Clinical Humility

Ten years ago, in Being With and Saying Goodbye, I described the term Medically Unexplained Symptoms as “grandiose on the part of medicine because it implies that medicine should be able to explain everything, and anything it cannot explain falls somehow into a special category.” I went on to suggest that this is a stigmatised category which includes the idea of placebo, for similar reasons. Medicine is encouraged in its belief that it can explain everything, and it doesn’t very much like things that undermine this believe.

When, some decades ago, I trained in medicine and psychiatry, Miranda Fricker had not yet coined the term “epistemic injustice” and the concept – the process – was not thought about. As with racial blindness, I suppose, the perpetrators of the injustice do not notice what they are doing. The phrase is a commonly used one now, and I think it is a useful one, even if the choice of words is itself a little exclusive.

We were, though, exposed to some of the ideas of Karl Jaspers. He believed that the patient’s subjective experience was key to understanding and treating their condition. I don’t think that phenomenology limits us to an interest in subjective experience but the rise of phenomenology in psychiatry coincided, broadly speaking, with a rise in the importance of subjective experience. So far, so good. But then this idea that medicine can understand, know, and explain everything gets in the way.

Clinical empathy is a highly regarded concept in medicine and related disciplines. The concept is variously described and used. It might mean the ability to understand and communicate a patient’s experience, or the act of correctly acknowledging the emotional state of another.

Note the different language and its implications.

How does this sit alongside the idea of epistemic injustice? Between finding words to describe someone else’s experience and helping them to find their own words, there is a chasm masquerading as a thin line. The idea that I can know someone else’s experience is a form of arrogance, and a misunderstanding of subjectivity. Perhaps it is a small step for medicine which expects itself to know everything about the workings of a human, to believe that it can – and should – know their experience.

If we step away from the jargon and think of common language we will recognise how common it is for people – particularly when they are striving to help someone – to say, “I know how you feel.”

The truth of the matter is that I don’t know, but I am trying. I am listening with all my faculties, and as best I can. I hope I am getting the gist. I may be wrong, but… And is this helping?

And, broadening it out again to clinical humility, let us continue to have clinical supervision, even when we have reached exalted status in our professions. And not just in psychiatry. “Supervisor” is not a comfortable word. It smacks of bureaucracy, infantilising, lack of autonomy. But let’s emphasise the special nature of Clinical Supervision, overcome the desire to be the top monkey, and acknowledge that we don’t always know and that we, ourselves, may need help in our attempts to help someone else.

For the time being, at least, this is what I mean by clinical humility.

Leaves Leaving

This Autumn, looking at the leaves, I was reminded of my post of 2018 Pebbles and People and struck by a contrast in my thinking. It is not new – in fact it is practically habitual – for me to reply to my own ideas with some sort of a challenge. On this occasion it was not so much that I challenged my earlier thoughts about pebbles, but rather it seemed that leaves, by their nature, encouraged a different analogy or line of thinking. Or was it a shift in my attention and meaning-making?

Where I had found myself drawn to individual pebbles taken from the mass, enjoying my conviction of their separate and inherent adequacy (a perfection that allows, even requires, imperfection; a good-enough-ness), here I found myself appreciative of the mass effect. Taking any leaf individually did not satisfy. I would find a blemish or a lack of lustre that was irrelevant when part of the grand show. I tossed them back quickly to rejoin their fellows and resume whatever process I had interrupted.

It struck me that leaves are not pebbles. They are organic and relatively transient. They were born individual and seem almost to relish merging when the opportunity arises. Pebbles, by contrast, were hewn from a mass existence to which they seem in no rush to return.

And what change in my own circumstances might be responsible for this different appreciation – this appreciation of the transience and communal beauty, over stubborn and proud individuality?

Loosening the knot

Coaching tends to have a reputation for pushing; pushing an athlete to exceed their personal best, for example, or pushing someone to focus on and fulfil an aspiration. This reputation is well-deserved. When relationships are skilfully task-focussed, a great deal can be achieved for one or more participants.

This reputation can put us off, though, and we may be right. It is not so much that we don’t want or need to develop, but that we sense that our development will be better served on this occasion by our staying roughly where we are for a while. Development is not always a relentless pull in one direction.

At times we need to look around; tease apart the obvious and tough issues and peer through at what hides in the spaces between.

I sometimes think of “loosening the knot”. No change is possible until the tension is off. Loosen the knot so you can better understand it; see where the strands wind around each other, where they come from and where they go, and what may be glimpsed between them. You can put more effort in once you are confident that it won’t just retighten the knot as it was before. Or you could back-track more, revise relationships, add, subtract, retie, or undo the knot entirely and start afresh.

