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.

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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.

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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.

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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?

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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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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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