre-ordained pathways, on the other hand are not justifiable, whatever they are called, but calling them “therapy pathways” commits a whole bundle of sins.

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