If you understand your circumstances, your resources, and your values, you are in a better position to make decisions and put your energies where, unequivocally, you need them to be.

So, be clear. Coaching can help you clarify and revise your goals. You don’t always need clear goals at the outset, to benefit from coaching.

This is posted for DevelopmentalConversations

A first version of this piece was posted on Linkedin in 26/7/21

Autumn and Parting

@occidens pointed out to me a while ago whilst walking through a wood that if a branch of a tree breaks during the summer when the leaves are fully out and green, the leaves do not fall but wither on the branch and stay there. When it comes to autumn and all the other deciduous leaves change colour and fall, these dried up dead leaves stay on the dead branch.

What this says to me is that when trees lose their leaves in the autumn it is an active process, not a passive one. It is part of living, and the letting go of the leaves is a living act. The tree clearly has to take steps to prepare – and release the leaves.

It is worth remembering this. when it comes to loss.

It recalls the film Truly Madly Deeply in which the bereaved protagonist has to actively let her husband go – almost drive him away – in order to be freed from the ghost of his presence lingering on like those dried up leaves.

Autumn reminds us that loss can be a beautiful thing. It is part of life and it enables new growth.

Reaching Across The Divide

Here is a sort of précis / romp through this piece I wrote a year ago for Thresholds – a BACP quarterly that addresses spiritual issues in counselling and psychotherapy. The article sprang from our efforts, early in the Coronavirus pandemic, to manage therapeutic contact across video-conferencing platforms. I was struck by my and others’ experience of finding the process particularly effortful and was led to reflect on the difference between this medium and the “real life” analogue situation, and to explore how it might shed light on what goes on in the latter (hitherto much commoner) setting.

I contend that the digital medium favours content over process whilst psychotherapy relies on content in the process which may therefore be lost, or at least harder to apprehend. The issue of timing, in particular, is important in communication; minute hesitations can say so much in the real world, but may be put down to latency when on-line. The platform algorithm, selecting which video of moving mouth parts to patch onto which bit of compressed speech, and often arbitrarily promoting one speaker over another, I liken to an enthusiastic and naïve co-worker in the therapy room.

This technological solution to the problem of being together during a pandemic brings obstacles to communication which I liken to the concrete obstacles that had to be overcome by adherents of non-conformist churches meeting together in Britain in the 17th century. This comparison, in turn, leads me to reflect on the common ground between psychotherapy and religion; a conviction of reality and benefit on the inside, struggling with an external demand for sufficient “evidence” to satisfy a sceptical audience.

I conclude (via yet another analogy drawn this time from marine biology) that when humans communicate, factual content has to be accompanied by some animating essence that I decide to call animus.

Bit of a stretch? Nah! But sorry; if this has whetted your appetite, you will have to get through the paywall.

Return to AFW in print

Keeping Intelligence in the Clinical Encounter

You may wonder why it has taken me this long to get around to reading Gödel, Escher, Bach by Douglas R. Hofstadter. I blame the conditions at the coal-face. It is brilliant stuff. On page 26 of the 20^th Anniversary edition by Penguin (2000), after an introduction to strange loops in music, art, and mathematics, the author turns to intelligence and the abilities that are essential for it to pertain. I précis the section slightly:

Essential for intelligence are the ability to:

respond to situations very flexibly
take advantage of fortuitous circumstances
make sense of ambiguous or contradictory messages
recognize the relative importance of different elements of a situation
find similarities between situations despite differences which may separate them
draw distinctions between situations despite similarities which may link them
synthesize new concepts by taking old ones and putting them together in new ways
come up with ideas which are novel

Of interest to me here are not the limits of artificial intelligence, but how much these abilities are utterly intrinsic to the job of a therapist. Hardly surprising, one might say, since therapists are human.

But let’s look again, and reflect on the extent to which mental health work is being encouraged to follow practices that blunt or neglect these abilities.

Above is a list of things that questionnaires, categories, proformas, and protocols are bad at.

Therapeutic Attitude, therefore, is the attitude that insists on retaining intelligence in the clinical encounter.

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Vortex Management

I have often thought about the vortex. It has been a vivid metaphor for that mood state that exerts a powerful pull and encompasses fatal peril, nameless dread, the unspoken, and unimaginable hopelessness.

The capital V provides the graphic.

Much of my life I have been blessed with a grandiosity and/or ignorance that has meant that skating across the edge of the vortex seemed more of a thrill than a danger. It has been possible for me to look in as I skirt the lip, my own velocity enough to ensure safety. I could even lend my confidence to others and act as a guide on those treacherous slopes.

But that energy wanes. Experience chips away at the assumption of safety. My sense of balance admits a hint of wobble…

So my awareness of vortex management has come to include more conscientious thinking and practice.

