Reaching Across and Introducing Animus

Reaching Across and Introducing Animus

The last nine Covid months have been weird. They have felt relatively unproductive, and yet I think something intangible or indefinite has happened. I think a great deal has been processing in the background. In the foreground, so to speak, one of the things I did was to write a piece for the British Association for Counselling and Psychotherapy in which I try, rather ambitiously, to set out what remote working has taught me about therapeutic process – or “being with”.

I attach a link to the pdf below and invite you to read it whilst respecting copyright. Here, though, are two essential points:

  1. I talk about content and process and assert that video conferencing platforms favour content at the expense of process. I give examples of how timing is messed with and non verbal material is sacrificed so that verbal content can be transmitted as intact as possible. But I acknowledge that the distinction between the two is not absolute or clear. “Which is the content and which the process, for example, when a mother and a baby look at one another?” The therapist looks for the content in the process. I believe this is one important reason for the increased effort needed to carry out certain categories of conversation when the participants are “remote”: How to be with someone when you can’t actually be with them.
  2. I invite the reader to an exploratory use of the idea of animus. I use this word, not in the gendered sense that Jung used it, nor in the sense of aggressive urge, but to denote that which gives life to or animates our utterance. If what I have to say to you is to reach you, and if you are to appreciate it in a holistic sense – ie not simply the overt content but also the content embedded in process – then it must reach you with its animus intact. Human contact is a living process. This, I believe, is something that the video conferencing platform with its binary coding, simplistic algorithms, and bias in favour of verbal content, cannot yet achieve.
The article provided here in pdf form appears in the October 2020 issue of Thresholds, published by the British Association for Counselling and Psychotherapy. www.bacp.co.uk/bacp-journals/thresholds/ BACP 2020©.

Two Stories About Jade

Two Stories About Jade

I was told these stories as a child. Looking back now I think they nearly summarise my approach to teaching.

The first tale was given to a group of us at junior school by the Bishop of Hereford.
A man wanted to become a connoisseur and collector of jade. One particular teacher came very highly recommended by his friend, so the man went to see him. He was welcomed, shown to a room and sat in front of a small piece of jade. The teacher left him there, returning an hour later to collect the piece of jade and his fee, and to bid our protagonist goodbye. This happened the next day and the next. Several weeks later the man bumped into his friend who asked how the lessons were going. “Appalling!” he replied, “He just leaves me alone in the room in front of a piece of jade for an hour. Doesn’t even say a word. And to add insult to injury, this morning it wasn’t even good quality jade!”

The other story my father liked to re-tell from the diaries of the diplomat Harold Nicholson. Nicholson was sat next to a Chinese official at a meal and was told, “In my country we have a proverb – Better a tile, intact, than a broken piece of jade.” “That is an excellent proverb” said Nicholson, writing it in his notebook. When he had done so he found his interlocutor frowning, “Or, maybe I have the proverb wrong. I think perhaps it is – Better a broken piece of jade than a tile intact.” “That, too, is an excellent proverb.” said the diplomat, “I shall write that down as well”.

I thought I should follow the example of the Bishop who, I can see now, was practising and preaching the same thing – at least on that occasion, but ending the blog at that point would no doubt results in a bemused reader, so here is my translation:

The Bishop’s point is that teaching is more effective if it is implicit. The man became an expert – he became something he had not been before. Had he been instructed by an explicit, content-based approach, he would have remained the same as before, just with some extra information. I did think I might do the same, and leave these stories suspended, but the required repetition and exposure (and in psychoanalytic terms the frustration tension) would have been missing; You would have had to sit with my blog for a few weeks.

The second story is, for me, about the nature of knowledge. Certainty is attractive but illusory, but the fact that the certainty is illusory does not make the information any less useful. In fact it makes it more useful by virtue of being more flexible. Secondly, apparently mutually exclusive opposites, far from being a problem, are what makes the world go around. The story is explicitly about whether it is substance or form that determines quality. That would be the explicit, content-based message – the substance, but it is the process, or form, that interests me more. Either that, or the flickering ambiguity that oscillates my attention between the two and leaves me suspended in a sort of pleasurable trance of unknowing.

