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

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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 a primitive, instinct-driven behaviour designed to ensure survival of the group at the expense of the outliers. The slowest, or those on the fringes, can sacrificed to the group cause; picked off by predators or extreme conditions.

Two things follow.

  1. 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?”
  2. The group, when under pressure, will expend less energy supporting individuals on the fringes, since their value to the group lies chiefly in their expendability.

There is another angle which is the stigma attached to being at the rim of the bell-shaped curve. I suspect that this is a little more complex. We are generally placid as long as things continue as they always have (and provided our basic needs, at least, are met). If something out-of-the-ordinary arrives, though, 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 (a skin blemish, or an unusual sensation, for example), or in my group, I may welcome it if I am feeling secure, or be suspicious of it, if not.

Because, in the latter instance, novelty is unwelcome, I do not want to be associated with it. If I run next to this individual, then I may be sacrificed by the herd along with them, or by association. They, by definition, are at the fringes and expendable – a target for predation, or a low priority for succour – so the further I am from them the better.

My conclusions are several:

  1. An insecure group will tolerate difference less; will stigmatise it more; will be happier to see it suffer and disappear.
  2. To decrease stigmatisation of minorities, we need not to attack the perpetrator more, but somehow reduce their sense of insecurity.
  3. 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 higher-level existence: welcoming and experiencing novelty, and providing succour to the needy.

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Horse-Whispering

Horse-Whispering

In Being With and Saying Goodbye I have concentrated mainly on the work that can be conducted through conversation of a fairly decorous and measured variety, even if not always using verbal language. There is a species of Being With that I neglected to mention. Thinking about it now, it is easy to imagine why. If you read on there is a possibility that you will be offended by the analogy that I draw, but I hope you can bear with that and get to the point I am trying to make.

The mental health problem that people fear most, I suspect, is that of totally losing control; of ceasing to be human. My hunch is that this is where a lot of the stigma against mental ill-health comes from. Instead of addressing that fear and stigma, society busies itself with surface psychology. Money and rhetoric are poured into this to reassure us that plenty is being done. Meanwhile, those with fear of fragmentation go round the mill of medications, revolving doors, and pejorative labelling. I think that they often feel profoundly alone and abused. This is the opposite of Being With.

I suspect that in BWSG I neglected this aspect through shame at how much fear I can feel myself and how much I can shrink from accompanying those gripped by that lonely fear. I am less afraid when wearing my work clothes. Power has its advantages.

This omission from BWSG occurred to me recently when I was talking to someone who re-trains ex-race-horses so that they can be ridden and loved in a second career. It recalled a conversation I had had shortly before with the extremely anxious parents of an incredibly anxious child. He had probably always been fairly anxious, but had managed it through his prodigious talents and sheer effort of will. Something had caused this approach to fail, and he had been sent plummeting into a vortex of sheer terror, when there is no floor and where successful omnipotence, potent parents, and the phantasised all-powerful benign oversight, are exposed as mere clay and collapse crashing all around. He was terrified.

In discussing this with the parents, drawing on past experience to try to advise them, I found myself explaining that for the time being at least they had to acknowledge that they could not hope to interact with their son in any way that was familiar to them. The analogy that seemed to help them was that of being in the presence of a very frightened animal: A spooked horse, perhaps.

I have been in the presence of terrified people. It is something that my formal training did not address very well, so I fall back on my native character, inherent and shaped over the years. The closest to explicit training that approaches this would probably be that hopelessly clunky bit where they tell you where to sit in relation to the door: I and the “other” are expected to be reassured by the fact that each of us can run out of the room if we have to. The image that this always evokes in me is of us colliding, jammed, in the doorway in a mutual rush to escape. To be fair there is some merit it getting us to think about our positions in the room. Position is power and power corrupts. We need to be big enough but not too big; friendly enough but not too friendly. But it doesn’t allow for the encounter on the stairs, for example. We are also taught about breathing rate, pacing, and such-like. Sure enough, it is useful to be aware of these things as well (there is so much to be aware of), but at the start of the meeting, as the whole family come in, I don’t want to look as though I was trained by the SAS.

And so, occasionally, there comes a point where I realise that there is a terrified animal in the room with me. Why does this apparently demeaning analogy help? What is the approach that it evokes?