We differ in our relationship with the vortex, no doubt depending on our temperaments, experience, and circumstances:

Some look the other way. This often works. Perhaps, by not seeing the possibility, the risk of vertigo is reduced. Unconscious awareness and a subtle lure may nevertheless remain. Whether one stumbles backwards into an abyss of which one had no knowledge, or one flings oneself backwards into something that has been kept in suppressed consciousness; either way, it comes as a total shock to the conscious mind.
Others are all too aware and spend much of their time and energy marching or scrambling away from it – for the most part successfully, but sometimes not, and perhaps always only partially so.
My approach for many years was, as I put it above, to skate across the lip. This brings to mind the “slingshot” used by spacecraft. If I have understood this correctly, the gravitational pull of a celestial body may be exploited to develop acceleration and turn directional into angular momentum. The vortex can actually be used as a means of changing direction. This requires considerable confidence and panache. Surely, there must remain a risk of miscalculation and a plummet into the core.
Finally (though do, please, add to this list) there is the skill of staying still.

I have been developing this skill. The current pandemic, with its erasing of the horizon and its repeated and protracted limbo states of lockdown can be held largely responsible, but my recent emergence from the institutionalisation of public sector employment must also figure. I suppose that, as I slow down, I can no longer rely on my ability to maintain an escape velocity. So I have learned some new tricks. I have learned not to lean away from the abyss, thereby keeping my centre of gravity over my feet with closer attention to the friction between feet and funnel.

(You can tell when a metaphor is getting desperate, because it starts to thrash around.)

I acknowledge the existence of the vortex and its pull, but I weigh against it my own resources, and most importantly this includes an ability to separate what is happening from what I fear might happen.

At that point I pause and reflect. If I can separate the actual from the feared, surely I can notice that this is not a vortex at all. That was a vivid metaphor, and useful up to a point, but the truth of the matter is that I am not falling; I am afraid.

Not falling; simply afraid. This helps because I have been afraid before, and I have learned that, if I can prevent myself from running away, the fear passes.

I have retained the term, though: vortex management. It seems a suitable label for what is going on at those times, and it reminds me that there is something I can do about it.

Home Page: Therapeutic Attitude

The Pain of the Wronged World

Here are two fragments of text. Each is there to comfort you if you are put off by the language of the other.

Elio Vittorini

Elio Vittorini was an Italian Communist, born in Sicily in 1908. The translator Alane Salierno Mason points to Vittorini’s conception of the novel as an art form akin to music – specifically opera. Music is a medium capable of taking us past words and into a non-partisan realm. In his posthumously published novel Conversations in Sicily his protagonist starts,

“…in the grip of abstract furies….not heroic, not living…furies for all doomed humanity.”

On the spur of the moment he sets out for his home village to see his mother, whose birthday it is. This proves to be something of an Odyssey during which he is welcomed by a group of men who bemoan the fact that,

“The world is big and it is beautiful, but it has been badly wronged. Everyone suffers each for himself, but not for the world that has been wronged and so it continues to be wronged.”

These men applaud our protagonist’s suffering with a phrase that becomes a sort of chorus:

“He suffers the pain of the wronged world.”

Lighting a cigarette as he leaves his mother’s house, he remembers, and starts to weep. He walks through the village weeping and, gradually, the villagers follow him:

‘Why are you crying?’ They asked. But I had no response to give them. I wasn’t crying for any reason. Deep down I wasn’t even crying; I was remembering.

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L. Violet Holdsworth

L. Violet Holdsworth, née Hodgkin, (1869-1954) was an English Quaker. Amongst her many writings is the following passage from Seas of the Moon (1940) quoted in the 1960 “Blue” version of Quaker Faith and Practice (©1969 London Yearly Meeting of the Religious Society of Friends):

Perhaps [in ageing] our other powers are being taken away from us to teach us to trust more to our prayer-wings, and to pray, pray for the needs of the whole world with an urgency unknown in earlier days, when our longings were more circumscribed by our immediate horizon. We can pray now, or rather we can try to let prayer stream through us, knowing that our prayer is not ours alone…”

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In Being With and Saying Goodbye I describe myself as a “moderately aggressive agnostic”. I am not someone who uses the word “prayer” – one has to somehow avoid alienating either side of the religious coin – but I am taken by the ground shared by these texts, and by the hope of a redemptive power in collective grief, compassion, expression, and the virtue of being open to the pain of the wronged world.

Here I am, then, with youthful powers gradually reducing, hoping that in some way I can contribute to a healing so much vaster than myself. I wonder if this is what Therapeutic Attitude might look like, applied beyond the individual, to a collective suffering.