Home Page: Therapeutic Attitude

Self-care and remote-working

Self-care and remote-working

Here are some self-care tips for remote-working. They should really be posted on my other site Developmental Conversations but I can’t get the blog to publish properly, so here they are.

Most of these ideas will apply generally to working from home whether or not this involves meeting with others via video link. Some apply particularly to video-linking.

I am not great at this myself. If you were to tell me to practice what I preach you would be half right. Not all suggestions will apply or be useful to everyone, though. Have a look and see what you think.

These ideas are partly drawn from experience and conversation but also through consulting multiple sources. Key sources are listed at the bottom.

Curating the context:

General wellbeing:

  • Eat, Exercise, Sleep
  • Protect boundaries (see below)
  • Practice self-compassion
  • Build morale (see below)

Transition

Pay attention to the transition from normal into remote working. This advice may seem a bit too late. A major problem with the Coronavirus pandemic is that it bumped huge numbers into remote working without any preparation or training, and without much in the way of choice. Nevertheless, there is still a lot you can do:

  • Acknowledge it as a major transition. Go easy on yourself. Don’t give yourself a hard time if you get some things wrong or are slow to pick up speed.
  • Don’t assume that you can work at the same pace as you did before. Communication by video link requires more effort. We have become communication novices overnight and there are lots of techniques still to learn.
  • Schedule a lighter diary to start with – that is, one that looks lighter. You may well find that you are more tired after it than you expect.
  • Learn and plan more explicitly than you normally do. So much of face-to-face communication and time management we learned by implicit means and over years, so now we need to read up and network to gather tips and strategies. Write them down. Adapt them to suit your work and temperament and build them into your practice.

Space

  • Dedicated space

If possible establish a space devoted entirely to work, remote linking or otherwise. If you do not have the luxury of space that can be devoted only to this, then have a place that you can reliably use – and you do use – for the remote linking, so that camera angles, background etc are already settled. Some people walk.

  • Good lighting

This is important for your comfort (eye strain), productivity (energy and focus) and, when it comes to video calling it is important that your face is clearly, but not harshly, illuminated for the person you are meeting.

  • Noise control
    • ambient noise needs to be minimised for you to be clearly audible, and for you and others to be undistracted.
    • volume control covered also below. This will be affected by equipment, distance from the microphone etc.
    • com suggest a white noise machine to shut out distracting sounds. I have no idea if this works and I am not going to try it, but it is a thought. I doubt if this is for the video call, though.
  • Comfortable seating
  • Plenty of surface area. You need to be able to take notes without rustling, reach for references without leaving the frame etc.
  • Personal joyful stuff. Traject recommend this, and I am not sure. The comfort and uplift that this provides needs to be weighed against distraction and boundary diffusion.

Time

  • Protect your time.
  • Set a daily schedule:
    • Make sure you know what is work time and when you are off work.
    • Make sure you know what project you are engaged in at any one time.
  • Include casual connections with colleagues (as you would do in the workplace), not just formal meetings.
  • Schedule fresh air and exercise.

Communication

Broadly speaking, channels of communication and communication skill have both been reduced drastically, all round, so more effort will be needed:

  • Be positive and supportive.
  • Overcommunicate rather than undercommunicate.
  • Clarify:
    • how others can reach you
    • when others can catch you
    • expectations
    • and clear up issues quickly with a phone call.
  • Interpret problems as miscommunication rather than malice.
  • Ask for feedback
  • Reply promptly
  • Establish how to share documents

The Work

Your working style

  • Identify your “productivity weaknesses” and address them:
    • Procrastination
    • Distraction
    • Fatigue
    • Boredom
  • Maintain your brand or culture and, if in a team, the team culture.
  • Maintain morale:
    • Dress and groom
    • Chart project progress

