Music Again

Music Again

This post is a sort of dialogue with a podcast interview about music therapy. I provide the link here and encourage anyone who reads this blog with any interest, to listen to the podcast. The interview is really more about the creation of therapeutic space, but it also economically exemplifies what I have called “Therapeutic Attitude” and has added to my own conception of it.

Philippa Derrington is a Senior Lecturer within the Division of Occupational Therapy and Arts Therapies at Queen Margaret University in Edinburgh and leads the MSc Music Therapy course there. Here she is interviewed by Luke Annesley, a jazz musician and music therapist who produces the British Association for Music Therapy podcast series Music Therapy Conversations.

Music Therapy Conversations. Episode 25. Philippa Derrington

In this interview, Philippa describes setting up a music therapy space in a school, in the corner of a garage, and using large instruments (to occupy and therefore command space) and anything she could salvage from the school skip. In doing this she demonstrates beautifully one aspect of therapeutic attitude, which is taking responsibility for the space.

Therapy is exploration and, as such, requires a secure base (1,2). The therapist is as responsible for this aspect of therapy as any other. If a therapist is lucky enough to be able to totally control the physical environment, then they can (and should) do so creatively. But it may be that significant aspects of the environment are fixed and out of the physical control of the therapist. When this is the case the therapist can make sure that, when in the room, they “extend themselves to its boundaries” (3).

When I have managed to put an idea into words and another practitioner from a different discipline expresses something similar, I find it hugely affirming. As I listened to this podcast I found myself thinking over and over again, “this is Therapeutic Attitude!”

Take, for example:

PD: “Respect takes first place for me in work with any adolescent” (16m00s)

– and compare with –

AW “A crucial aspect of therapeutic work with children is the forming of a respectful relationship with them: discussing, offering genuine choices, and relating to them as valid, motivated humans with a right to, and the potential for, a life of their own, rather than simply existing as a product and part of the lives of others.” (BWSG p 151)

Or:

PD “A most important element is being able to get alongside the young person” (18m40s)

compare…

AW “…my position is alongside the child, looking at the conundrum, as though to say, “Is this what you would like us to think about?” (p12)

And:

PD “…the importance of not-knowing, and staying with that.” (20m09s)

compare…

AW Chapter Four on Uncertainty which leans heavily on D. W. Winnicott’s “..contain conflicts…. instead of anxiously looking around for a cure” (4) and John Keats’ concept of Negative Capability (5).

I am excited enough by the similarities, but here is a point of divergence or extension which gives me pause for thought. Luke and Philippa have a conversation (14m08s) about how in the school she is “always a music therapist, but not always doing music therapy”. This is really interesting. I wrote a section (p11) “Being a Psychiatrist” in which I contrasted being a psychiatrist with doing psychiatry, but I wanted to make a different point and distinguish between (in the frame of virtue ethics) being a psychiatrist as opposed to performing a set of tasks which constituted psychiatry but which might as well be alien (being versus doing). I still think that my point is an important one, but Phillipa and Luke’s point is also, and they complement one another . A therapist must have therapeutic attitude when “doing therapy” but the attitude is also important when in one’s professional role – being a therapist – but not actually in session. Philippa clearly protects the sessions in betweenwhiles, but only to the extent that each client requires. This is a form of “holding in mind”. The attitude extends beyond the session and becomes part of the professional person; Perhaps even the person.

Have a listen!

refs:

  1. Bowlby, J. (1988). A Secure Base: Clinical Applications of Attachment Theory.
    London: Routledge.
  2. Byng-Hall, J. (1995). Creating a secure family base: Some implications of
    attachment theory for family therapy. Family Process, 34: 45–58.
  3. Being With and Saying Goodbye. Cultivating Therapeutic Attitude in Professional Practice p89.
  4. Winnicott, D. W. (1971b). Therapeutic Consultations in Child Psychiatry. London: Hogarth & The Institute of Psycho-Analysis. p2.
  5. Gittings, R. (1966). Selected Poems and Letters of John Keats. Oxford:
    Heinemann Educational. p40-41.

Return to Home Page

A new home in free musical improvisation

A new home in free musical improvisation

I do have concerns, though, about those children who have been taught to play a sport, a musical instrument, or a complex board game, to the exclusion of playing which is the freer, more creative, and developmental activity.  = Being With and Saying Goodbye, Ch 5 Thinking

I joined Oxford Improvisers in 2018 because I am a musician as well as a clinician and was in need of stimulation and a new direction. This turned out to be a brilliant move, and further explanation is perfectly relevant to Therapeutic Attitude.