In the middle of your life

The future can easily look bleak and, when it does, motivation to move forwards can be noticeably lacking. There is no end of self-help stuff around and I am not about to rehearse or list self-help strategies now. Here I am interested in attitude, rather than strategy or instruction. And one aspect of attitude is perspective. When feeling a bit stuck, it can help to consider my position and my present perspective.

One perspective caught my ear in a short spoken piece on sitting meditation and has stayed with me since. Ed Brown is a Zen priest whose delivery is simple and clear. On the CD that accompanies a small introduction to meditation Quiet Mind he describes a sitting posture for Zen meditation. I can’t lay my hands on the CD at the moment, so what follows is from my recollection.

When he has concluded his description of posture he says, “This is a really good position in which to sit, right in the middle of your life”.

This is the bit that caught me. I have listened to it many times since and thought about it many times more.

Up until then the metaphor for my life had me stationed at the prow of ship as it cleaved the waves. This is fine when everything is going well, but when the ship has shrunk to a coracle and is not forging ahead, it is not such an inspiring image.

Perhaps we are at a disadvantage with our eyes at the front of our heads. I wonder if raptors get anxious or depressed when they are not on the chase. Alternatively, perhaps it is to do with the dominance of vision in our lives. With my eyes shut I realise that space is equally distributed around me. Sound, smell, and general sense of being are all around, not only in front.

And when I come to think of it, my life is all around me. There are cultures, I believe, where the dominant idea is that people travel through time facing backwards, as it were, watching their increasingly rich and diverse past fanning out behind. I can’t say that I would particularly want to swap my cultural perspective for that one, but when I am inclined to an idea of the future as a sharply focussed cone in front of my face, what do I do when it is poorly focussed or empty?

So here I am, right in the middle of my life. Not nearing the end. Not with a past forever buried or dwindling to an invisible and unreachable speck. Not in a dinghy drifting to a standstill with a fading wake the only thing to show for my progress. There is change, but no linearity. Am I growing like an onion from the inside, adding layers? Or am I a benign black hole, drawing experience into me from all directions, so that I gather in density at my core?

And I need not develop the image at all, but it repeatedly feels to me that this shift of perspective offers the attitudinal change I need.

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Therapeutic Chess… or… When the engineering analogy breaks down

This Christmas a three-player chess-set was given as a present and we had a game. It was a fascinating experience. I am not a great chess-player. As someone said to me recently, I always have the sense that my opponent has some far-reaching grand scheme that I unequivocally lack. This hexagonal chess board reduced the three of us to very similar levels of ineptitude as we reminded and re-reminded ourselves and each other which squares the pawn could take, how many bent diagonals were currently open to the queen, and the oddly straight knight’s move.

But that was not all. We found how hard it was to build any strategy when the person you took to be your opponent for the last two moves turns out to be an ally. The rules (one version, at least) spell out that, if you fail to take available steps to prevent a checkmate, you lose. And yet no checkmate that we encountered in two days of playing was achieved without the effective, if inadvertent, collusion of the other player.

We have been raised with a firm understanding that the triangle is the most stable structure. And yet, with this game, we found ourselves unseated from a stable, albeit viciously confrontational, dyadic structure into a disorienting dream world in which familiar shapes abounded but relationships flickered constantly and with bewildering rapidity. Chess had changed.

It seems that however important the triangle may be in the creation of stability and rigidity in the physical world in the world of interpersonal dynamics they represent a massive step into instability.

Our first relationships are with one Other (even if based on a misunderstanding about the identity and composition of that other) and I suggest that we would happily have it stay that way provided the Other remains committed and continues to come up with what we need. We often use a metaphorical third party to stabilize the dyad (you and me against the world) but the truth of the matter is that the world inexorably introduces genuine third parties with agency and their own urges to combine forces. What is more, the Other we have got used to fails, from time to time, to come up with the goods, we develop our own roving eye and the world, for evermore, is a place of unstable triads.

Or, if you prefer, the world is for evermore a stable-ish scenario of constant flickering transitions as triads configure and reconfigure. This is the world we found ourselves in with three-sided chess. It was initially disconcerting but, once the unfamiliarity was overcome, a new relief settled in. We found that the bitter paranoia of being in the lonely position was always momentary and was replaced by a higher-level sense of everyone being equally and temporarily both in a dyad, and in relationship with a dyad. Rigidity had actually been the problem; This idea that I am rubbish at chess, for example, or the constant search for a chess partner exactly like me.

This set could be sold as Therapeutic Chess …. and triangles rock.

Therapeutic Attitude

This site explores "being with and saying goodbye", the attitude that sustains professional practice, and that itself now needs sustenance

Author: afwesty