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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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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PTSD and the space between

This no-brainer came out of the conjunction of three things: the offer of writing a chapter for a book on PTSD, the requirement to write an essay for my intermediate training in Family and Systemic Therapy, and the recollection of a clinical vignette.

Well, and a fourth thing – a friend returning from the borders of Rwanda where she had been working with Medecins Sans Frontiers. She and a couple of colleagues had been overwhelmed by refugees, and then an outbreak of Cholera in the refugee camp. She described squeezing through the first bag of IV fluid, putting up the second (with no drip-stands) and moving on to the next patient, knowing she was unlikely to see the person again. Her trauma was palpable, as well as her need to disseminate it, diluting it in doing so – the clearest illustration of the “ripples of trauma” I have ever seen – or felt.

It seemed perfectly clear that trauma does not only exist in individuals, but is communicated and therefore exists between them. I found some literature that supported the idea, and the essay was well-received. I have no idea if anyone read the book. Perhaps this is an indication – I have had none of the over-solicitous emails inviting me as an “expert” in PTSD, in the way that I have, so many times, in relation to a single co-authored paper on constipation.

Exposing Trends

This was an interesting project! I was working as a senior trainee in paediatric liaison psychiatry and was gripped by the problem of demonstrating that our interventions worked. The scenario is frequently one of a young person repeatedly presenting with a somatic concern which the medical team fails to assuage. It is often possible to enable this concern to reduce and even vanish through a series of conversations or activities broadly informed by a “mental health” mindset (but who will establish causality to general and scientific satisfaction?).

I thought that a time series might help in this task of demonstrating benefit, though I did not have any training in the use of time series. I found a young person who was admitted astonishingly frequently and obtained the admission and discharge dates for a period of about three years, during which time he enrolled in the local CAMHS day programme where he played pool a couple of times with a nurse and maybe chatted about seemingly inconsequential things.

Whether or not there was a drop in his admissions (which I think there was) became lost in my fascination with the numbers. In order to overcome the problem of seasonal variation, known to affect admission in his condition, I calculated moving annual totals (of days spent in hospital) on monthly basis. There still appeared to be a rhythmical cycle in the figures, so I repeated the exercise but using random figures, generated by Excel, setting the range between 0 and 30 days in per month. There was still a cycle visible!

I decided that there was something going on that I couldn’t understand and, under the circumstances, I should go back to being a trainee psychiatrist. I did ask around for some ideas. Someone said that some random number generators don’t generate very random series of numbers. My own idea was that an outlier (let’s say 28 days in one month – but see post below!) might dominate the total as it passed through from being a newby, to a has-been, causing a wave.

If anyone wants to take this up and explain it to me, go for it! There is a “leave a reply” box below, or go to HOME and leave a reply there.

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Piloting fathers’ group

Wanting to challenge the received “wisdom” that fathers are “hard to reach” I invited a bunch of guys to an early evening group. Four came consistently. Another four (if I remember rightly) expressed interest for another time. They “formed, stormed, normed, and performed” but mainly formed and normed. Without knowing it I had basically created a focus group and, as there was little likelyhood of repeating the exercise, this was more like qualitative research than a pilot. I felt that they were not “hard to reach” at all – not if you were prepared to put in a tiny bit of effort.

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