In Oxford Improvisers I found myself immediately welcomed, and at home. Home, of course, is a secure place from which one can venture.

Exploration requires a secure base, as attachment theory has taught us, but there is no certainty* in terms of the anticipated outcome. The confidence shown by the clinician, then, must be a confidence in process coupled with an optimistic acknowledgement of the uncertain future” (BWSG Ch 4).

In that chapter, which is on Uncertainty, I consider “an appropriate analogy [for the practising clinician] to be that of the improvising musician who uses landmarks and artistry, and is confident that the result will be music whilst not being at all sure what will actually come next”. I was already describing clinical work in child and adolescent mental health as improvisation, though I had little experience of musical improvisation at the time.

The picture above, taken by Gabriele Pani and tweeted for @OX_Improvisers , shows overlaid objects; a piano (barely visible in this version), toy piano, guitar, watch, plastic spoon, drum sticks and mallets. What moves me about this picture is that each of these objects is taken seriously and lightly at the same time. The same is true of participation.

The difference between participants is respected; indeed this difference is essential to the activity. At the same time participants are valued equally; valued to the same extent, but for different reasons or qualities.

Uncertainty is not only accepted; nor even simply embraced; it is encouraged and nurtured. Any “rules” introduced are not to constrain movement, but to provide something to bounce off.

From the conclusion of Chapter 3, The Nature of evidence, I have selected the following points:

  • For the development of an individual existence there must be freedom of movement.
  • If statistics and “facts” are to be used in relation to human growth, they must be understood such that the individual’s room for manoeuvre can be demonstrated.
  • This amounts to an attitude of irreverence towards the apparently immovable.
  • Humour in the clinical setting reveals the creative space between how things are and how they might be.
  • Despite humanity’s constant search for certainty, possibility and hope can only exist where there is uncertainty.

This all contributes to the attitude of clinical practice that evolved through my own working mid-life and that I have come to call Therapeutic Attitude. Small wonder that I found myself a new home with a group of free musical improvisers on retirement from my NHS job. Therapy has to be creative and for therapeutic creativity one requires freedom of movement within a safe space.

♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪♫♪

*PS in the lines quoted above I actually wrote “security” but “certainty” gets us closer to what I was thinking.

Back to Home Page

Everything worth waiting for is worth the wait

Everything worth waiting for is worth the wait

Jan Fortune has just blogged on Why writers need to wait – indeed, not just writers but all artists. The virtue of waiting is not generally appreciated in our everyday worlds where anything that doesn’t arrive instantly runs the risk of being walked away from – or, more accurately, we run the risk of walking away from – and therefore losing – everything that does not come to us at the snap of the fingers.

This chimes so well with what I have said about therapeutic attitude that it might be considered an argument defining therapy as art but for the false dualism. Art and science are not a mutually exclusive dyad any more than body and mind. Each involves the other; And good scientific research also requires the capacity to wait.

I shall briefly recap on waiting in therapy as this is a blog on Therapeutic Attitude.

D. W. Winnicott, the ground-breaking paediatrician-turned-child-therapist probably best-known for the idea of the “good-enough mother” wrote of the “capacity in the therapist to contain the conflicts … and to wait for their resolution in the patient instead of anxiously looking around for a cure”. In doing so he was, whether he knew it or not, echoing the poet John Keats who wrote to his brother of his admiration for people who were “capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason”. (I suspect that Winnicott was perfectly aware of the connection because he also wrote elsewhere that, “if what I say has truth in it, this will already have been dealt with by the world’s poets”.)

This irritable reaching after cures and facts is something we see a great deal of at the moment. Perhaps it can come as some relief to know that it was also prevalent in Keats’ time.

Everything worth waiting for is worth the wait. Therapy and healing are creative processes, the instant therapy is a con and an addiction, your doctor is an artist as well as a scientist, and emergence is the key. We are living things, and development (of which healing is an example) is a living thing. We need to create the right conditions, be patient, and allow it to emerge.

Refs.

  1. Winnicott, D. W. (1971). Therapeutic Consultations in Child Psychiatry (p2). London:
    Hogarth & The Institute of Psycho-Analysis.
  2. Gittings, R. (1966). Selected Poems and Letters of John Keats (p40-41). Oxford: Heinemann Educational.
  3. Winnicott, D. W. (1986). Fear of breakdown. In: G. Kohon (Ed.). The British School of  Psychoanalysis: The Independent Tradition (pp. 173–182). London: Free Association Books.