In the presence of this terrified being, with whom there can no longer be any normal social interaction, we resort to sounds and behaviours. There are three tasks. One is to reduce the threat. We (I say “we” advisedly because there is pacing and matching going on – that is part of the point) – we manage eye contact differently, soften the voice to soothing sounds, and position ourselves in the space so that the other feels neither abandoned, nor encroached upon or trapped. The second task is for me to manage myself. There is no merit in being unthreatening if I, the parent or professional, am obviously terrified. I must at least appear as though I am intact and unthreatened; undaunted by the vortex. This is easier to project if it is the truth. The third task is to re-establish some semblance of conversation with the other person. No use, though, expecting my words to be grasped and responded to in kind. It is more likely that, whatever words I choose, the meaning conveyed will be “I am OK, we are OK, the world is OK, it’s OK, you can be OK…”. It is more like a dance, or a musical improvisation. I am situated and relaxed in the world and I am inviting you to mirror me because if you do, then I think you will feel more in the world as well.

Now here is a problem. If I managed this moment successfully, and the parents were with me, then I have modelled what may be a new behaviour for them. But they are unlikely to be able to replicate it straight away. When this situation is behind us, the parents usually have to return home with their child. They will ask me what they should do in a recurrence. I will make some suggestions, but instruction under these circumstances inevitably become clunky, like the training we receive. How many times have parents been told to “make sure all knives and sharp implements are out of the way”? This is like “sit equidistant from the door”. It is all well and good, but it is impossible. We cannot make the environment safe – only safer.

It is the attempt to make situations totally safe that result in abuse – what is sometimes called iatrogenic abuse, though this hurts me – it is not only doctors who are guilty, and most of us do the best we can. Going back to the first and second tasks, above (reduce the threat, and manage my own fear) there will come a time when this cannot be done. What do we do then? Well, here are two examples from early in my training, before I started specialising in Child and Adolescent work. Go easy on me. I was a kid myself:

  1. An adult male ran – barefoot, as it happened – first at the wall and then at me, in a corridor. I stepped to one side and let him pass. I followed him some way out into the street, gave up the chase, and called the police.
  2. An adult female, at a similar stage in my training, slapped me in the face. I shouted at her, “Don’t ever do that again!” and continued the assessment.

The genders in these vignettes are telling. This is about power. In the first instance I knew I was outgunned and I called on a service that I knew would not be. What they did, was out of my hands. In the second I believed myself to be the more powerful, in a crude, physical sense. When the chips are down, the world we live in is physical. I exploited, perhaps, her past experience of abuse and her fear. I did so entirely on reflex and out of instinct. The fact that we were able to sit again, and to return to talking, reassures me to some extent that she felt safe enough. I knew I had made a mistake – it would be years before I knew enough about myself to guess that the mistake was likely to be that I had shown too much of my smart-Alec. But the point is that the container has to be capable, physically, of containing. And it has to imply that capacity without resorting to it. It is another impossible paradox that we manage as best we can.

I want to return to the animal kingdom. It is a useful analogy because it makes explicit the fact that we have regressed, in this situation, to a pre-verbal level of existence. At these times we call on our animal avatars. What would I like my avatar to be at these times? I would like to be an elephant, caring, wise, and benevolently invulnerable. But I have to be nimble enough to step to one side without trampling. I know, also, that I can show my cornered tiger. I hope that I have learned its power, so that all that is needed is the bearing of teeth in a smile, or the raising of a bushy eyebrow. It is a tough (beautiful) brutal world. I may be able to help you if I survive.

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Pebbles and People

Pebbles and People

Whenever let loose on a beach I immediately find myself looking at the ground around me, stooping, and picking up objects for closer examination. Sometimes it is shells or driftwood. Occasionally it is a useful piece of nylon string. But what I find fascinates me most frequently are pebbles.

On the beach at Filey in Yorkshire, about ten years ago it occurred to me that, although I was exercising great discrimination in selecting pebbles, I might just as well shut my eyes and pick up the first one I stumbled across and that single pebble would give me as much satisfaction.

This observation troubled me slightly, and bided its time, quietly fizzing in the very back of my mind until a few months ago on a beach in Pembrokeshire. That idea about “any old pebble” popped up to greet a new niggling observation. I was noticing in myself a sense of affection bordering on love and nostalgia towards the stones I was picking up and, with some reluctance, releasing again to the wild.

Suddenly these were people. Indeed, they were my patients! Do I have a favourite? No, of course not. Is any one not worthy of love? No. Is any of them perfect? No. Do they share features, and yet retain, each of them, a uniqueness? Yes. Do I take a particular interest in some over others, for a time? Yes. Does each of them accompany me for a time and then leave? Yes. And do I have a sense of the number that I can safely carry, and the number that I can examine closely, at any one time? Yes.

Of course the analogy has its limits. Any analogy that is total or complete ceases to be an analogy or of any interest. I do not see myself as of any use to these stones. I don’t expect any of them to be in any kind of predicament that I might be able to help them through. In fact the roles are somewhat reversed. It is more likely that they can help me with my predicament.

But do they talk to me? Yes.