The meeting

  • Not everything requires a meeting.
  • On the other hand, the human face humanises.
  • Ground yourself before you start.
  • Volume
    • Can you be heard?
    • Can you hear without strain?
    • Consider confidentiality – being overheard
    • Earphones?
  • Decide on Chair, facilitator, use of mute, hand signals, and chat.
  • Decide on speaker view or (eg for chair) gallery view.
  • Decide on chat before, after, or not at all.
  • Establish alternative routes of communication
    • For documents
    • In event of interruption
    • Chat function
  • Ask for feedback
    • Can you be heard?
    • Were you understood?
    • Did you understand?
  • Avoid multitasking
  • Avoid rudeness in the room (like looking at your phone)

Here are some sites to which I am indebted for ideas:

A good description of the need: https://twitter.com/LeapersCo/status/1257941168182243328?s=20

Traject:                                                                                                          https://bytraject.com/blog/tips-for-working-remotely/?utm_medium=social&utm_source=twitter.com&utm_content=&utm_campaign=&utm_term= https://twitter.com/ByTraject/status/1244814375485083648?s=20

Inc.com                                                                                                           https://www.inc.com/lindsey-pollak-eileen-coombes/remote-work-home-productivity-communication-self-care-morale-team.html?utm_content=122166550&utm_medium=social&utm_source=twitter&hss_channel=tw-893547756282822656

MyCareAcademy https://twitter.com/MyCareAcademy/status/1242015839433474048/photo/2

Realbusiness.co.uk                                                                         https://realbusiness.co.uk/mental-health-covid-19/

@Leapers (eg on video calls, Matthew Knight) https://www.leapers.co/articles/2020-04-17/i-think-youre-on-mute-seven-ways-of-making-video-calls-less-stressful

And back to Home Page: Therapeutic Attitude

Staff Wellbeing in Crisis

Staff Wellbeing in Crisis

Protecting Staff Mental Health Through Covid-19

There are still plenty of things that individuals, teams, and services can do to minimise the traumatic impact on individual staff in the impending pandemic “peak”.

The following are action points extrapolated from two key review papers. Links to those papers are provided below. Emphasis is on current staff mental and emotional well-being and reducing the risk of future sequelae of trauma.

All members have a role in the health of the team, but some individuals, on behalf of the organisation, hold explicit responsibility for the health and efficacy of teams. To highlight this I have created separate lists for individuals and those with specific leadership responsibilities.

Individuals:

  • Competence and efficacy. Feeling competent and prepared helps to protect you from negative outcomes. Practice procedures. Satisfy yourself that you are ready. If there is an area you feel less confident of, seek support and develop a plan.
  • Motivation. Motivation is protective. Remind yourself how important your work is.
  • Fitness improves your resistance to emotional strain. Use proactive, strategies to stay mentally and physically well. Don’t deny. Use action to distract. Exercise, relax, fix something, meditate – whatever is familiar and suits you. Make relaxation a skill. Use planned problem-solving. Hold back on alcohol. Avoid drugs.
  • Being integral to a team is protective. Plan together. Rehearse the plan for the day. Practice skills. Share successes as well as fears and other reactions. Do not stigmatise feelings, either in yourself or others.
  • Secure your secure base. Satisfy yourself you have done what you can to protect yourself and your family. Practical steps; insurance, wills.
  • Social connection is protective. Connect with friends and family. Don’t expect them to understand what work is like, exactly. Spend quality time with them, even briefly. They will want to help you but may not know how. Make clear requests.
  • It helps to feel effective. If you need quarantine, use this time away from maximum exposure to recharge your emotional batteries. If it frustrates you to be prevented from work, find something you can do to support the team – revise protocols etc.