Home Page: Therapeutic Attitude

Therapeutic Alliteration

Therapeutic Alliteration

Every argument worth making, it seems, can be summarised in a limited number of words all beginning with the same letter. So here are the Four Ps of Therapeutic Attitude. The last one is A, so I made the middle two either P/A to balance it out.

By the way, the “you” addressed here may be a therapist, but not necessarily. Everyone can bring some therapeutic attitude to the table in whatever relationship they are in. If you are in a position of professional responsibility, then I believe you have a duty to do so. Oh, and first check out Attitude

So here are the four Ps: Position, Posture, Purpose, and Appreciation. That’s P for ‘preciation.

Position

Are you visible? Accessible? Are you in a place in your own life that enables you to park your issues and engage fully in the therapeutic relationship for the allotted time? There is little point in having all the other attributes of a therapist if you are hidden away or beset constantly by other demands. Position can also refer to your “position on issues”. Where are your red lines? I suggest, very simply, “Support the other if you can do so without harming anyone”. If you have read much else of what I have written you will know that I have other red lines; I will not serve the machine, for example. Red lines are relatively static and provide the channels through which Purpose (see below) is directed.

Posture/Appearance

Body posture is both a useful metaphor, and a way to evidence and influence a more internal posture. You need to be upright without being rigid; relaxed without being slumped; alert without being rapacious; responsive without jumping to conclusions or into action. Some aspects of your posture will become evident from your responses. To maintain therapeutic attitude, you need to be located in the real world, but not too subservient to it. Stable, yet poised for movement. How you appear will hopefully inform others as to your position and likely style.

Purpose/ Approach

The purpose of therapy is to enable positive developmental change; enable and encourage, but never force or demand. The agenda arises in – is set and owned by – the other person. Any other would-be influences can be considered part of the environment. If the client has been sent or brought by a third party – then the agenda of that third party is something that you and your patient or client can look at with interest. Someone may come to you with an agenda and that is fine, but you will be curious towards it, and ready for it to change.

Appreciation

Appreciation of the other includes warmth, greeting, acknowledgement (that they are real and valid), acclaim, and humour. There are two keys to appreciation. One is Sensitivity. There is no merit to acclaim, for example, if it is insensitive. Some people are not rewarded by a fanfare, but rather a shy nod. Others will only notice a fanfare and will experience a shy nod as a brush-off or will not notice it at all. The other key to appreciation is genuineness, and it is at the point of appreciation that genuineness is most crucial. It is possible to manufacture Position, Posture, and Purpose and act them out – possibly against the grain, though this will require a good deal of effort – but genuineness must be genuine. Fake genuineness, when detected, simply results in disengagement; if undetected, fake genuineness can be toxic. Therapeutic work, therefore, is a vocation. You do it because you really want to, and because it really matters to you.

TA = P + P(A) + P(A) + A(P)SG . What could be simpler?

Return to Home Page

Conscience is Our Safeguard

This piece was written in response to an article in the BMJ by the Oxford philosopher Julian Savulescu. I really didn’t like what he had to say at all. I thought his argument to be poorly constructed, and the position he reached (or perhaps started out from) to be repellent and dangerous. Here is a link to my rapid response to the BMJ, published on the 2nd of February 2006: Conscience is our Safeguard I don’t know why the formatting is so shoddy when you get there. It doesn’t make it any easier to read, so I have pasted it here for ease of reading. If it was due to my error in the original submission, then my apologies to the BMJ:

Conscience is our safeguard

Julian Savulescu’s piece on conscientious objection demands, and will no doubt receive, critical discussion. My initial reaction was to respond ironically, presuming that he wrote the piece tongue-in-cheek. However, I am not practised at irony. Saying one thing and meaning another has always seemed too much like lying, and my conscience (sic) has tended to prevent me from being ironic with the conviction that is needed to bring it off. The other problem, which a colleague raised, was that Savulescu may have been writing with sincerity, and that to respond with irony might be disrespectful. I have therefore decided to respond as though he meant what he said.

He is right that individual values can get in the way of ethical health care. He is catastrophically wrong in jumping to the conclusion that doctors should eliminate their own values from their practice. He might just as well argue that, as there can sometimes be problems with policies, we should ignore them all. It was this startling lack of philosophical and ethical sophistication in his writing that caused me to presume that he was being ironic.