What makes these pebbles like people to me? What is it they share?

A pebble’s character is shaped by two things: their inherent material, and their experience. Each stone is made of a material which may be soft, hard, brittle, porous. These features, in turn, have their distant origin in constituent and experience – their chemical makeup and the terrible forces that gave birth. There may also be a fault line, or a sheering plane due to differing materials joining. And then there is the tossing and churning, the action of water, and jostling with their fellows which has brought them to their current shape. The interaction of these two broad sets of influences is important. Some will have been more or less resilient to this abrasion. Others may have seemed impenetrable until they split after a sharp tap, to reveal a hollow interior. And then this, in turn, was smoothed and adapted. And some may have been brought here from elsewhere, finding themselves in the company of other shapes and colours.

I found myself moved by the stories of these stones. And by the fact that, yes, some of them caught my eye – bright colours or a wet shine – but that I could pick any one of them, take an equal interest in it and enjoy its company – for a time.

Ultimately, of course, the analogy relaxes its grip and we fall back into our respective places. I turn to my human companion, perhaps compare notes, and move on.

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Diagnosis: With great power goes great responsibility

Sadly, I must start by drawing a distinction between the practice of diagnosis and that of formulation. I wish I didn’t have to. Formulation is about understanding. It is tentative, has a narrative component, includes strengths as well as difficulties, integrates the socio-political with the biological and psychological, and notices the all-important context that an individual finds themselves in. It reflects engagement and empathy. It is genuine, and genuinely holistic, in its aims and approach.

Personally, I think that “diagnosis” should mean pretty much the same. Instead, it has come to mean “attach a label”. Rather than attempt here to swim against the tide and rehabilitate the idea of diagnosis, I shall accept this as the new meaning. This is what reductionism does. By banishing nuance it leaves a husk of an idea which readily attracts negative connotations. Abuse, injustice, and pain are rampant and we are desperate for them to be contained in some way – in a brass lamp or Pandora’s box, if you will, or a tightly corked bottle at the bottom of the ocean. Enough people have been and have felt misunderstood, ignored, pushed around, and painted in colours of other people’s convenience by the diagnoses that they have been given, for this husk of an idea to be a deserving recipient. So be it. Diagnosis shall forever mean “the attachment of a label”.

Certain kinds of scientific research are required to be reductionist, to homogenise the sample, and to strip away confounding factors. Something akin to diagnosis can be useful there.

Even with this horribly narrow meaning, diagnosis may be useful in clinical practice if it points to a helpful explanation, beneficial intervention, or opens the door to resources. But there is a cost, and to provide informed consent to diagnosis, one needs to understand the cost. Working as a clinician in Child and Adolescent Mental Health, I have spent almost as much time actively avoiding giving a child a diagnosis as I have discerning or providing one.

I am lucky to work with children. Generally, they are wiser than adults. Saint-Exupery understood this, as have countless others. Mostly children are not very interested in diagnoses, in my experience, whilst pretty well everyone else is clamouring for one, ostensibly on their behalf. It may be the school, Social Services, the parents, or my own service. Each has their own agenda. Extra funding to the school or the provision of support beyond a certain level may be withheld unless a diagnosis is given. Children’s Services ask me, these days, for a diagnosis in a way that leaves me wondering if their purpose is to check out if I know what I am doing. Mental health services are themselves desperate for something official-sounding to justify the funding that maintains them. Parents are typically the most scared, and so deserve the least criticism for requesting a diagnosis which may not be in their child’s interests. Very occasionally, though, they are seeking ratification of their urge to locate the problem in the child, and this must be resisted.

Sometimes, of course, it is necessary to make a diagnosis. It can be essential to provide a clear opinion enabling an unambiguous clinical management plan.

What I would like diagnosticians, anyone who amateurishly throws around diagnostic labels, and anyone who demands a diagnosis for legal or other decision-making reasons, to bear in mind is the following:

Labeling (I shall use the word labeling)…

1) is not the same as understanding

2) is an exercise in power

3) has a meaning to the patient which must be explored. What does it signify or imply?

4) follows fashion

5) is an intervention

6) can harm as well as help

7) may be inaccurate or approximate

8) should therefore not be done unless necessary, helpful, and in a context and relationship in which the patient’s values and understanding can be explored,  misunderstandings corrected, harm repaired, and informed consent is an ongoing and evolving understanding.

Because diagnosis is (or should be) integral to the process of treating/healing/helping it needs to be done with Therapeutic Attitude.

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The Sins of the Pathway

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

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

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

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

1) Adversity  

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

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

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

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

2) Therapy

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

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

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

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

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

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

3) Pathways

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

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

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

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

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

4) Control

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

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

5) Development

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

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

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

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

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