The Pain of the Wronged World

The Pain of the Wronged World

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

Elio Vittorini

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

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

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

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

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

He suffers the pain of the wronged world.”

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

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

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L. Violet Holdsworth

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

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

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

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

In the middle of your life

In the middle of your life

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

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

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

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

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

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

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

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

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

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Therapeutic Chess… or… When the engineering analogy breaks down

Therapeutic Chess… or… When the engineering analogy breaks down

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

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

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

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

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

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

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

Reaching Across and Introducing Animus

Reaching Across and Introducing Animus

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

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

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

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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