The paper opens with a quote from Shakespeare’s Richard III. Savulescu chooses to cite the values of a king who was known for his ruthless dishonesty (arguably almost devoid of conscience) , who put the Princes in the Tower, and whose subjects were ultimately too ashamed to fight for him at the Battle of Bosworth. In doing so, Savulescu has inadvertently put the case for the importance of conscience as an essential element of respectful and trusting relationships. He attributes the words to Shakespeare rather than his character, thus giving them greater weight. The Bard was probably himself writing ironically. Conscience, for Shakespeare’s Richard III was, after all, mostly guilt in the shape of the ghosts of his past victims. He could not go to war with a good conscience, so he had to ignore it. Finally, Savulescu, in what may be a Freudian slip, directs us in error to Scene iv, in which Richard, the “bloody dog” , gets the gruesome end that he deserves. This is an admonition and warning to those who would eschew the importance of conscience. Savulescu appears to take it as the opposite.

Next we are introduced to the concept of conscience invoked to avoid duty. I would call this idea oxymoronic: One cannot knowingly, by definition, use conscience for an ulterior end, although one could pretend to, in which case avoidance of duty is the value to which one’s conscience is urging adherence. I hope that Savulescu is not suggesting that avoidance of duty is an important value for doctors.

It is impossible to be impressed with the moral or philosophical weight of Savulescu’s argument when he uses absolutes ( “always” appears in two consecutive sentences) and value-laden phrases ( “Their values crept in…”, and “..has been squarely overturned…”) with reckless abandon. He refers to duty without saying to whom the duty is owed, and introduces “true” and “grave” duties without definition. He speaks of action in the public interest without alluding to the inevitable conflict between individual and public interest that pervades any debate about state provision of health services. Even his use of the word “paternalism” implies that it is a negative, when in ethical discourse it is a value of
central importance to be weighed against autonomy – each having their role to play in differing proportions. He reduces complexity to a series of right / wrong dichotomies, and claims that a position that is morally defensible when adopted by a few becomes indefensible when adopted by a larger number. He conflates distinct concepts (for example conscience with values with religious belief with adherence to a school of religious thought). He seems to believe that acting according to one’s conscience is the same as “making moral decisions on behalf of patients”. This is not a good example of reasoned argument!

By his exclusive use of the termination of pregnancy as the medical paradigm, he exposes his starting point, but he doesn’t begin to discuss even this narrow area with balance. I would agree that a doctor who objects to abortion might choose to work in another area of medicine, but he fails to acknowledge that a woman who has a conscientious objection to abortion may have a right to treatment by a gynaecologist who does not perform the operation. He totally ignores other branches of medicine, such as general practice, geriatrics, psychiatry.

Savulescu suggests that doctors should simply carry out instructions and that the full range of a doctor’s duties can be set out at medical school for the student to take or leave. I can only infer that he left clinical medicine at a relatively junior stage. Medicine must, by its nature, be an evolving profession, responding to an evolving world The doctor’s commitment must therefore be constantly renewed.

It seems that, in Savulescu’s utopian vision of the world, medicine is neither an art, nor has it anything to do with a relationship between individuals; our scientific and moral knowledge is comprehensive and incontrovertible; last year’s scientific theories were held in good faith but were wrong, whilst this year’s are correct, and so faith doesn’t come into the equation. He seems to be advocating blind adherence to the current dominant values and he does not consider the risk of institutionalised abuse of medicine. He implies that though this happened in Hitler’s Germany and in the USSR, we have learned that lesson once and for all. He seems to have forgotten that the values of individual clinicians may be the only real safeguard against that horror.

There is a place for the maverick and the iconoclast in ethical discourse and I welcome the provocation of this debate, but Savulescu has given us no clue, other than the outrageous nature of his argument, that he may be acting as “devil’s advocate”. He appears. therefore, to bring the weight of philosophy, Oxford University, and medical ethics with him. What worries me more than Savulescu’s views, therefore, is the fact that the BMJ has published them without qualification, disclaimer, or balancing argument. The danger of publishing this extreme view on its own and provoking uncontrolled debate is that the (hopefully) inevitable howl of protest may be read by some as the squealing of doctors as we are brought further to heel.

I must conclude, therefore, by readily accepting that individual values can result in unethical practice. The risk, though, is best minimised by teamwork, continuous professional development, appraisal, and supervision. Personal integrity underpins the doctor-patient relationship. The values of the individual doctor are our safeguard against the institutionalised abuse of medicine.