Leadership

  • The wellbeing of team members depends on being and feeling Safe, Skilled, Connected, and Prepared. Make every effort to ensure all team members have the skills and the equipment to do their work safely and well.
  • Team spirit and morale protect. Make yourself accessible to team members. Encourage supportive relationships within teams.
  • Preparation protects. Train team members, and rehears roles, skills, and communication. Establish key phrases for difficult moral decisions, such as “your own oxygen mask first.”
  • Belonging, and team morale are protective. Meet and share. Normalise (do not mandate) grief, doubt, frustration, fear. Celebrate positives, like cohesion, team spirit, tenacity. Identify learning if it can be operationalised. Divert from stigma and blame, including self-blame. Include all, including reception and support staff.
  • Communication is key. Establish regular times for sharing information and updates.
  • Appreciated voluntary contribution protects. Take seriously, and find a way to act on, any suggestions from individuals. As much as possible enable individuals to feel in control of their work.
  • Vulnerability to trauma varies between individuals and between roles. Know your team members and be aware of early signs – fatigue, poor sleep, health worries, avoidance, increased alcohol use. Act early to support.
  • Sharing protects. Try to avoid individuals having sole responsibility for areas or individual patients.
  • Traumatic harm is cumulative Consider rotating a team member through roles to reduce overall exposure.
  • Competent contributing protects. If rotating team members into less exposed situations ensure they understand they are recharging their batteries, and still have a skilled contribution to make. Train them in that skill if they are not confident.
  • Individuals differ in what they need from down time and support. Have a flexible approach to support and down time and agree this with individuals. Establish a stepped approach to support in the organisation. Support the supporters.

Source material can be found on the website for the Association of Anaesthetists. These are review papers summarising findings from research carried out during and following the SARS pandemic:

A Systematic, Thematic Review of Social and Occupational Factors Associated With Psychological Outcomes in Healthcare Employees During an Infectious Disease Outbreak (PDF) Brooks et al JOEM Volume 60, Number 3, March 2018,

Traumatic stress within disaster-exposed occupations: overview of the literature and suggestions for the management of traumatic stress in the workplace (PDF) Brooks Rubin and Greenberg 2018 British Medical Bulletin, 2018, 1–10 doi: 10.1093/bmb/ldy04

Andrew West April 2020 2/2

Return to Home Page

Narrative Matters

Narrative Matters

We have kept a lot of our children’s books. They represent such good value in terms of revisit rate, and they remind us of happy times.

I just had another look at Creation Stories retold by Ann Pilling and Michael foreman (Walker, 1997). The first story tells how, before there was anything else, there was an egg. A giant popped out and grew (over the next eighteen thousand years) pushing the land and sky apart until he could rely on them to stay in their place, at which point he went on to other tasks like carving valleys and mountains. When he died, all of his body parts were used in some way; his hair for forests, bones for rocks, and his tears formed the rivers.

I am impressed by the multiple layers of wisdom in this tale. At the level of content (and with a nod to the likely purchaser) it acknowledges the tiring job of the parent in creating and maintaining the space in which offspring can grow. It also introduces us to the importance of sustainability.

But at the level of process we realise that those who developed and treasured this story chose, for their progenitor, not an immortal but a flesh-and-blood being very much like us. Someone who can get tired and weep; Someone who dies and decays, and for whom it is possible to grieve.

Also, we are not invited to believe this story as a literal representation of fact, or required to believe the improbable; Dogma, immortality, and unreachable qualities, are not held up as objects of devotion or aspiration.

In this way generations are taught the importance of symbolic truth and the ordinariness of cosmic events, as well as the crucial role that narrative has in making sense of our existence and contextualising our experience.

We can take reassurance from the fact that stories will do this important job for us, particularly if they are obviously located in the symbolic realm, rather than the concrete. It is better if these stories don’t take themselves too seriously. Stories that are too eager to convince us of their truth and too bullying in their insistence upon compliance are harder to make friends with; are less adaptable; are more likely to drive us from our neighbour over issues of difference.

A parent reading this story to their child might stand to learn at least as much as the child, if not more. And I generally think that that is the mark of a proper children’s story.

Back to Home Page: Therapeutic Attitude

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