Competing interests:
None declared

cite as BMJ 2006;332:294

Compass Bearings

Compass Bearings

A compass needle will point towards magnetic north, as long as there is not too much metal around, but typically when travelling we want to get to a geographic location, so it is geographic north that is the more useful reference in deciding our direction.

We often use the compass as a metaphor to evoke those bearings we use (or ignore) to varying degrees when deciding our values and actions. Individual politicians or business-people, for example, are occasionally criticised for their lack of “moral compass”.

Retiring from a post I have worked in for seventeen years has given me a new perspective on what I was doing and some of my strengths and weaknesses. This reflection is in its very early stages. I am two weeks retired and still disorientated by my sudden de-institutionalisation. I have decided to dig out that old compass.

And so it was, in conversation with a friend, that I found myself owning up to a relative lack of attention to what he and I came to call the “pragmatic compass”.

I have spent a fair bit of my time kicking against the pricks (a brilliant phrase that offers in its archaic imagery scope for serious irreverence). This has not achieved as much as I always hoped at the time. Early on, my optimism could have been put down to naivete but later, with greyer hair, one has to wonder at my lack of pragmatism. If I had a pragmatic compass I was not following it very closely.

Needless to say, I had some colleagues who were following theirs and, whilst they were doing so, I accumulated accolades for “standing up for people”. I am proud of that, of course, but I have wondered if I had the balance right and if I might have been able to achieve more if I had adjusted things a little.

My friend and I agreed that in the world – and perhaps especially in the workplace – we need to set our course somewhere between two bearings; those of the moral compass, on the one hand, and those of the pragmatic compass, on the other. If they coincide, then we are truly lucky. If on the other hand they point in opposite directions which, sometimes, they do – we have a particularly thorny problem to resolve. Sometimes, the pragmatic action is in the opposite direction to the moral one.

Anyway, this has got me musing on various situations in which “pragmatic north” and “moral north” diverge by differing angles and, in each case, which course I have chosen – or might in the future choose. I am not a great one for regret, but I think it is worth learning from experience.

Why “Normal”

Why “Normal”

Strolling through woods, my friend asked me “is that normal?” and seemed astonished when I replied, “Is that question even relevant?” We were talking about thoughts, feelings, experience – I can’t remember, now, exactly which. In any case, I have been asked that question, or variants of it, so often. We seem to be obsessed with normality; strange when in so many areas of life we are busy deconstructing the notion.

So here is my theory. Normality is an idea that stems from the herd. Herd behaviour is primitive, instinct-driven, and designed to ensure the survival of the group at the expense, if necessary, of the outliers. The slowest, or those on the fringes, can be sacrificed to the group cause; picked off by predators or extreme conditions.

Two things follow.

  • The individual, when the group is operating at this primitive level, becomes anxious if they find themselves at the back, or off too far to one side. “Am I normal?” becomes a proxy for “am I safe?”
  • The group, when under pressure, will expend less energy supporting individuals on the fringes and may even push them further to the edge, since their value to the group lies chiefly in their expendability.

And this is how insecurity leads to Stigma:

  • We are generally placid as long as things continue as they always have (and provided our basic needs, at least, are met). But if something out-of-the-ordinary arrives we are challenged, and the degree of challenge depends on the extent to which we feel insecure. If something unfamiliar turns up in my experience or in my group, I may welcome it if I am feeling secure, but if I am feeling insecure I shall be suspicious of it.
  • Because, in the latter instance, novelty is unwelcome, I do not want the group to associate me with it. If they do – if I run next to this individual – then the group may sacrifice me also, in the interests of its survival. The unusual person – near the rim of the bell-shaped curve – is at the fringe and expendable; a target for predation or a low priority for succour – so the further I am from them the better.

We have developed an attachment to “normality” and when our attachment behaviours are activated this can contribute to stigma and marginalisation.

  • An insecure group will tolerate difference less; will stigmatise it more; will be happier to see it suffer and disappear.
  • A secure group – one in the mood for exploration and discovery rather than survival – will be more likely to welcome difference in its midst, as a possible new resource .
  • To decrease stigmatisation of minorities, maybe we need not to attack the perpetrator more, but somehow reduce their sense of insecurity.

When we find ourselves asking “is it normal?” we are operating from a primitive and insecure position. The better question might be “is it dangerous?”. At least then we allow ourselves the possibility of a higher-level existence; welcoming and experiencing novelty, and providing succour to individuals rather than marginalising them.

Home Page: Therapeutic Attitude